Recovery after childbirth

The postpartum period is commonly defined as the six weeks after childbirth. After your baby arrives, you’ll notice some changes — both physical and emotional. This is a very important time for both you and your newborn baby as you adjust to each other and your expanded family. In the first few hours and days after childbirth, you will experience many changes, both physically and emotionally. Over the next six weeks or so, your reproductive tract will slowly return to the way it was before you became pregnant. If you had a caesarean section, your recovery will be different from that of a vaginal delivery.

Your breasts, which began enlarging during pregnancy, will be filled with a special clear fluid called colostrum for the first few days after childbirth. At first when your breasts fill with colostrum and then breast milk, your breasts may become enlarged, firm, and painful. This is called breast engorgement, and it should disappear after a few days. Try to persevere with breastfeeding during this time, as breast milk is the ideal food for your newborn baby.

Some new mothers develop physical problems after childbirth. These may include infections, difficulty urinating, constipation, hemorrhoids, or other conditions. Prompt and appropriate treatment can help to alleviate discomfort and treat the problem.

You might feel irritable, indecisive, anxious, and prone to sudden mood swings after childbirth. This is called the “baby blues” and it usually lasts just a few days. Some women experience a depression that is so pronounced and continuous that it disrupts their normal functioning. This is called major depression or postpartum depression, and if left untreated, it can last for months. Early diagnosis and treatment is very important to the well-being of the mother.

What to expect physically

As your body recovers from pregnancy and childbirth, you may experience some physical changes including exhaustion, breast changes, urinary system changes, flabbiness and stretch marks.

If you do not breastfeed your baby, your period should return in about six to eight weeks; if you do breastfeed, if can return between two to 18 months after delivery.

You will have a postpartum check-up with your health-care provider at about four to six weeks after delivery.

Physically, you might experience:

• Sore breasts. Your breasts may be painfully engorged for several days when your milk comes in and your nipples may be sore.
• Constipation. The first postpartum bowel movement may be a few days after delivery, and sensitive hemorrhoids, healing episiotomies, and sore muscles can make it painful.
• Episiotomy. If your perineum (the area of skin between the vagina and the anus) was cut by your doctor or if it was torn during the birth, the stitches may make it painful to sit or walk for a little while during healing. It also can be painful when you cough or sneeze during the healing time.
• Hemorrhoids. Although common, hemorrhoids (swollen blood vessels in the rectum or anus) are frequently unexpected.
• Hot and cold flashes. Your body’s adjustment to new hormone and blood flow levels can wreak havoc on your internal thermostat.
• Urinary or fecal incontinence. The stretching of your muscles during delivery can cause you to accidentally pass urine (pee) when you cough, laugh, or strain or may make it difficult to control your bowel movements, especially if you had a lengthy labor before a vaginal delivery.
• “After pains”. After giving birth, your uterus will continue to have contractions for a few days. These are most noticeable when your baby nurses or when you are given medication to reduce bleeding.
• Vaginal discharge (lochia). Initially heavier than your period and often containing clots, vaginal discharge gradually fades to white or yellow and then stops within several weeks.
• Weight. Your postpartum weight will probably be about 12 or 13 pounds (the weight of the baby, placenta, and amniotic fluid) below your full-term weight, before additional water weight drops off within the first week as your body regains its balance.

If you had a normal vaginal birth, your body will still need time to recover from pregnancy and the birth. You may notice certain changes occurring in your body over the next six weeks. At your six-week check-up, your health-care provider will check to make sure you are recovering well, and you can ask them about any questions you may have about your health.

Recovery and medical care after normal vaginal birth

If you had a normal vaginal birth, your recovery and postpartum care should go through the following steps:

Blood pressure and pulse

After childbirth, your blood pressure should remain about the same as it was during labor, and your pulse will gradually decrease. A high or low blood pressure can be helpful in diagnosing potential complications such as hemorrhaging or hypertension. A fast pulse may be due to blood loss, anemia, fever, or shock. Your health-care providers will check your blood pressure and pulse periodically.

Blood loss

Most women lose about 500 mL (half a quart) of blood during and immediately after childbirth. Your body has been preparing for this by making extra blood in pregnancy. The amount of vaginal bleeding will be monitored. Because the risk of hemorrhage is greatest immediately after childbirth, a trained attendant will monitor you for the first hour or longer. The attendant will check your vaginal blood loss and whether your uterus is firm and well contracted. You will continue to lose blood at a slower pace for the next two weeks or so, and your body will bring its blood level back to its pre-pregnancy state. If you notice large clots, notify your health-care provider.

Vaginal discharge

You will have a vaginal discharge called lochia, which may be colored red with blood at first. Your health-care provider will monitor the amount and character of the lochia. After a week, the bleeding should gradually cease, and the lochia should be a white or yellowish color. You may have some bleeding on and off within the postpartum period. If you notice heavy or bright red lochia, with or without clots, notify your health-care provider right away.

Vaginal and perineal soreness

Your vagina will be sore and swollen after delivery, and there may be small tears in the vaginal wall. Your perineum, which is the area between your vagina and anus, will be sore and red, even if you did not have an episiotomy. Applying an ice pack to the area for the first 24 hours may help to reduce swelling and discomfort. To help you take care of your vaginal and perineal area, many hospitals will recommend the use of a squirt water bottle, to cleanse the area after passing urine or bowel movements. To reduce soreness and help in healing, try soaking the area in warm water for 10 to 15 minutes several times a day until the area is well-healed. You can do this just after feeding your newborn baby so you can relax in the bath knowing someone else can take care of their needs.

