Postpartum nursing care focuses on preventing and detecting complications (hemorrhage, infection, VTE, hypertension, mood disorders), promoting recovery and comfort, supporting infant feeding, and preparing the family for discharge. Postpartum care is an ongoing process: ACOG recommends contact with the obstetric provider within the first 3 weeks and a comprehensive visit no later than 12 weeks after birth.

Lactation physiology

• Prolactin (anterior pituitary) → milk production; levels rise with frequent, effective suckling
• Oxytocin (posterior pituitary) → let-down (milk ejection) and uterine contractions; triggered by suckling and even by the infant's cry; inhibited by stress and pain
• Supply and demand: milk removal drives production; infrequent emptying reduces supply
• Colostrum (first days) → transitional milk → mature milk (about 2 weeks)

Breastfeeding recommendations

• WHO and AAP (2022): exclusive breastfeeding for about 6 months, then continued breastfeeding with complementary foods for 2 years or beyond, as long as mutually desired
• Benefits for the infant: fewer infections (otitis media, gastrointestinal, respiratory), lower risk of SIDS, obesity, and diabetes. For the mother: less postpartum bleeding, lower risk of breast and ovarian cancer, hypertension, and type 2 diabetes

Contraindications to breastfeeding (few)

• Infant classic galactosemia
• Maternal HTLV-1/2, untreated brucellosis, suspected or confirmed Ebola, and use of illicit drugs such as cocaine or PCP
• HIV: US guidance now supports shared decision-making for people on antiretroviral therapy with a sustained undetectable viral load; otherwise breastfeeding is not recommended where safe replacement feeding is available
• Temporary: active untreated tuberculosis (expressed milk may be given), herpes lesions on the breast, some chemotherapy or radioactive drugs
• Most medications are compatible; check a lactation drug reference. Codeine and tramadol are avoided (ultra-rapid metabolism → infant respiratory depression)

Postpartum assessment (BUBBLE-HE) — breasts, uterus (fundus firm, midline), bladder, bowel, lochia, episiotomy/incision (REEDA), legs (calf pain, swelling), emotions and bonding; plus vital signs, pain, and fatigue.

Effective breastfeeding

• Wide open mouth, lips flanged outward, areola in the mouth (not just the nipple), chin touching the breast
• Rhythmic suck–swallow with audible swallowing; no pain after the first few seconds
• 8–12 feedings in 24 hours; feed on early hunger cues (rooting, hand-to-mouth, lip smacking) — crying is a late cue
• Adequate intake: by day 5–6, at least 6 wet diapers and 3–4 yellow stools per day; weight loss usually under 7–10%, with birth weight regained by about 10–14 days

• Hemoglobin after birth; blood type and Rh; rubella and varicella immunity
• Blood pressure checks after hypertensive disorders (within 72 hours for severe hypertension and by 7–10 days for others)
• Depression and anxiety screening at postpartum visits
• Infant weight and bilirubin as indicated

• Pain: ibuprofen and acetaminophen first line; opioids short-term and lowest dose if needed; local anesthetic sprays and witch hazel pads for the perineum
• Rh(D) immune globulin 300 mcg IM within 72 hours for Rh-negative, unsensitized mothers of Rh-positive infants (check first; larger fetomaternal bleeds need more)
• Vaccines: MMR and varicella if nonimmune (avoid pregnancy for 4 weeks); Tdap if not given in pregnancy; influenza and COVID-19 as indicated — all compatible with breastfeeding
• VTE prophylaxis by risk (mechanical; low-molecular-weight heparin for high risk)
• Contraception: plan before discharge. Progestin-only methods, implants, and IUDs can be started immediately; estrogen-containing methods are not started before 21 days in anyone (VTE risk); if breastfeeding, generally not before 30 days; and not before 42 days with additional VTE risk factors (US MEC 2024). Lactational amenorrhea method is effective only if all three apply: no menses, exclusive or nearly exclusive breastfeeding day and night, and infant younger than 6 months
• Lactation suppression (not breastfeeding): supportive bra, cold packs, avoid breast stimulation; bromocriptine is not used (stroke, seizures, MI)

Listed in priority order.

