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Physiological Changes Postpartum

Your postpartum experience begins as soon as the baby and placenta (afterbirth) are delivered. The process by which your body returns to its pre-pregnant state is called “involution.”

Your body has made preparations during pregnancy for giving birth, building up to the point where the levels of the hormones estrogen and progesterone have risen very high; your uterus has grown large and strong enough to carry the baby, the placenta, and amniotic fluid; your abdomen has stretched and grown enough to accommodate the uterus and its contents; your internal organs have been displaced enough to make the necessary room; and your vaginal canal has increased its stretching capacity enough to accommodate the size of the newborn during the journey from the uterus to the outside world. This nine-month process climaxing in the birth of the baby and placenta only takes about two or three months to reverse itself completely. The majority of these changes back to the prep regnant state occur during the first six weeks after delivery. Such dramatic changes in so brief a period are unknown in any other normal health situation.

The Uterus

After the baby is born, uterine contractions continue, assisting in placental separation from the uterine wall; this usually takes about five minutes. Separation of the placenta exposes the extensive vascular uterine bed through which feto-maternal biochemical exchange had been taking place. The continued contractions of the uterine muscle fibers serve to constrict, compress, and obliterate most of these blood vessels, thus preventing hemorrhaging. Having no placenta and baby within, the uterine cavity diminishes in volume. It continues to shrink in size by maintaining contractions and by breaking down and reabsorbing the muscle cells. The uterus becomes firmer and smaller as it begins to sink lower in the abdominal cavity.

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If you breastfeed your baby, the infant's sucking triggers the release of oxytocins - hormones which contract the uterine muscles. Each time your baby nurses, you Will be aware of these uterine contractions which might or might not be painful. If they are painful, try using breathing and relaxation techniques. If these do not help enough and you so desire, your doctor might prescribe a mild painkiller such as acetominophen (e.g., Tylenol) prior to each feeding of the baby.

To give you an idea of the magnitude of the uterine involution process, consider that before the birth the full-term uterus weighed approximately two pounds. The top of it, the fundus, could be felt just beneath your ribs. Within about a half-hour after delivery, the uterus can be felt as a hard mass, midway between your navel and your pubic bone and not much larger than a large grapefruit. It remains about the same size for the next two days. By about the third day after birth, the uterus descends further into the pelvic cavity, growing smaller and losing weight. By the fourth or fifth day, you might be able to feel it just slightly above your pubic bone. At approximately one week after delivery, it weighs about one pound. By the tenth day, the uterus has descended below your pubic bone and cannot be felt through the abdominal wall. It weighs about twelve ounces by the second week and returns almost to its pre-pregnant position and size by the sixth week - weighing only approximately two ounces.

Afterbirth Pains

Afterbirth pains, or afterpains, are most intensely experienced by mothers having their second or subsequent babies, although some first-time mothers may have them also. These are caused by the extra effort expended by these previously stretched uterine muscles in order to contract effectively. While the uterus of the first-time mother usually remains firmly contracted after delivery, the uterus of the second-time or subsequent mother often contracts and relaxes at intervals. Because the musculature is more relaxed, the uterus works harder to contract sometimes resulting in pain severe enough for the new mother to request medication during the first few days after delivery. Using Lamaze or other childbirth breathing and relaxation techniques during painful contractions can help minimize this for you.

Chills

Soon after giving birth, while still in the delivery room you might develop chills - so much so that your teeth may chatter and your arms and legs may shake uncontrollably. It may seem almost funny to you as you watch and experience this, except that it might be frightening if you didn’t know it is usually normal. Chills and/or “the shakes” may last for as long as thirty minutes. It is thought that these may be partially a result of the nervous reaction to and exhaustion from the birth process, your lowered body temperature due to the decreased blood volume now that the placenta has been delivered, and your body's process of dealing with the extreme temperature change in a brief period of time. Also, because you may have perspired heavily during the exertion of the delivery stage, during your post-delivery relaxation the relatively cool air in the room may chill you. You can ask for an extra blanket or two to be tucked closely around your body, and you can try Lamaze slow chest breathing, which sometimes helps, but chances are that nothing except time and perhaps a hot-water bottle or heating pad will help. If the tremblings are excessive and nothing else helps, your doctor may prescribe a tranquilizer.