In the first few weeks after childbirth, your vagina will gradually become smaller. It will approach the size it was before childbirth, although it will never be quite that small again.

Exhaustion

At first, you will feel exhausted, and this exhaustion will last a few weeks. You need to be well rested in order to recover properly and to promote milk production. Also, extreme fatigue can make you feel frustrated and depressed. Try to make sure that you have support from your partner or another friend or family member, so you can rebuild your energy and take over more responsibilities. Limit visitors so that you can get your rest, and try to sleep when the baby sleeps.

Mobility

Within a few hours after childbirth, an attendant will help you to sit up and move around off the bed. Moving about early helps to increase circulation and reduce the risk of developing bladder complications, constipation, and other health problems.

Breast changes

Your breasts will become filled with a clear fluid called colostrum, which will gradually change over the next few days into breast milk. In the first few days, your breasts may feel quite engorged and your nipples sore. Ask your health-care providers to help you with breastfeeding so you can get off to a good start.

Uterine contractions

After you give birth, you might be surprised that your belly does not immediately shrink down. This is because your uterus is still quite large after childbirth. Soon, though, your uterus will start to rapidly contract and shrink. These contractions may feel like cramps, and are called “after pains.” The after pains will subside in a few days. Your health-care provider will monitor the size and consistency of the top of your uterus. Your uterus should be back to its pre-pregnancy size by about four weeks. By this time, it will have decreased to 10% of the weight it was just after childbirth. Your uterus will be about the size of your fist.

Narrowing of the cervix

Your cervix measures about the width of two fingers for a few days after childbirth. Within the next few weeks, the cervix gradually narrows and thickens. Your cervix might not become as narrow as it was before you gave birth.

Urinary system changes

At first, you may have some problems emptying your bladder, or with leaking. This may be due in part to certain types of anesthesia that were used during childbirth, or to trauma from the birth itself. It may be difficult for you to urinate at all. However, it is important that you urinate as soon as possible after giving birth, to help restore the tone of your bladder. You should also try to urinate every few hours so as not to overstretch your bladder. If you find it difficult to urinate, drink lots of water, run warm water on your perineal area with the water bottle, and turn on the tap water to provide the sound of running water. Your urinary system should return to normal in about two to eight weeks.

Flabbiness and stretch marks

Your abdominal wall will be flabby due to the stretching it received during pregnancy, and you may have a few silvery stretch marks. Exercise can help you to firm up your abdominal muscles after childbirth.

Sweating

You may notice excessive sweating soon after delivery, especially at night. This is generally associated with hormonal changes and the normal loss of blood volume after childbirth. Sweating is not something to be concerned about unless you also have a fever.

Having sex again

After a few weeks, if you have completely stopped bleeding and your doctor gives the OK, you can try having sex again. Don’t forget to use birth control because you can get pregnant again. You may feel tenderness at first, so try to relax as much as possible. Note that breastfeeding can make your vagina dry, and you may need a good lubricant to make intercourse more comfortable. Sometimes being on top can help, because you can control what happens during penetration.

Return of menstruation

If you do not breastfeed your baby, your period should return in about six to eight weeks. If you do breastfeed, your first period can occur anytime from two to 18 months after delivery. Ovulation is much less frequent in women who breastfeed, but it is still possible to get pregnant while breastfeeding.

Your six-week check-up

Most women have a postpartum check-up at about four to six weeks after delivery. During this visit, your health-care provider will check a number of things, including:

• blood pressure
• weight
• size, shape, and location of your uterus
• condition of your cervix and vagina
• incision sites such as those for episiotomy, tear repair, or caesarean section
• breasts

Usually a Pap smear and swabs are done at the same time to make sure everything is OK. At this point, you can also ask questions about your health, and discuss contraception options.

What to expect emotionally

Emotionally, you may be feeling:

• “Baby blues”. Many new moms have irritability, sadness, crying, or anxiety, beginning within the first several days after delivery. These baby blues are very common and may be related to physical changes (including hormonal changes, exhaustion, and unexpected birth experiences) and the emotional transition as you adjust to changing roles and your new baby. Baby blues usually go away within 1 to 2 weeks.
• Postpartum depression. More serious and longer lasting than the baby blues, this condition may cause mood swings, anxiety, guilt, and persistent sadness. Postpartum depression can be diagnosed up to a year after giving birth, and it’s more common in women with a history of depression, multiple life stressors, and a family history of depression.

Also, when it comes to intimacy, you and your partner may be on completely different pages. Your partner may be ready to pick up where you left off before baby’s arrival, whereas you may not feel comfortable enough — physically or emotionally — and might crave nothing more than a good night’s sleep. Doctors often ask women to wait a few weeks before having sex to allow them to heal.

Relationships and friendships after birth

Your emotional and sexual relationship with your partner might feel different in the early weeks after your baby arrives. For example, it’s quite normal to take weeks, even months, before you feel like having sex again. It’s OK to wait to have sex until you feel ready.

New friendships can open up after you have a baby. For example, many women join a mothers group in the first couple of months.

It can be comforting and reassuring to talk in person or online with other mums who’ve had a similar experience to you.

