by Emily Oster
Lingering Consequences
A few days later, you’re home. The most immediate consequences—heavy bleeding, uncomfortable first pee, etc.—will be over.
You will not, however, feel normal.
First of all, you’ll still look pregnant. This appearance will subsist for a few days or weeks. Then you’ll just have a bunch of floppy skin. This does resolve eventually (by which I mean weeks or months later, not days), but it’s a little disconcerting to look down at. Even once the floppy skin is gone, many of us find we have what is referred to as “mummy tummy,” a pouchy stomach that doesn’t ever seem to quite snap back. I can find no literature on this, but I assure you it is a real thing that no amount of Pilates can get rid of (and by “no amount” I specifically mean one hour a week with Larry, whose other clients are mostly elderly women).
If you had a vaginal birth, the most significant lingering physical consequences are for your vagina. As one medical description puts it, “After birth, the vagina will be capacious.”2
Things will just not be quite the way they were before. You may have stitches; the whole area will be painful and just kind of off. It is not the vagina you are familiar with.
This does heal, but it takes time, and for most women, things don’t quite go back to the way they were before birth. (This doesn’t necessarily mean worse, just different.) And your vagina will definitely not be back to normal two weeks later. The rest of you might be feeling pretty normal at this point (minus the pudgy tummy, the exhaustion, and the enormous boobs), but this could also take longer—it took you forty weeks to stretch out, so it’s hard to rush going back.
With a caesarean section, your problems will be different. Depending on how it went down, you may have little or no vaginal trauma. As one friend with a scheduled C-section told me, “No one got anywhere near my vagina.” Not everyone is so lucky—if you got far into labor before needing surgery, you’ll have a recovery not dissimilar from a woman who’s had a vaginal birth. And every C-section, planned or not, is major abdominal surgery, meaning it will be painful to do anything that involves your abdominal muscles. This includes walking, going up stairs, sitting, picking things up, rolling over, etc. Everything you do just hurts.
Here’s an example: Say you’re in bed and you’re thirsty in the middle of the night. Your painkillers have worn off and you reach for your water. This is extremely painful.
The pain and discomfort will get better over time, but (on average) it will take longer to feel like you’re back to normal than if you’d had a vaginal birth.
Regardless of how you gave birth, it’s a good idea to have help, but this is especially important if you’ve had a caesarean. You need someone around who can help you get up, get to the bathroom, do the activities of daily life. Even if you can handle the baby on your own, someone needs to help handle you. Depending on your recovery, it may be a challenge to even lift the baby on your own for the first week or two. With a complicated caesarean (or even a complicated vaginal birth), it might be weeks before you feel like you can get up and shower alone.
With both vaginal and caesarean deliveries, there are other common, mostly minor, lingering consequences. Hemorrhoids, for example. Also, incontinence. Many women find that after childbirth, they pee a bit when they cough or laugh, or seemingly for no reason. This, like other things, will improve over time.
Women will have a wide range of experiences during recovery, regardless of how they gave birth. I had a very lucky draw with both my children. With Finn, I walked out of the hospital twelve hours later, carrying his car seat. But this isn’t the norm, and even then it wasn’t as if I was running a marathon anytime soon (or ever). Much of what determines your experience is luck, or some anatomy of your pelvis. Perhaps the most important thing is to ask for help when you need it, and not to expect so much. Many cultures have a tradition of women basically doing nothing for a month or so after birth, while older women in their family take care of them. This isn’t common in the US, but it does give a sense of what this time is like. Just because some fit-pregnancy blogger is back to CrossFit ten days after giving birth does not mean her recovery is typical.
Serious Complications
Post-delivery, some rare, serious complications can arise. These include excessive bleeding, dangerously high blood pressure, and infection. Risks vary across women—infection, for example, is a more common risk for women who have had a caesarean. Your doctor will likely tell you what to look out for, based on your own birth experience and any particular complications from it.
There are a few specific red flags to look out for:
Fever
Severe abdominal pain
Increase in bleeding, especially bright red blood
Bad-smelling vaginal discharge
Chest pain or shortness of breath
In addition, it is important to pay attention to any changes in vision, serious headaches, or increasing swelling (say, in your ankles), especially if you had or were at risk for preeclampsia.
These instructions can be hard to remember in the haze of new parenting, though. If something doesn’t seem quite right to you, call your doctor.
