Birthing persons experience a variety of body changes after giving birth, some of which fade with time and others that are more likely to be permanent. Temporary body changes include abdominal cramps, night sweats, pain from the incision site for c-sections, swollen breasts, swollen belly, hemorrhoids, mood swings, hair loss, and postpartum depression. Some changes that are more likely to be permanent are wider hips, stretch marks, scars from any incisions from delivery, varicose veins, and larger feet.
Cramping and Pain
The process of reproductive organs returning to their prepregnant state is known as involution. The uterus begins to contract shortly after delivery. Immediately postpartum, the uterus typically weighs 1,000 grams falling to about 500 grams by one week postpartum, and 50 grams at six weeks.1,2 After initial uterine contractions reduce the size of the uterus, involution begins. Involution includes autolysis and infarction of uterine blood vessels,3 and this is aided by hormonal shifts that lead to an increase in collagenase and proteolytic enzyme activities.4
Involution can result in abdominal cramping and pain, sometimes called afterpains, especially during breastfeeding and for those who have had more than one baby.5 There is minimal literature examining how long these cramps tend to last. A Cochrane review published in 2020 claims that afterpains may last 2-3 days.6 A review article from 2017 claims they last 2-4 days,7 and the introduction to a study published in 2021 claims they last 5-7 days,5 although none provide substantiation for these timeframes.
If the birthing person required an episiotomy or suffered a laceration during childbirth, they may experience discomfort in the perineal area until healing occurs and/or stitches are removed.8 A 1999 study of mothers who had given birth vaginally (n=5,404) found that 78% of those who experienced trauma in childbirth reported perineal or vaginal pain two days postpartum compared to 41% of those who had no trauma. That dropped to 43% at ten days for women who experienced a trauma and 10% for women with no trauma. At three months, 9% of women who experience a trauma still reported pain compared to 3% of women with no trauma.
Pelvic Floor Disorders
Pregnancy and childbirth can lead to weakening of the pelvic muscles, which can lead to pelvic floor disorders including genital prolapse, urinary incontinence, anal incontinence, and sexual dysfunction. A 2021 prospective multi-center study including 959 women within six weeks postpartum found that 62.6% reported constipation, 48.9% dyspareunia, 35.8% incomplete voiding, 33.8% stress urinary incontinence, 20.7% urge urinary incontinence, and 2.2% fecal incontinence.9
Pelvic floor exercises such as Kegel exercises can improve pelvic floor-related dysfunction. A 2013 meta-analysis of 14 randomized control trials (n=6,454) examined the effect of Kegel exercises on urinary incontinence postpartum.10 At six months postpartum, 22.6% of women performing Kegel exercises experienced self-reported urinary incontinence compared to 28.0% of controls (Odds Ratio [OR] 0.75, p<0.001).
Lochia
After delivery, whether vaginal or cesarean, birthing persons experience vaginal bleeding for 3-8 weeks, sometimes stopping and restarting. Lochia, defined as vaginal bleeding during the postpartum period, has traditionally been divided into three phases: lochia rubra (initial phase during which lochia is comprised of red-brown blood), lochia serosa (secondary phase during which lochia is brown-pink), and lochia alba (final phase during which lochia is yellow-white).11,12 Lochia begins as a flow of blood and rapidly diminishes to reddish brown, becoming lochia serosa within about four days postpartum.13 Lochia serosa, which lasts a median of 22-27 days, is mucopurulent and has been described as malodorous.
Sometimes there is heavier bleeding when the placental eschar sloughs 7-14 days postpartum.13 Myometrial vessels are present for up to two weeks postpartum and can cause short episodes of heavy bleeding for 1-2 hours. While bleeding or spotting for up to eight weeks after delivery is normal, if patients experience excessive bleeding, they should seek medical attention. There are no consensus statements or practice guidelines regarding the definition of excessive bleeding. ACOG’s Alliance for Innovation on Maternal Health (AIM) education initiative and the Center for Disease Control and Prevention (CDC)’s HEAR HER campaign list heavy bleeding as soaking through one or more pads in an hour or passing clots bigger than an egg, although neither of these resources substantiate these estimates. These definitions appears to be based on a 1999 study seeking to identify the characteristics of normal lochia that defined heavy bleeding as saturating a pad within one hour.12
Lactation and Breasts
During pregnancy, the body develops the ability to secrete milk, resulting in growth of the breasts.14 After childbirth, colostrum begins to secrete within an hour.15 Milk secretion starts within the first few days postpartum, with reported timing varying from 38-98 hours after birth.16 Lactation increases with the baby’s demands and similarly decreases as the baby is weaned.17,18 Breasts return to pre-pregnancy size by 15 months of lactation.18 Lactation can also involve the involuntary secretion of breastmilk, even beyond weaning, although this fades with time.19 The fast change in volume along with hormonal changes may cause softening of breast tissue and sagging breasts postpartum.20 This change is often permanent.