Baby blues

During the first week after childbirth, many women get what’s often called the “baby blues”. Women can experience a low mood and feel mildly depressed at a time when they expect they should feel happy after having a baby. “Baby blues” are probably due to the sudden hormonal and chemical changes that take place in your body after childbirth.

Symptoms can include:

• feeling emotional and bursting into tears for no apparent reason
• feeling irritable or touchy
• low mood
• anxiety and restlessness

All these symptoms are normal and usually only last for a few days.

Postpartum depression

In the first few weeks of caring for a newborn, most new moms feel anxious, sad, frustrated, tired, and overwhelmed. Sometimes known as the “baby blues,” these feelings get better within a few weeks. But for some women, they are very strong or don’t get better. Postpartum depression also called postnatal depression, is when these feelings don’t go away after about 2 weeks or make it hard for a woman to take care of her baby. Postpartum depression after a baby is born can be extremely distressing. Postpartum depression is associated with impaired bonding and development, marital discord, suicide, and infanticide ¹.

Postpartum depression is thought to affect around 1 in 7 to 1 to 10 women and can begin anytime within the first year after giving birth. While mom seeks help for her mental health needs, it is still possible to meet breastfeeding goals.

It’s not anyone’s fault or a weakness when a woman gets postpartum depression. Postpartum depression is treatable. Treatment helps most women feel like themselves again. Then they can enjoy having a new baby at home.

Nonsystematic reviews have indicated that the risks to children of untreated depressed mothers (compared to mothers without postpartum depression) include problems such as poor cognitive functioning, behavioral inhibition, emotional maladjustment, violent behavior, externalizing disorders, and psychiatric and medical disorders in adolescence ². These nonsystematic reviews reported the outcomes of these children from birth to adolescence. Other nonsystematic and systematic reviews have also explored specific maternal risks when mothers’ postpartum depression is untreated, including more weight problems ³, alcohol and illicit drug use ⁴, social relationship problems ⁵, breastfeeding problems ⁶ or persistent depression ⁷ compared with women who have received treatment. Nevertheless, there are no well-established systematic reviews of the overall maternal and/or infant outcomes of maternal postpartum depression. However, study results suggest that postpartum depression creates an environment that is not conducive to the personal development of mothers or the optimal development of a child. It therefore seems important to detect and treat depression during the postnatal period as early as possible to avoid harmful consequences ⁸.

The American Academy of Pediatrics ⁹ recommends pediatricians screen new mothers for Postpartum Depression at their baby’s 1, 2, 4, and 6 month well-child visit.

The screening tool most pediatricians use is the Edinburgh Postpartum Depression Scale, a 10-item questionnaire for mom to fill out.

The Edinburgh Postpartum Depression Scale is a simple, 10-question screen that is completed by the mother. A score of ≥10 indicates risk that depression is present ¹⁰. An affirmative response on question 10 (suicidality indicator) also constitutes a positive screen result ¹⁰.

The 2-question screen for depression is ¹¹:

• Over the past 2 weeks:
  • Have you ever felt down, depressed, or hopeless?
  • Have you felt little interest or pleasure in doing things?

One yes answer is a positive screening result. This screen is suitable to indicate risk of depression for adults in general and is not specific to postpartum depression. Beyond the postpartum period, incorporating surveillance for parental mental health is warranted as well and might be accomplished by use of this 2-question screen.

Figure 1. Edinburgh Postpartum Depression Scale

Postpartum depression signs and symptoms

Symptoms of postpartum depression can vary from woman to woman. But common signs include:

• feeling sad, hopeless, or overwhelmed
• feeling worried, scared, or panicked
• blaming yourself unnecessarily
• crying a lot
• feeling moody
• anger
• sleeping too much or too little
• eating too much or too little
• trouble concentrating
• not wanting to be with friends and family
• not feeling attached to the baby
• not wanting to do things that usually are enjoyable

Although it is very rare, some women have very serious symptoms such as:

• thoughts of hurting the baby or themselves
• hearing voices, seeing things that are not there, or feeling paranoid (very worried, suspicious, or mistrustful).

Who gets postpartum depression?

Postpartum depression can affect any woman — but some may be more at risk for developing it. Women who have had any kind of depression in the past (including postpartum depression) or who have a family history of depression are more likely to get postpartum depression.

Other things that might increase the chance of postpartum depression include serious stress during the pregnancy, medical problems during the pregnancy or after birth, and lack of support at home.

How does postpartum depression affects my baby?

There is no denying that a mother’s mental health is crucial—not just to her, but also to her baby. A depressed or anxious mom, however, may not be able to provide the nurturing that her baby needs to grow and thrive. She is less likely to read to, cuddle with, and interact with her baby—putting him or her at risk for a number of negative health outcomes, such as:

• Failure to thrive
• Delayed development
• Sleep difficulties
• Behavioral and emotional problems
• Learning problems

Note that sometimes these symptoms take years to show up. In addition, many studies have also found mothers with postpartum depression neglect to follow the American Academy of Pediatrics schedule of well-child visits and health care advice, including safety measures such as car seats and childproofing.

What causes postpartum depression?

Postpartum depression is caused by a combination of:

• hormonal changes that happen after a baby is born
• changes such as the loss of sleep and increased stress that come with taking care of a newborn baby

Postpartum depression diagnosis

A doctor or psychologist usually diagnosis a woman with postpartum depression based on her symptoms. Sometimes the woman herself notices the symptoms. Other times a concerned partner, spouse, family member, or friend notices the symptoms.