Hunger

You may feel ravenously hungry after the baby is born, and no wonder. Your stomach is no longer compressed and, more important, you have not eaten since labor began. Also, after working hard, which is what labor is all about, people do get hungry. You may desire and be given something to eat or drink in the recovery room.

Cervix

After delivery, the cervix becomes soft and flabby for a few days. By the seventh day, the cervix firms and narrows considerably.

Vagina

The vagina, which had been stretched to accommodate the baby's passage, begins gradually to reduce in size but does not usually return to its pre-pregnant condition. Slackness in the vaginal supports may be helped by regular and continued use of the so-called Kegel exercises - contracting and releasing the vaginal floor muscles, approximately five contractions at a time, perhaps three or four times each day, building up to a total of about fifty contractions each day.

The labia majora and labia minora become flabby after childbirth. The other birth-related structures - ovaries, Fallopian tubes, and ligaments supporting the uterus - after undergoing such great tension and stretching, are now relaxed and take some time to return to what is close to their pre-pregnant size and position.

Abdominal Walls

The process of involution of the abdominal walls takes about six weeks. If the muscle tone has been retained, the abdomen will gradually return to its pre-pregnant condition. But if the muscle tone has been lost, the abdominal organs cannot be properly supported and a woman will give the appearance of still being several months pregnant.

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Very few women are able to fit into their regular clothes within the first few days following childbirth. Most find their abdomens are very much distended and flabby for three or four days. Still others take several weeks before they can adequately fit into non-maternity clothes. After subsequent babies, many women find that it takes even longer to fit into their regular clothing.

Obstetricians disagree on whether abdominal exercise begun soon after delivery can minimize flabbiness. Some believe exercise is useless until the natural process of involution has sufficiently reduced the abdominal muscle fibers; this takes about four to six weeks. Others in the health care field believe in the advisability of early, gentle abdominal exercises (e.g., pelvic rock, abdominal tightening and releasing) to reestablish muscle tone and control. Still others believe that the special exercises taught in prenatal classes and practiced during pregnancy go far toward building up and maintaining tone even after delivery.

Many women are afraid to use their abdominal muscles during pregnancy, mistakenly thinking it will hurt the baby. They allow these muscles to become weak due to disuse. If a woman does not use these muscles during pregnancy, it will be harder for her to regain muscle tone after delivery. Muscle tone can be restored to some degree by proper diet, good posture, and prescribed exercises. Do not, however, begin exercises - whether during pregnancy or after delivery - without your doctor's permission. During the postpartum period, begin only with mild exercises, building up intensity and frequency gradually in relation to your rate of recuperation. When you feel that you are really straining, you've had enough exercise for the time being. Try again several hours later or even the next day.

Bloody Discharge

After delivery of the placenta, a bloody discharge called “lochia” begins to be expelled from the uterus and continues for about two to four weeks. Lochia is made up of blood from the site where the placenta was attached, particles of the lining of the uterus now being discarded, and blood oozing from small superficial vessels. It takes six to seven weeks for the placental site to heal and half this time for healing of the rest of the uterine wall.

The color and consistency of the lochia changes from bright red (with some mucus and small blood clots) during the first three to five days, to a lighter reddish-pinkish brown flow over the next five to ten days. This then turns a yellowish-white and later becomes an almost colorless, watery discharge before it stops completely. Doctors advise the wearing of sanitary pads rather than tampons during this period. The use of tampons blocks the free flow of lochia from the vagina, thereby providing an environment for possible infection. Since the cervix may not have fully closed, infection can more easily enter the uterus.

The quantity of lochia varies with each woman, but tends to be less heavy in breastfeeding women. It is usually more profuse in women having their second or subsequent babies. The first time that you get out of bed after delivery, there will be an increase in the amount of flow due to the accumulation of lochia while you were lying down. In some cases, the duration of red lochia continues for as long as ten or more days; spurts of red lochia may recur during the weeks that follow. These episodes usually occur after urination, particularly in a woman who is not breastfeeding. If the lochia remains bright red for more than three weeks and if it becomes as heavy as the amount of blood lost during the first day of a menstrual period, your doctor should be consulted. If lochia does not begin to taper off, it might indicate the retention of small pieces of the placenta, or that your uterus might need additional stimulation in order to contract more strongly and seal off more uterine blood vessels at the placental site.