Lactation requires energy expenditure, leading to an increase in calorie expenditure varying based on many factors including height, weight, and level of activity.21,22 Caloric demand increases by an estimated 330 calories for the first six months of lactation and 400 calories for the second six months of lactation. Therefore, breastfeeding can lead to weight loss.
Nipples can become sore due to nursing with a variety of potential causes including incorrect positioning and attachment, ankyloglossia, infection, insufficient milk supply, mastitis, flat or inverted nipples, vasospasm, and palatal anomaly.23 Appropriate intervention can often resolve discomfort.
Menstruation
Timing for return of menses postpartum depends on duration of lactation.24 A 1998 meta-analysis found that among lactating women, the median duration of amenorrhea was 4-9 months, and longer duration was linked to longer duration of breastfeeding. A 2011 analysis of four studies found that nonlactating women experience the return of ovulation between 45-94 days postpartum. One third of first menses were preceded by ovulation, 70% of which were potentially fertile.25
Edema
Lower limb edema is common in the third trimester and postpartum due to increased plasma volume and retention of fluid as well as pressure on the venous system causing decreased return to the heart.26 A 2017 study (n=54) found that 77.8% of participants experienced edema in their feet and lower legs in the third trimester and during the 24-hour period following delivery.27 A 2011 prospective study of 41 Korean women found that intracellular water fell from by 2.42 kg and extracellular water fell by 2.28 kg from two days postpartum to six weeks postpartum for a total reduction in body water of 4.7 kg.28
World Health Organization practice guidelines state that edema improves for most women within a few months of giving birth.29
Hematologic System
Pregnancy is a hypercoagulable state, a physiologic response that helps to minimize blood loss during delivery.30 This state also increases the risk of pathologic embolism for 8-12 weeks into the postpartum period as the hematologic system returns to the pre-pregnancy state.31 A 2005 population-based cohort study using data collected over 30 years found that the baseline incidence of venous thromboembolism events (VTE) among nonpregnant, non-postpartum women of reproductive age was 0.46 per 1,000 person-years compared to 9.9 per 1,000 person-years during the first six weeks postpartum.32 Incidence normalized by three months postpartum. The risk of VTE is roughly twenty times higher in the early postpartum period compared to nonpregnant states.
Hematocrit also undergoes shifts in the early postpartum period.33 Although uncommon, it can drop due to blood loss during delivery, then rise due to fluid shifts and decreases in plasma volume. A 1996 study (n=12,397) found that only 7% of women delivering vaginally had low hematocrit (<27%) after delivery, with greater volume of blood loss associated with lower hematocrit. For those that experience a shift in hematocrit, return to normal hemoglobin may not occur for 4-6 months post-delivery.34
Gastrointestinal System
Constipation is very common during pregnancy but improves in the postpartum period.35 A 1995 study (n=1,249) found that 19% of women experienced constipation within two weeks of delivery, 20% at eight weeks, and 7% at 12-18 months postpartum.
Hemorrhoids are also very common during and after pregnancy. A 2014 prospective cohort study (n=280) found that 43.2% of pregnant women developed hemorrhoids.36 Hemorrhoids occurred most commonly during the third trimester and after delivery with symptoms mostly resolving within one month postpartum. Among those with hemorrhoids, 1.6% occurred during the first trimester, 61% during the third trimester, 34.1% in the first two days after delivery, and 3.3% in the first month postpartum. Another 2024 study (n=51) found that 15.7% of women experienced hemorrhoids in the first trimester, 27.5% in the second trimester, and 52.9% in the third trimester and six weeks postpartum.37
Pregnancy Belly
After delivery, the lower abdomen can return to prepregnant size, although how long this might take depends on a variety of factors including the time it takes the uterus to shrink, the time it takes for fluid build-up to abate, and lifestyle factors like diet and exercise. Generally, pregnant people can return to their pre-pregnancy weight withing six months of delivery, although without diet and exercise, people can fail to lose the weight gained during pregnancy.38
The presence of a slightly protruding abdomen in the postpartum period, colloquially called mommy pooch, is mostly attributable to diastasis recti abdominis, or the separation of the lower abdominal muscles by 2 cm or more.39 A 2016 study following 300 first-time pregnant women found that 45.4% had diastasis recti abdominis six months postpartum and 32.6% had it at 12 months postpartum. There’s little research on how long these lax abdominal muscles can last or effective interventions to aid with recovery.40 A meta-analysis of seven studies following participants for 6-16 weeks found that abdominal muscles moved 0.66-2.37 cm closer together, with most findings not reaching the threshold for significance and most studies rated as poor-quality evidence.