How is postpartum depression treated?

Treatment for postpartum depression can vary. It might include:

• counseling or talk therapy
• improving self-care (getting enough sleep, eating well, exercising, and taking time to relax)
• getting more support by joining a group or talking (by phone or online) with others going through postpartum depression
• taking medicine. There are medicines that are safe to take while breastfeeding.

Milder cases of postpartum depression can be treated with counseling. This can be given by the health visitor or a psychotherapist. More severe cases often require antidepressants and you may need to see a specialist.

It’s important to let your doctor know if you’re breastfeeding. If you need to take antidepressants, they’ll prescribe a type of medication that’s suitable while you’re breastfeeding.

Your local children’s center can put you in touch with your nearest postnatal group. These groups provide contact with other new mothers and encourage mums to support each other. They offer social activities and help with parenting skills.

Avoiding alcohol

Alcohol may appear to help you relax and unwind. In fact, it’s a depressant that affects your mood, judgement, self-control and co-ordination. It has even more of an effect if you’re tired and run-down. Be careful about when and how much you drink, and don’t drink alcohol if you’re taking anti-depressants or tranquilizers.

Postpartum depression recovery

Recovering from postpartum depression involves ongoing treatment, family support, education and coping skills as well as regular self-help practices. A full recovery from postpartum depression is almost always possible for anyone affected. Though no one can guarantee when it will go away, it eventually does pass.

The reason that postpartum depression recovery looks different to each person is that many different factors determine how you will recover. Some of these factors may include:

• The severity of the postpartum depression
• How soon you sought treatment after symptoms began
• The effectiveness of the treatment plan you are on
• Other life factors that are contributing to depression symptoms
• Past medical and mental health histories

Any of these factors will determine someone’s ability to recover and even the length of time it may take to recover.

While the process itself may be different for each person, there are certain practices that can help you effectively recover from postpartum depression. These include continuing medical support, implementing self-care practices, prioritizing diet and exercise and getting enough rest.

Tips for postpartum depression recovery

If you’re currently recovering from postpartum depression then here are some helpful tips to consider. These tips will help you to set realistic expectations about the recovery process.

• Don’t compare yourself to others: It’s natural to compare your story to others in order to try and make sense of your suffering. However, this can create unrealistic expectations and place more added pressure on yourself. Remember that your recovery process is different from others for any number of reasons and you cannot necessarily control the outcome.
• Forget perfection: You may feel a strong sense of needing to be perfect and not living up to this ideal can be hard. Instead, remind yourself that you’re doing your best and that’s all you can ask for.
• Include your friends and family: Suffering through postpartum depression alone creates a more difficult path to recovery. Avoid isolating yourself. Be sure to include your friends and family in your recovery process. This support will help improve your confidence.
• Adjust your treatment plan as needed: Remember that nothing is permanent when it comes to your postpartum depression treatment. If you feel that your treatment isn’t working, talk to your doctor to adjust it. It may be necessary to change medications or to include other types of therapies.
• Don’t rely on medication alone: While medication can dramatically improve symptoms, it shouldn’t be the sole approach to postpartum depression recovery. A holistic treatment plan that includes other well-being practices can greatly aid your recovery.

Ongoing doctor visits

As you recover, it is best to stay in communication with your doctor or a mental health professional. Communication with doctors shouldn’t end after a diagnosis is reached and treatments are prescribed.

Ongoing communication with doctors allows you to adjust your treatment plan as needed. It’s also a way for you to bring up any concerns you may have throughout your recovery. Seeing your doctor regularly can also provide a sense of support and understanding about your condition and symptoms.

Self-care and well-being practices

To help ensure a healthy recovery, it’s important for women to be proactive when it comes to self-care. While this can be difficult, it is important to look after yourself during this time.

Self-care practices can include meditation, yoga, journaling, prayer, deep breathing and anything else that calms the mind. Positive self-talk and reminding yourself of the temporary nature of postpartum depression can also help you during this time.

Ultimately, the goal of these self-care practices is to limit the amount of stress you experience. This is why it’s important to not take on any unnecessary responsibilities or commitments, as these can trigger anxiety.

Diet and exercise

Proper diet and exercise are important for everyone, but they are especially important for women suffering from postpartum depression. The food you eat can directly impact the symptoms you experience. If you are undereating or aren’t eating the right foods, it can worsen your symptoms. Nutritional deficiencies can cause fatigue, which further compounds feelings of sadness and irritability.

The amount of exercise you get can also directly impact postpartum depression symptoms — for better or worse. Without exercise, the body becomes weak and susceptible to illnesses that can aggravate depression and anxiety. Daily exercise, even in limited quantities, can go a long way to managing postpartum depression symptoms.

If you’re concerned about your diet and exercise habits as you recover, consult a professional to coordinate a diet and exercise plan that’s right for you.

Rest and relaxation

There is perhaps nothing more important during postpartum depression recovery than getting enough rest. Sleep deprivation is a terrible condition that can worsen postpartum depression symptoms. Without enough rest, the risk of becoming further depressed, anxious and irritable increases. A lack of rest also affects the immune system which increases your risk of illnesses and infections.