EXERCISE AND SEX
While you are struggling to roll over in bed for a drink of water, dealing with the world’s heaviest period, and also caring for someone who cries all the time, exercise and sex may not be your first priorities. On the other hand, exercise and sex were likely among your pre-birth activities, and in an effort to return to feeling like yourself, you may want to get back to them.
So despite the barriers, many of us do wonder, When is it okay to get back on the treadmill, or back in bed?
In the case of exercise, there is relatively little concrete evidence on when it is okay to start. The American College of Obstetricians and Gynecologists says that it is safe to resume exercise “within a few days” after a normal vaginal delivery. This isn’t to say you will be running interval workouts a week later, but some walking may be feasible.
They caution, though, that this will be different if you’ve had a caesarean or significant vaginal tearing. In the case of a caesarean, the standard recommendations include some walking within the first two weeks, introducing the possibility of abdominal curls or other related exercises by week 3 and a resumption of “normal” activities by around week 6.3 Again, healing rates differ from woman to woman, so this is really just an average.
In the case of vaginal delivery, where the issue is tearing, return to exercise should be even faster, with appropriate care taken to make sure you feel okay. Nearly all people—including elite athletes, but also recreational athletes and those of us who just walk or run for exercise—should be able to resume pre-pregnancy activity levels by six weeks postpartum and some modified version before that.
If you are an elite athlete, even a couple of weeks may seem like a long period to be off training, and depending on circumstances, it may be possible to work with your doctor to more quickly get back to training. But honestly, outside this group, the physical ability to exercise will probably arrive substantially before you are mentally ready to take advantage of it.
Once you can exercise, it can be challenging to find time in your schedule, but if it’s important to you, you should try. Exercise can help combat postpartum depression and generally improves mood. Yes, there are other demands on your time, but taking care of yourself also matters.
When it comes to sex after baby, there is a commonly accepted rule: no sex until six weeks postpartum, after you have had a checkup with your doctor. This is so often cited that I had assumed it was evidence based, that there was some biological reason why you need to wait this long, no more, no less.
In fact, this is completely fabricated. There is no set waiting period for resuming sex after giving birth. The six-week rule appears to have been invented by doctors so husbands wouldn’t ask for sex. Thi
s somewhat odd tradition persists. When I had my first postpartum checkup around six weeks after having Finn, the doctor (not my midwife, but the doctor who happened to be available that day) told me I was fine, and then asked if I wanted him to write me a note to tell my husband I was not. I found this very uncomfortable.
This is not to say there are no real guidelines for when you can resume having sex. Physically, if you have had tearing, it is important to wait until the perineum is healed. Depending on the severity of the tearing, this could happen much before six weeks, or it could take longer. Your doctor will check this at your first postpartum checkup (which is, in fact, around six weeks), but you may be able to tell if you’ve healed before that.
There are two other considerations. First, contraception: Even if you are breastfeeding and just had a baby three weeks ago, you can get pregnant. Most people do not plan babies ten months apart, so unless you have, make sure you are using some kind of birth control. (And think carefully about what type: some kinds of birth control, specifically some birth control pills, can interfere with milk production.)
The other consideration is, as the medical guidelines state, “emotional readiness.” You need to want to have sex. There is a tremendous amount of variation across women (and their partners) in when they feel ready to resume sex after giving birth. And you both need to be ready.
Birth is a very physical ordeal—even with a pretty easy birth, there will be physical consequences for at least a few weeks. Also, three or four weeks in, your family is likely to be exhausted. The baby may still be eating every two or three hours, and the idea of spending some of the time between feedings having sex, as opposed to sleeping or showering or eating, may seem laughable.
This is, of course, the standard story. But it is probably important to say that some people do want to have sex a few weeks later—and not just the non-birthing parents, either. If you are healed up and you want to have sex, go for it.
Looking at the data—which, in this case, may not be so helpful, since really the question is when you want to do it—most couples have resumed at least some sexual activity by eight weeks postpartum. For those with an uncomplicated vaginal delivery, the average is about five weeks, versus six weeks for caesarean and seven for those with significant vaginal tearing.4 Having said this, it takes an average of about a year to get back to pre-pregnancy sex frequency, and many people never return to having quite as much sex as they did before.
A final note: Sex after childbirth can be painful. Breastfeeding promotes vaginal dryness and lowers your sex drive. In addition, injuries during birth can have persistent effects. Many women, after having a small person attached to them nearly constantly, really do not want to be touched. Most women need some lubrication the first few times they have sex after giving birth to deal with vaginal dryness. And you want to take it slow at the start. And, of course, this all focuses on penetrative vaginal sex. Other activities—oral sex, either given or received—may be easier to restart, and could be more enjoyable early on.