It is normal for the lochia to stop completely for a few days and then resume. However, if it has begun to taper off and darken, or if it has stopped completely for several days and then suddenly re-appears as a heavy red flow or gush - or if your lochia has been discharging steadily and there is a sudden heavy red flow or gush - perhaps you have been too active, moving furniture or lifting heavy items, running up and down stairs too often, or doing strenuous exercises. These can all interfere with the process of involution. If resting and cutting down your activities do not help, consult your doctor. Bleeding should taper off, not increase.

It can be frightening to pass blood clots if you do not know this can be normal and quite common. Sometimes, several clots, or one large clot several inches in diameter, can be felt as they pass through the vagina. Often, this type of loose clot is formed by blood that has accumulated in your vagina while lying prone; when you get out of bed, it comes out. If it is not accompanied by active or persistent bleeding, it is usually nothing to worry about. However, if such clotting is accompanied by such bleeding, it may be a sign that something is wrong. It may also mean that the clot had been blocking the blood behind it from coming out. If you are breastfeeding, a good first-aid action is to try breastfeeding the baby to see if the resultant contractions of the uterus decrease the flow of blood. If this heavy bleeding and/or passage of clots occurs, whether you are breastfeeding or not, you should consult your doctor. Meanwhile, remain in bed and check the number of sanitary napkins needed per hour. Your doctor may tell you that if you need more than one per hour, or if this heavy flow and passage of clots continues beyond six hours, you should consult him or her again.

After the lochia stops, you might notice the presence of a whitish or brownish mucous discharge which eventually lessens. Some amount of discharge keeps the vaginal mucous membrane moist and is normal in all women. However, if you notice a heavier-than-usual discharge, one with a foul odor, one that is yellowish, greenish, or frothy, and/or you have vaginal itching, you might have an infection and require medical treatment. In such instances, it is wise not to douche without your doctor's knowledge because, in some cases, douching can spread the infection higher up the vaginal canal and possibly (although rarely) into the uterus.

Breasts, Nipples, and Lactation

During pregnancy, the breasts become temporarily enlarged and require a richer blood supply in preparation for lactation. This explains the swelling of blood vessels supplying the area. After delivery, the breasts remain about the same size for approximately two days. Meanwhile, colostrums - a thick, yellowish pre-milk fluid - is secreted. During pregnancy, the hormone prolactin which is known to stimulate lactation is present in your body, but its effects are inhibited by high levels of estrogen and progesterone. The delivery of the placenta and the resultant complex hormonal changes initiate the lactation process. Colostrum is soon followed by milk which is bluish-white and appears thinner than cow's milk.

The day during which the milk “comes in” is, to some degree, determined by how soon after birth the baby is allowed to nurse for the first time and how often thereafter. Some claim that milk production can begin on the first or second day if the baby is put to the breast often and is receiving no other fluids. The reason that most people assume the milk does not come in before the third or fourth day is because most babies' feeding patterns are regulated by hospital nursery schedules, limiting the number of nursings and thereby postponing the mother's milk production. If the baby is encouraged to breastfeed soon after birth and often thereafter, milk may come in sooner.

The establishment of lactation is enhanced by the baby's continued sucking, which signals the pituitary gland to release more prolactin. The more the baby sucks and empties the breast, the more milk is produced. As the lactation process establishes itself, the breasts may become larger, extremely sore, hard, and warm or hot to the touch. Known as engorgement, this might last twenty-four to forty-eight hours and is caused by the pressure of increased blood in the area and increased milk in the ducts. Painful engorgement, which, according to some breastfeeding authorities, is caused by the four-hour hospital feeding schedule, can be relieved by manually expressing some milk from the breast. If engorgement advances to the point that it is accompanied by a headache and fever, it might be a sign of a breast infection and the doctor may prescribe an antibiotic (one that is not harmful to the baby) for a few days. While the mother takes such medication, she can and should continue nursing.

If you do not breastfeed, the lactation process will start by itself - even without the encouragement of a sucking baby - and you may find that your breasts engorge on or about the third or fourth day for twenty-four to forty-eight hours. Because there is no stimulation from the baby's sucking, milk production usually ceases within a few days. However, it would be wise for you to decrease somewhat the amount of liquids you drink because liquids encourage milk production. Do not, however, stop drinking entirely.