Ensuring that you are in a relaxed state is important so you get enough rest. Part of relaxation should include spending time in nature and getting outside frequently.

Postpartum depression recovery timelines

Due to the personal nature of postpartum depression, there is no definite recovery timeline. While most cases heal within one year after symptoms begin, many women might still experience postpartum depression symptoms years after their onset.

The most important aspect of ensuring the smoothest recovery possible is adhering to and adjusting your postpartum depression treatment plan. The more proactive you are in regards to your own health, the sooner you will likely recover from postpartum depression. Women who leave their symptoms unaddressed and untreated can suffer from long-term postpartum depression.

Postpartum psychosis

Postpartum psychosis also called puerperal psychosis, is extremely rare. Postpartum psychosis is a medical emergency. Women who have been diagnosed with bipolar disorder or schizophrenia before their pregnancy have a higher risk or getting postpartum psychosis but it can happen to any woman, even if they have not had a mental illness before.

You should get help as soon as you think you (or someone you know) might have postpartum psychosis. It can be frightening, but most women make a full recovery with the right treatment.

Only 1 or 2 mothers in 1,000 develop postpartum psychosis that requires medical or hospital treatment after the birth of a baby. Postpartum psychosis can develop within hours of childbirth and is very serious, needing urgent attention.

Other people usually notice it first as the mother often acts strangely. Postpartum psychosis is more likely to happen if you have a severe mental illness, a past history of severe mental illness or a family history of perinatal mental illness. Specialist mother and baby units can provide expert treatment without separating you from your baby.

Most women make a complete recovery, although this may take a few weeks or months.

What are the symptoms of postpartum psychosis?

Symptoms of postpartum psychosis include:

• being severely depressed and/or being manic – extremely energetic and talkative
• quick changes of mood (up and down)
• being restless and agitated
• being very withdrawn and not talking to anyone
• being very confused
• not sleeping
• racing thoughts
• hearing voices or seeing things that aren’t there (hallucinations)
• developing unusual beliefs (delusions)
• feeling things aren’t real (like you’re in a dream world)
• feeling paranoid and suspicious of other people
• behavior that is out of character
• feeling suicidal
• thinking about, and/or planning suicide, and sometimes thinking of taking your baby with you because of bad feelings about the world around you.

This is a list of all possible symptoms. If you have postpartum psychosis you may not have all these symptoms and they may change. You may not be able to look after yourself or your baby very well.

Who is more likely to get postpartum psychosis?

Postpartum psychosis is not your fault and isn’t caused by anything you have done. Some women develop postpartum psychosis even if they have never had a mental health problem before. However, you are at greater risk of getting postpartum psychosis if you have:

• had postpartum psychosis before
• had a diagnosis of bipolar disorder or schizoaffective disorder
• had a diagnosis of schizophrenia or another psychotic illness
• a mum or sister who have had postpartum psychosis.

Can anything be done to prevent postpartum psychosis?

If you have one of the mental health conditions mentioned above, you can have treatment that may prevent you getting postpartum psychosis.

Tell your midwife as soon as possible about your condition, even if you have been well for some time.

The midwife can refer you to a mental health service (ideally a specialist perinatal mental health service) so you can talk about what can be done to prevent you becoming unwell. They will also make a plan with you to make sure you stay as well as possible and get help quickly if you do become unwell.

You should be visited regularly by a healthcare professional after you have your baby so any symptoms can be spotted quickly.

It would also be helpful to share the list of symptoms above with others in your household (for example, your partner or a parent who is helping out) so that they can be watchful too.

How is postpartum psychosis treated?

You will normally be treated with medication. It’s essential to get treatment as soon as possible because if you get treated quickly you will usually recover well.

Most women need to be treated in hospital. Ideally, you should be offered a bed in a psychiatric mother and baby unit so your baby can stay with you. These are not available in every hospital so you may be admitted to a general psychiatric ward. If this happens your partner or family may need to look after your baby.

It can take 6-12 months or more to recover from postpartum psychosis.

Breastfeeding and medication

It is possible to breastfeed while taking some types of medications.You can talk to the doctor about the pros and cons of this.

Social services referral

If you have a high risk of developing postpartum psychosis in pregnancy or you develop it after giving birth you may be referred to social services. The referral will be discussed with you (unless you are too unwell).

Sometimes women worry that this means that people think they can’t care for their baby. This isn’t usually the case. In fact, asking for help and getting treatment is a good sign and shows that you are thinking about your baby’s wellbeing. It is very rare for babies to be removed from women with postpartum psychosis.

A social services assessment will:

• check what support you have from family, friends and professionals
• make sure there is safe plan for your baby if you are too unwell to care for him or her.

You may need extra help from family members while you are unwell and during recovery. Social services may be able to help if you don’t have any support. Social workers can find a temporary carer for your baby if you need to go into hospital and there is no place available in a mother and baby unit.

Postnatal post-traumatic stress disorder (PTSD)

Postnatal post-traumatic stress disorder (PTSD) is often the result of a traumatic birth, such as a long or painful labor, or an emergency or problematic delivery. It can also develop after other types of trauma, such as:

• a fear of dying or your baby dying
• life-threatening situations

The symptoms of postnatal PTSD can occur alone or in addition to the symptoms of postnatal depression.

The symptoms can develop straight after the birth or months afterwards.