Many women experience continued pain and discomfort during sex long after giving birth. This is not something you should ignore or grit your teeth and learn to live with. There are treatments that can help, including physical therapy. If sex is painful, talk to your doctor about it. If they’re not comfortable discussing it, find a doctor who is.
EMOTIONAL HEALTH: POSTPARTUM DEPRESSION, ANXIETY, AND PSYCHOSIS
So far, this discussion has dealt with the physical consequences of childbirth. But there are also often serious emotional consequences. Postpartum depression, postpartum anxiety, and even postpartum psychosis are common, to varying degrees. Too many women suffer from these conditions in silence, and this needs to stop.
In the first days and weeks after your baby arrives, you will experience a wave of hormones. Most women find they are emotionally sensitive during this period. This is not, for example, the time to watch the first fifteen minutes of the movie Up.
In thinking about this period, I recall our first outing, to a brunch at a friend’s house when Penelope was a week old. I spent two hours hiding in their guest room, nursing and crying. There wasn’t anything wrong; I just couldn’t stop crying. It was set off, I think, by the realization that the hat I had carefully knitted for Penelope was too large. And that once she did fit into it, it would probably be too warm to wear it. This was enough to sustain several hours of tears.
I’m lucky these were good friends, who brought me brunch on a tray. Of course, that only made me cry more.
This early experience is sometimes referred to as the “baby blues” and is self-limiting in the sense that the hormone surge is worst in the first few days after giving birth and dies down a couple of weeks later.
But true postpartum depression or other postpartum mental health conditions can crop up in this period. They can also arise later, even months later. Many women discount later-onset depression, thinking postpartum depression happens only right after the baby arrives. This is not the case.
The prevalence of postpartum depression, even if we focus only on diagnosed cases, is high. An estimated 10 to 15 percent of women who give birth will experience it.5 Most obstetricians are trained to look for depression during pregnancy, but, although less acknowledged, the data suggests that about half of these women actually experience the onset of depression during pregnancy, something many people are surprised to learn. Women are otherwise typically (although not exclusively) diagnosed with postpartum depression within the first four months.
There are some important risk factors for postpartum depression. These fall into two categories: predisposition and situation. By far the biggest risk factor for postpartum depression is predisposition, or prior experience of depression. Mental health isn’t as well understood as we would like, but there are clearly some genetic or epigenetic factors that affect it. If you’ve had episodes of depression before, they are more likely to crop up again in pregnancy or in the postpartum period. Be on the lookout for signs, and get help if you see them.
The other risk factors are largely about situation. Some of these factors are modifiable, some are not. Women (or men) who have less social support, who experience difficult life events around this time, or whose baby has medical or other problems are more likely to be depressed. And the baby itself can also play a role; people with babies who are poor sleepers are at greater risk for depression, almost certainly due to the fact that they, in turn, get less sleep.
How is postpartum depression diagnosed? Ideally, every woman is screened for this using a short questionnaire at their six-week postpartum visit. The most widely used questionnaire is probably the Edinburgh Postnatal Depression Scale, though a few others are common. Here it is:
EDINBURGH POSTNATAL DEPRESSION SCALE
In the past 7 days:
1. I have been able to laugh and see the funny side of things.
☐ Yes, all the time
☐ Yes, most of the time
☐ No, not very often
☐ No, never
2. I have looked forward with enjoyment to things.
☐ As much as I always could
☐ Not quite so much now
☐ Definitely not so much now
☐ Not at all
3. I have blamed myself unnecessarily when things went wrong.
☐ Yes, most of the time
☐ Yes, some of the time
☐ Not very often
☐ No, never
4. I have been anxious or worried for no good reason.
☐ Not, not at all
☐ Hardly ever
☐ Yes, sometimes
☐ Yes, very often
5. I have felt scared or panicky for no good reason.
☐ Yes, quite a lot
☐ Yes, sometimes
☐ No, not much
☐ No, not at all
6. Things have been getting on top of me.
☐ Yes, most of the time I haven’t been able to cope at all
☐ Yes, sometimes I haven’t been coping as well as usual
☐ No, most of the time I have coped quite well
☐ No, I have been coping as well as ever
7. I have been so unhappy that I have difficulty sleeping.
☐ Yes, most of the time
☐ Yes, sometimes
☐ Not very often
☐ No, not at all
8. I have felt sad or miserable.
☐ Yes, most of the time