Since engorgement can be very uncomfortable, doctors recommend that you wear a firm supporting bra during this period. If you are not breastfeeding, binding the breasts and/or applying ice packs for brief periods of ten or fifteen minutes are often prescribed.

If you had received an antilactogenic hormone to “dry up” the milk, either by injection or pill, you may or may not be spared the discomfort of engorgement. Sometimes it works; sometimes it doesn't. If you were given this hormone in the form of an injection in the delivery room, you will probably be very aware of having received it because your hip area will feel extremely sore for days afterward.

After deciding not to breastfeed, and experiencing the fullness of your breasts and resultant leaking, you may have mixed feelings and wonder if your decision not to breastfeed was right after all. Should this occur, you can still change your mind, even after having received an antilactogenic hormone. Put your baby to your breast and the sucking will stimulate lactation.

Breastfeeding is a supply-demand situation. Babies who are given additional bottle feedings (either water or formula) have reduced need for sucking at the breast. This diminished amount of breast stimulation results in the decreased production of milk. Milk production is also affected if a woman fails to eat a well-balanced diet, does not drink adequate amounts of fluids, is under great stress, etc.

The supply of breast milk also depends on another factor. Although the milk is produced in the glands of your breast, it must be released from these glands into the collection area behind the areola (the dark area surrounding the nipples) and then out through the nipple. This release is known as the let-down, or milk-ejection, reflex and is essential to the nursing process. If your milk does not let down, the baby will be unable to obtain all the milk you have produced. Because, in the early weeks, the let-down reflex can be affected by too much activity, fatigue, or aggravation, it is important to intelligently limit your activities. Rest! While nursing, put your feet up or, even better, lie down and relax. Don't worry about everything that has to get done. It will - in time. Breastfeeding women needn't become bedridden; they just must be sensible about getting rest and not overtaxing themselves.

Nipples

Dried milk or colostrum which may accumulate on your nipples can cause irritation. Therefore, it is suggested that you rinse the area with warm water (no soap) before each nursing, or at any time that there is such an accumulation, whether or not you are breastfeeding.

Urination

Urinating after you give birth may feel somewhat strange. If you have had a regional anesthetic (caudal, spinal, epidural, saddle-block), you might be less aware of a full bladder and you may find it difficult to empty it completely until your sensitivity returns. If you are unable to urinate after several hours (time varying from hospital to hospital), a nurse will insert a catheter through your urethra into your bladder to withdraw urine. If you try contracting and releasing your pelvic floor muscles (Kegel exercise) a few times every fifteen or twenty minutes, you might succeed in stimulating urination without the need for catheterization.

Urinary Tract Infections

These occur often enough to warrant mention of their symptoms, which you should report to your doctor. They are: chills, fever, pain or burning sensation while urinating, urinating often and in small amounts, back pains or lower abdominal pains.

Bowels

Do not expect to have a bowel movement until the second or third day after delivery, at which time you might feel as though you are constipated. This may be because you had an enema during labor and/or hadn't eaten for several hours before the delivery. Also, after childbirth the intestinal and abdominal muscles are relaxed and do not assist efficient evacuation of intestinal contents. In addition, you might be avoiding a bowel movement, fearing it will be uncomfortable or put stress on your episiotomy sutures; this avoidance can lead to constipation. To prevent straining, we recommend that you drink more liquids. Since liquids stimulate milk production, you might want to encourage bowel function by eating fresh or cooked fruits, prunes, dates, raisins, figs, whole-grain cereals, bran, or leafy vegetables. Or, your doctor might prescribe a bowel softener (this is not a laxative) to be taken perhaps the evening of the second day after delivery. This softens the movement so there's no need for straining.

Hemorrhoids

The presence of hemorrhoids is a possible, although not probable occurrence after childbirth. Hemorrhoids are enlarged blood vessels which can pop out of the anus from the enormous pressure the baby exerts against the pelvic floor as uterine contractions push the infant through the birth canal. Hemorrhoids, which look more like swollen lumps of flesh than veins, can occur in a woman who is sedated during delivery and not actively bearing down, as well as in a woman who is awake and adding her own conscious bearing-down efforts to help deliver the baby.