1. Hemorrhage prevention — fundus and lochia checks; massage if boggy; ensure voiding (a full bladder causes atony); quantify heavy bleeding
2. Vital signs and warning signs — fever, tachycardia, hypertension, hypotension, shortness of breath
3. Bladder care — void within about 6 hours of birth; palpate for distension before deciding on catheterization; try privacy, running water, and warm water over the perineum first
4. Infection prevention — hand hygiene; perineal care front to back after each voiding with a peri-bottle; change pads at least every 4–6 hours
5. Perineal comfort — ice packs for the first 24 hours (edema, pain), then warm or cool sitz baths; topical agents; sit on firm surfaces while squeezing buttocks together
6. VTE prevention — early ambulation (the main purpose), hydration, compression devices
7. After cesarean — incision care, splinting, early ambulation, incentive spirometry; avoid applying heat directly to a fresh incision
8. Breastfeeding support
   • Skin-to-skin and first feeding within the first hour; rooming-in; feed on demand
   • Help with positions: cradle, cross-cradle, football (clutch) — good after cesarean, side-lying
   • Break suction with a clean finger before removing the infant
   • Avoid bottles and delay pacifier until breastfeeding is well established (about 3–4 weeks); give no formula unless medically indicated
9. Breast problems
   • Engorgement: frequent effective feeding, hand expression to soften the areola before latch, cold packs between feedings, supportive bra, anti-inflammatory analgesia; a brief warm shower before feeding may help let-down (avoid prolonged heat, which can worsen swelling)
   • Sore nipples: correct the latch first; expressed milk or purified lanolin may soothe (neither is clearly superior — fixing the latch is the key)
   • Mastitis: continue breastfeeding (see Postpartum Infection)
10. Psychosocial support — encourage rest, involve the partner, screen for mood symptoms

Urgent maternal warning signs (AWHONN POST-BIRTH) — call 911 for: chest pain, obstructed breathing or shortness of breath, seizures, thoughts of hurting self or baby. Call the provider for: bleeding that soaks a pad in 1 hour or clots the size of an egg or larger, an incision that is not healing, a red, swollen, warm, painful leg, temperature 38.0 °C (100.4 °F) or higher, headache not relieved by medicine or with vision changes.

Breastfeeding and milk handling

• Feed 8–12 times a day; wake a sleepy newborn if more than about 3 hours pass (per guidance)
• Mothers may need extra fluids and calories; continue a prenatal vitamin
• Vitamin D 400 IU daily for breastfed infants
• Milk storage (CDC): room temperature up to 4 hours, refrigerator up to 4 days, freezer best within 6 months (up to 12 months acceptable); use thawed milk within 24 hours; never refreeze or microwave

Recovery

• Gradual return to activity; pelvic floor exercises; avoid heavy lifting after cesarean
• Sexual activity when bleeding has stopped, the perineum has healed, and the client feels ready — discuss contraception first; ovulation can occur before the first period
• Recommended interpregnancy interval: at least 18 months
• Keep the early postpartum contact and comprehensive visit; safe infant sleep on the back in the parent's room without bed-sharing

• Early ambulation prevents VTE
• Ice to the perineum first 24 hours, then sitz baths
• Assess the bladder — distension causes atony and bleeding
• Prolactin = production; oxytocin = let-down
• Exclusive breastfeeding about 6 months; continue 2 years or beyond (AAP 2022/WHO)
• 8–12 feedings/day; ≥ 6 wet diapers by day 5–6
• Engorgement: frequent feeding + cold between feeds
• Football hold after cesarean
• No estrogen contraception before 21 days (30 days if breastfeeding; 42 days with VTE risk factors)
• Contraindications: galactosemia, HTLV, illicit drugs; codeine and tramadol avoided
• POST-BIRTH warning signs; fever ≥ 38.0 °C (100.4 °F)