It’s extremely important to talk to someone about how you’re feeling. Your midwife or doctor will be able help you. If you’re worried about talking to a health professional, consider asking a close friend or family member to come with you for support.

There are effective treatments available, such as cognitive behavioral therapy (CBT) and medications.

Assessment

Before having treatment for PTSD, a detailed assessment of your symptoms will be carried out to ensure treatment is tailored to your individual needs.

Your doctor will often carry out an initial assessment, but you’ll be referred to a mental health specialist for further assessment and treatment if you have had symptoms of PTSD for more than 4 weeks or your symptoms are severe.

There are a number of mental health specialists you may see if you have PTSD, such as a psychologist, community psychiatric nurse or psychiatrist.

How is post-traumatic stress disorder treated?

The main treatments for post-traumatic stress disorder (PTSD) are psychological therapies and medication. Traumatic events can be very difficult to come to terms with, but confronting your feelings and seeking professional help is often the only way of effectively treating PTSD.

It’s possible for PTSD to be successfully treated many years after the traumatic event or events occurred, which means it’s never too late to seek help.

Watchful waiting

If you have mild symptoms of PTSD, or you have had symptoms for less than 4 weeks, an approach called watchful waiting may be recommended. Watchful waiting involves carefully monitoring your symptoms to see whether they improve or get worse. It’s sometimes recommended because 2 in every 3 people who develop problems after a traumatic experience get better within a few weeks without treatment.

If watchful waiting is recommended, you should have a follow-up appointment within 1 month.

Psychological therapies

If you have PTSD that requires treatment, psychological therapies are usually recommended first. A combination of a psychological therapy and medication may be recommended if you have severe or persistent PTSD. Your doctor can refer you to a clinic that specialises in treating PTSD if there’s one in your area.

Or you can refer yourself directly to a psychological therapies service.

There are 3 main types of psychological therapies used to treat people with PTSD:

1. Cognitive behavioral therapy (CBT)
2. Eye movement desensitization and reprocessing (EMDR)
3. Group therapy

Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy (CBT) is a type of therapy that aims to help you manage your problems by changing how you think and act.

Trauma-focused CBT uses a range of psychological techniques to help you come to terms with the traumatic event.

For example, your therapist may ask you to confront your traumatic memories by thinking about your experience in detail.

During this process, your therapist helps you cope with any distress you feel while identifying any unhelpful thoughts or misrepresentations you have about the experience.

Your therapist can help you gain control of your fear and distress by changing the negative way you think about your experience (for example, feeling you’re to blame for what happened, or fear that it may happen again).

You may also be encouraged to gradually restart any activities you have avoided since your experience, such as driving a car if you had an accident.

You’ll usually have 8 to 12 weekly sessions of trauma-focused CBT, although fewer may be needed. Sessions usually last for around 60 to 90 minutes.

Eye movement desensitization and reprocessing (EMDR)

Eye movement desensitization and reprocessing (EMDR) is a relatively new treatment that’s been found to reduce the symptoms of PTSD. Eye movement desensitization and reprocessing (EMDR) involves making side-to-side eye movements, usually by following the movement of your therapist’s finger, while recalling the traumatic incident.

Other methods may include the therapist tapping their finger or playing a tone.

It’s not clear exactly how EMDR works, but it may help you change the negative way you think about a traumatic experience.

Group therapy

Some people find it helpful to speak about their experiences with other people who also have PTSD. Group therapy can help you find ways to manage your symptoms and understand the condition. There are also a number of charities that provide counseling and support groups for PTSD.

Medication

Antidepressants, such as paroxetine, sertraline, mirtazapine, amitriptyline or phenelzine, are sometimes used to treat PTSD in adults. Of these medications, only paroxetine and sertraline are licensed specifically for the treatment of PTSD. But mirtazapine, amitriptyline and phenelzine have also been found to be effective and may be recommended as well.

These medications will only be used if:

• you choose not to have trauma-focused psychological treatment
• psychological treatment would not be effective because there’s an ongoing threat of further trauma (such as domestic violence)
• you have gained little or no benefit from a course of trauma-focused psychological treatment
• you have an underlying medical condition, such as severe depression, that significantly affects your ability to benefit from psychological treatment

Amitriptyline or phenelzine will usually only be used under the supervision of a mental health specialist.

Antidepressants can also be prescribed to reduce any associated symptoms of depression and anxiety, and help with sleeping problems.

But they’re not usually prescribed for people younger than 18 unless recommended by a specialist.

If medication for PTSD is effective, it’ll usually be continued for a minimum of 12 months before being gradually withdrawn over the course of 4 weeks or longer.

If a medication is not effective at reducing your symptoms, your dosage may be increased.

Before prescribing a medication, your doctor should inform you about possible side effects you may have while taking it, along with any possible withdrawal symptoms when the medication is withdrawn.

For example, common side effects of paroxetine include feeling sick, blurred vision, constipation and diarrhoea.

Possible withdrawal symptoms associated with paroxetine include sleep disturbances, intense dreams, anxiety and irritability.

Withdrawal symptoms are less likely if the medication is reduced slowly.

Recovery after cesarean section

After your cesarean section, you’ll have some vaginal bleeding and soreness around your vagina or caesarean wound. You might also have afterpains and nipple or breast tenderness. That’s why the first week or so after birth is also a time for you to rest and recover as much as you can. You’ll stay in hospital for about 3-5 days. This can vary between hospitals. Sometimes it depends on how long your cesarean recovery takes.