If hemorrhoids do appear, you must be sure to avoid straining during bowel movements. Not only can straining cause more hemorrhoids to pop out, but the harder the bowel movement, the more it will irritate the existing swellings. Hemorrhoids can be extremely painful, and several treatments are recommended by most physicians:

1) Soak your entire bottom in the warm sitz baths available in the hospital. This is very soothing and promotes healing.

2) Tuck the hemorrhoid(s) back into the anus with your lubricated fingertip (be sure your fingernail is not too long or sharp) and contract your vaginal and anal muscles five to ten times.

3) Apply an anesthetic ointment.

4) Apply a special hemorrhoidal ointment.

5) Apply specially treated gauze pads available in pharmacies specifically for the treatment of hemorrhoids.

6) Apply your own gauze pads soaked in witch hazel. Some doctors recommend comfortably hot or warm sitz baths or applications; others advise cold witch hazel solutions.

In most cases, the hemorrhoids will regress about ten days after delivery.

Weight Loss

The amount of weight you can expect to lose immediately after delivery of the baby and placenta is approximately twelve pounds: about seven pounds of baby, about one and a half pounds of placenta, about one and a half pounds of amniotic fluid, and about two pounds of other body fluids and blood.

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You will lose approximately three more pounds in the following week as body tissues rid themselves of excess fluids. Approximately another two pounds will have been lost by the time the uterus returns to its usual two-ounce, pre-pregnant size. After the initial six weeks, weight loss continues gradually, depending on how carefully you eat and how much you exercise.

Hot Flashes

During the first few days after delivery, you may feel your face becoming red and hot. Called “hot flashes” or “hot flushes,” this condition is caused by the hormonal shifts occurring within your body.

Swelling Of The Perineum

If you've had stitches to repair an episiotomy, we recommend that while you are in the recovery room you request an ice pack to be placed directly on your perineum. You may leave the ice pack in place for about ten to fifteen minutes, take it off for fifteen minutes, and then repeat the procedure for the first few hours; then apply it every hour or so for fifteen minutes during the remainder of the first day. This helps to prevent the swelling of the perineal tissues which causes tension on the sutures and pain or discomfort for days or even weeks. We also suggest that you ask your doctor, before you give birth, if he will record on your chart his permission for the application of ice so the nurses will not tell you, “Sorry, your doctor didn't order it.”

We suggest that you try doing a few Kegel exercises in the recovery room, every fifteen or twenty minutes, to promote healing of the episiotomy by stimulating blood circulation in the affected tissues. It may be difficult to do at first, because the area may feel numb and/or weak, but that does not matter. Any mobilization of these muscles will help, and the more you try to exercise, the more strength and ability you will develop. Do not strain yourself. Concentrate on tightening your muscles a little at a time, resting for fifteen or twenty minutes and then doing it again two or three times more, if you are comfortable. Remember - do not strain.

Stretch Marks

After having a baby, some women are left with brownish or reddish stretch marks - called striae - on their abdomen, breasts, buttocks, or thighs. These gradually shrink and become paler within four to six months postpartum, but remain to some degree as pearly-white scars in white women and dark scars in black women. Striae are more noticeable in some women than in others.

Pigmentation

Increased pigmentation caused by heightened hormonal levels is common during pregnancy and might intensify the color of already dark areas of your body such as the genitals and around the nipples and the navel. You may also have developed some freckling or dark patches on your face, or, if you have any recent scars, you might notice they have become darker. Within a few weeks after delivery, when your hormonal levels decline, most of this pigmentation fades. Linea nigra - the dark line which appears on the abdomen during pregnancy and extends from the navel down to the pubic hair, also lightens in time.

Skin Changes

During pregnancy, it is also possible that you have noticed “spiders” - bright red, branch-like skin markings - on various parts of your body. These are actually distended capillaries just beneath the surface of the skin. They usually regress within two months after delivery.

“Skin tags” - pinhead-sized bumps that sometimes appear on the breasts, neck, or underarms during the prenatal period - grow a bit larger with each pregnancy and do not disappear. However, if necessary, they can be removed surgically or by cauterization (destroying them with an electric needle).

The redness of palms and soles of feet which may occur during the last three months of pregnancy and which becomes brighter after delivery is caused by increased blood volume and enlarged blood vessels. This usually disappears within two weeks after birth.