Skin and Skeletal System
Skin changes during and after pregnancy are not well studied, so there is little evidence to support how long these changes may take to resolve. Generalized reviews give time estimates, but they are unsubstantiated by incidence or prevalence data.
Up to 90% of pregnant people experience hyperpigmentation with unclear physiology.41,42 An American Family Physician practice guideline states that hyperpigmentation resolves with a few months postpartum.43
Stretch marks can occur due to the stretching of the skin during pregnancy, and these usually do not disappear entirely although they may become less visible over time. A 2015 cross-sectional study (n=905) found that new stretch marks, mainly in the lower stomach and breasts, appeared for 47.0% of pregnant women.41 Other vascular changes such as spider veins, varicosities, hemangioma, and granuloma were observed in 41.2% of pregnant women. These changes also may not resolve after the postpartum period.
Hair loss in the early postpartum period is common, also due to hormonal shifts. A 2005 cross-sectional study (n=905) found that 11.04% of women reported hair loss.41 An American Family Physician practice guideline states that hair growth returns to normal in 12-18 months.43
Greater pressure during pregnancy and the process of giving birth may also slightly widen hips, which usually does not resolve postpartum.44 Many women also report that their feet grow slightly, sometimes asymmetrically.45 Larger feet may not resolve postpartum.
Night Sweats
Night sweats may occur in the early postpartum period due to hormonal shifts. A 2020 study (n=229) of Japanese women found that 58.6% of women reported night sweats at three days postpartum falling to 33.1% two weeks postpartum and 15.2% one month postpartum.46 A 2013 study (n=429) examining hot flashes that disrupted sleep found that 20% of women reported these symptoms at two weeks postpartum, 14% at 12 weeks postpartum, 11% at 26 weeks, and 10% at 52 weeks.47
Mental Health
Hormonal changes can increase empathy and maternal attachment, colloquially known as mommy brain.48,49 These changes have been observed for two years following delivery but could possibly last longer. A 2024 study confirmed earlier reports of gray matter thinning and increases in white matter microstructural integrity that was global across the brain at two years following delivery, the end of the study’s observation period.49
Hallmark symptoms can include emotional lability, depressed mood, tearfulness, unstable mood, insomnia, and anxiety.50 It typically starts very close to birth and ends within two weeks. Symptoms lasting longer than two weeks or severe symptoms such as suicidal ideation are not part of the baby blues but instead are an indication of incipient postpartum depression or another illness.
Postpartum depression is a major depressive episode occurring in the postpartum period.51 The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) does not differentiate between depression and postpartum depression but rather uses peripartum onset as a specifier for major depressive episode, with the requirement that onset be during pregnancy or within the first four weeks postpartum, in effect combining postpartum depression and perinatal depression in this specifier.52
Postpartum depression is common – a 2018 meta-analysis of 58 studies found that the global prevalence of postpartum depression was 17% (95% Confidence Interval [CI] [0.15-0.20]).53 A 2013 study (n=9,998) found that at four and six weeks postpartum, 14.0% of women had depression as assessed by the Edinburgh Postnatal Depression Scale (EPDS, scored from 0-30 with scores of 10 or higher indicating a positive screen for depression).54 Minority women were more likely to have postpartum depression, with 19.4% of Black women, 18.9% of Asian women, 18.1% of Hispanic women, and 22.6% of those identifying as other having depression compared to 12.5% of white women. Among the 826 participants who accepted further diagnostic assessment, 40.1% experienced onset of depressive symptoms within four weeks after birth, 33.5% had onset during pregnancy, and 26.5% before pregnancy, meaning that the 14.0% incidence of depression represented a mixture of antenatal and postpartum depression cases.
It is difficult to know how long postpartum depression can last without treatment. One 2020 population-based cohort study (n=4,866) found that the mean number of participants with depressive symptoms (assessed using an abridged 5-item Edinburgh Postnatal Depression Scale [EPDS-5]) remained relatively similar from four months to three years postpartum (2.73% at four months, 2.42% at 12 months, 2.26% at two years, and 2.42% at 3 years).55
Postpartum depression is distinct from postpartum blues, colloquially called baby blues.50 Baby blues does not have a strict definition, but it is a common transient emotional condition that occurs early in the postpartum period. A 2020 systematic review and meta-analysis of 26 studies found that the estimated prevalence varies from 13.7% to 76.0%, with an overall aggregated prevalence of 39.0%.56 Despite its commonality, its pathophysiology is poorly understood.
Fatigue
Fatigue is common postpartum. A 2005 study (n=2,413) reported that 64% of women report fatigue 4-8 weeks postpartum.57 Postpartum fatigue can stem from a variety of factors from recovering from childbirth to sleep disruption from the newborn to postpartum depression.58 Depending on the cause, fatigue can last for varying amounts of time.
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