In some hospitals you can choose to go home early in the first 72 hours and have your follow-up care at home. Ask the nurse or midwife about what your hospital offers.

A cesarean is major surgery, so it’s important to focus on caring for your baby and giving your body the rest it needs to recover.

Some communities have a tradition of the mother staying at home in the first six weeks after birth, and others don’t. Whatever your situation, taking it easy as much as you can and being kind to yourself are really important in these weeks.

If you see any signs of infection around your wound, see your doctor or midwife straight away. Signs of infection include pain, redness, swelling, smelly discharge or the wound coming apart.

Bleeding after cesarean

Even though you’ve had a cesarean, you’ll still have bleeding from your vagina after birth. This is normal bleeding from where the placenta was attached to your uterus.

To deal with the bleeding, you’ll need to have plenty of maternity sanitary pads handy, both in hospital and when you come home. You shouldn’t use tampons in the first six weeks after birth.

The bleeding might be quite heavy in the first week, like a heavy period. It might also be heavy after exercise, when you first get up in the morning and after breastfeeding. You might see some small blood clots on your pad. If you’re soaking through a pad in one hour or seeing lots of blood clots, tell your doctor, midwife or child and family health nurse.

After the first week, your bleeding should gradually get lighter and change from red to dark-red to brown to yellowish-white. You’ll probably be able to use regular sanitary pads around this time. You might have some bleeding for up to six weeks.

Check with your doctor, nurse or midwife if the bleeding gets heavier rather than lighter, you have a sudden heavy blood loss or large clots after the first few days, the blood smells bad, your uterus feels tender or sore, or you’re still bleeding after six weeks.

Pain relief after cesarean

In the early days, it’s OK to take pain relievers. Talk with your doctor about which pain relievers will be best for you, especially if you’re breastfeeding.

Some women find that basic things like coughing, laughing and showering can hurt in the first weeks after a cesarean.

Cesarean wound care

Your cesarean wound will usually be along or just below your bikini line. Very rarely it might be straight up and down your tummy. It will usually have dissolvable stitches or staples.

Keeping your wound clean and dry helps to prevent infection.

The wound will be covered by a waterproof dressing for several days, and you can usually shower with this on.

Once the dressing has been removed, you can gently wash your wound with water and dry around it with a towel. It’s best to leave it uncovered to ‘air dry’. Be especially careful if your wound is under a tummy fold because this will make it harder to keep dry.

Some bruising around the wound is common. Numbness or itching around the wound is common too. This can last a long time in some women.

Wear loose cotton clothing that doesn’t press on your wound.

It’ll take 6-10 weeks for your wound to heal completely.

Postpartum stitches healing

The abdominal incision will be sore for the first few days. Your midwife should also advise you on how to look after your wound.

Your doctor can prescribe pain medication for you to take after the anesthesia wears off. A heating pad may be helpful. There are many different ways to control pain. Talk with your ob-gyn or other health care professional about your options.

You’ll usually be advised to:

• gently clean and dry the wound every day
• wear loose, comfortable clothes and cotton underwear
• take painkillers if the wound is sore – see controlling pain
• watch out for signs of infection – see when to get medical advice

Non-dissolvable stitches or staples will usually be taken out by your midwife after five to seven days.

Your cesarean section scar

The wound in your tummy will eventually form a scar.

This will usually be a horizontal scar about 10-20cm long, just below your bikini line.

In rare cases, you may have a vertical scar just below your belly button.

The cesarean section scar will probably be red and obvious at first, but it should fade with time and will often be hidden in your pubic hair.

Controlling pain and bleeding

Most women experience some discomfort for the first few days after a cesarean, and for some women the pain can last several weeks.

You should be given regular painkillers to take at home, for as long as you need them.

Paracetamol is usually recommended for mild pain, co-codamol for moderate pain, and a combination of co-codamol and ibuprofen for more severe pain.

You may also have some vaginal bleeding. Use sanitary pads rather than tampons to reduce the risk of spreading infection into the vagina, and get medical advice if the bleeding is heavy.

What should I expect during recovery?

While you recover, the following things may happen:

• Mild cramping, especially if you are breastfeeding
• Bleeding or discharge for about 4–6 weeks
• Bleeding with clots and cramps
• Pain in the incision

To prevent infection, for a few weeks after the cesarean birth you should not place anything in your vagina or have sex. Allow time to heal before doing any strenuous activity. Call your Obstetrician–Gynecologist or other health care professional if you have a fever, heavy bleeding, or the pain gets worse.

If you experience severe mood swings, loss of appetite, overwhelming fatigue and lack of joy in life shortly after childbirth, you might have postpartum depression. Contact your health care provider if you think you might be depressed, especially if your signs and symptoms don’t fade on their own, you have trouble caring for your baby or completing daily tasks, or you have thoughts of harming yourself or your baby.

The American College of Obstetricians and Gynecologists recommends that postpartum care be an ongoing process rather than just a single visit after your delivery. Have contact with your health care provider within the first three weeks after delivery. Within 12 weeks after delivery, see your health care provider for a comprehensive postpartum evaluation. During this appointment your health care provider will check your mood and emotional well-being, discuss contraception and birth spacing, review information about infant care and feeding, talk about your sleep habits and issues related to fatigue and do a physical exam. This might include a check of your abdomen, vagina, cervix and uterus to make sure you’re healing well. In some cases, you might have the checkup earlier so that your health care provider can examine your C-section incision. Use this visit to ask questions about your recovery and caring for your baby.