Hair

Increased hormonal levels might also cause unwanted hairiness on the body, which usually disappears within the first three months. About four to six months after delivery, many women experience the phenomenon of excessive hair loss from the scalp which is caused by hormonal imbalances. If this occurs, be assured the condition is temporary and usually lasts only a few weeks.

Emotions

The hormonal changes occurring immediately after delivery affect you emotionally as well as physically. Each woman who is awake and aware reacts differently at the moment of her baby's birth. Reactions vary depending on the hormonal shifts which occur and the sentimentality attached to being witness to and active during the birth event. Often, on the third or fourth day after delivery, women feel “let down,” blue, or slightly depressed.

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During the period of time following delivery, possibly even until your first menstrual period, you may experience swings of emotions from great heights of joy to great lows of sadness. Be assured that reasonable emotional extremes are normal and are brought about by the dramatic hormonal changes which have been taking place within your body. There need be no other explanation if anyone comments on your being moody, and you yourself need not analyze the situation any further.

Menstruation

After childbirth, when you resume menstruation depends on several factors. Most non-breastfeeding women menstruate six to eight weeks after giving birth. A breastfeeding woman will probably not menstruate for as long as she totally breastfeeds her child and gives no solids or formula. In addition, since ovulation is suppressed by total breastfeeding, it is unlikely, although not impossible, that she can become pregnant. Some women do resume menstruation even while totally breastfeeding their babies; therefore, there is a chance that ovulation - and pregnancy - may occur.

If menstruation does resume while you are breastfeeding, it has no effect on the quality of the milk, as some people believe. However, some babies have been known to be temporarily “turned off” to nursing while their mothers are menstruating.

While most women find their menses return soon after solids are introduced or the baby is weaned to a bottle, others do not menstruate for several months thereafter. It is also possible for a breastfeeding woman to menstruate and then skip a month or two. The menstrual cycle may be different from what it was before the baby. This irregularity generally occurs in a woman whose baby has just begun solids and whose output of breast milk varies. As solids are increased and breastfeeding is decreased, more normal menstruation resumes. If the baby gets sick or has teething pain and refuses solids, temporarily increasing the number and duration of nursings, menstruation may be temporarily suppressed once again.

The type of menstrual period you have the very first time after childbirth will depend on your rate of hormone production. Some women experience a comfortable bleeding-as-usual menstrual period; many others have a very heavy flow for several days, with or without severe cramps. If you are not sure whether or not your menstrual bleeding is excessive, try resting in bed for a day and keep track of the number of sanitary napkins you need per hour. lf the heavy rate of blood flow continues past six hours, or becomes heavier and requires a change of napkin more often than every hour, it is advisable to consult your doctor.

Postpartum Emergencies: When To Call The Doctor

  • Sudden heavy gush of red blood from vagina after flow has been stabilized, decreased and changed in color
  • Vaginal bleeding requiring more than one pad per hour for several hours
  • Large amounts of clots, all sizes, with accompanying heavy flow
  • Faintness
  • Dizziness
  • Extreme exhaustion
  • Severe back pain
  • Severe pain in the chest, lower abdomen, or legs
  • Malodorous vaginal discharge
  • Severe headache
  • Chills
  • Temperature of over 101° F

If Breastfeeding:

  • Sensitive or inflamed lumps in breast
  • Flu-like feeling accompanied by fever over 100° F, possibly engorgement and red areas on breast
  • Sore nipples that last more than a few days
  • Bleeding nipples
  • Pain during nursing that extends from the nipple into the breast and does not go away when the milk lets down

What To Expect As Normal: How To Deal With It

  • Chills, trembling immediately after delivery and perhaps lasting as long as thirty minutes (use warm blankets, hot-water bottle, Lamaze slow chest breathing)
  • Fatigue (get plenty of sleep)
  • Swings of emotions (accept your feelings)
  • Body aches (take warm showers and massage)
  • Backache (massage)
  • Heavier-than-usual lochia flow if more than usual activity (rest)
  • Leaking breasts, whether or not you breastfeed (wear gauze pads in your bra)
  • Burning or itching at episiotomy site, especially if you were shaved (cold witch hazel applications or ointment prescribed by doctor)
  • Numbness in area of I.V. infusion (warm, wet compresses)
  • Bruises from I.V. infusion (warm compresses)

Health | Reproduction | Pregnancy


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