Returning to your normal activities

Try to stay mobile and do gentle activities, such as going for a daily walk, while you’re recovering to reduce the risk of blood clots. Be careful not to overexert yourself.

You should be able to hold and carry your baby once you get home. But you may not be able to do some activities straight away, such as:

• driving
• exercising
• carrying anything heavier than your baby
• having sex

Only start to do these things again when you feel able to do so and don’t find them uncomfortable. This may not be for six weeks or so.

Ask your midwife for advice if you’re unsure when it’s safe to start returning to your normal activities. You can also ask your doctor at your six-week postnatal check.

Practical help after cesarean

It’s OK to ask for help at any time, especially in these first six weeks after cesarean. And family, friends and other people will probably appreciate you telling them exactly what you need.

For example, you could say, ‘Could you pick up some bread and milk on your way to visit today?’ Or ‘Thanks for offering to pick up some groceries, but I really just need someone to hang out the washing today’.

Check whether your hospital offers any home services to help with these jobs for a few weeks.

If you feel you need other support at home – for example, with breastfeeding – talk with your doctor, midwife or child and family health nurse.

Lifting, stretching and bending

You’ll definitely need some help with any jobs that involve stretching upwards, lifting or bending, because of the strain these activities put on your cesarean wound. This means you’ll need someone to hang washing on the line, do the vacuuming and help with any other strenuous household jobs.

Don’t lift any weight that’s heavier than your baby or anything that causes you pain – for example, a full basket of wet washing or your toddler.

If your toddler is used to being picked up, there are other ways for the two of you to be close. For example, she could sit next to you on the couch while you put your arm around her and read a story.

Driving

Doctors usually recommend that you avoid driving a car until your cesarean wound has healed and you can brake suddenly without feeling sharp pain. This is usually around 4-6 weeks. It’s best to talk with your doctor or midwife about when it’s safe to start driving again.

Check the policy of your car insurance company because some companies won’t cover you if your doctor hasn’t cleared you to drive.

Exercise, food and sleep after cesarean

A gentle walk each day can help your body and your mind feel better – for example, you could start with five minutes walking around your home. You might like to ask a physiotherapist at the hospital to give you some other good exercise ideas as you start to recover.

Healthy eating and drinking can help you feel better too. And foods that are high in fibre are good for avoiding constipation – these foods include cereals, fruits and vegetables. Drinking water will also help and is especially important if you’re breastfeeding.

Getting as much rest and sleep as you can is another top tip. Try to rest or sleep when your baby sleeps, and don’t feel guilty if the housework isn’t done – you and your baby are more important.

Breastfeeding after cesarean

You can try different positions for breastfeeding to find what’s most comfortable for you. Ask the midwives to show you different positions while you’re in hospital.

Positions you might find useful for breastfeeding after cesarean birth are:

• sitting with a pillow on your lap to support your baby and protect your wound
• lying down on your side
• holding baby underarm with baby’s feet towards your back – the ‘football’ position.

Your feelings after cesarean birth

Some women feel fine about having a cesarean, whereas others feel disappointed or sad that they weren’t able to give birth vaginally.

For women who have an unplanned (emergency) cesarean, the change in plan can sometimes be a shock. Whatever your feelings, they’re OK. But it can really help to talk through those feelings with someone you trust.

Your six-week check

Your health and your baby’s health will be reviewed at a six-week check-up with your doctor, midwife or child and family health nurse.

This is a good time to ask any questions you still have – for example, why you had a cesarean or what your birth options are if you have another baby. After any birth, it’s good to leave time for your body to heal between births.

Your doctor, midwife or nurse can also give you information on topics like family planning and baby development.

Cesarean section complications

A cesarean section is generally a very safe procedure, but like any type of surgery it carries a certain amount of risk of complications. The maternal mortality rate in the USA is approximately 2.2 per 100,000 cesarean deliveries ¹². Though this is overall low, it is significantly greater than for vaginal delivery. The maternal mortality for a vaginal birth is approximately 0.2 per 100,000 ¹².

It’s important to be aware of the possible complications, particularly if you’re considering having a cesarean for non-medical reasons.

The level of risk will depend on things such as whether cesarean section procedure is planned or carried out as an emergency, and your general health.

If there’s time to plan your cesarean section, your doctor or midwife will talk to you about the potential risks and benefits of the procedure.

Possible complications include:

• infection of the wound or womb lining
• blood clots in the legs, pelvic organs, or lungs
• excessive bleeding
• damage to nearby areas, such as the bowel or the bladder or the tubes that connect the kidneys and bladder (ureter)
• temporary breathing difficulties in your baby
• accidentally cutting your baby when your womb is opened

As with any delivery and with surgery in general, there is a risk of excessive bleeding during and after a cesarean section. Bleeding (hemorrhage) is the leading cause in the United States of serious maternal morbidity ¹³. Certain conditions preceding a cesarean, such as prolonged labor or fetal macrosomia or polyhydramnios, may increase the risk of uterine atony and subsequent hemorrhage. Intraoperative conditions such as the need for significant adhesiolysis or extension of the hysterotomy laterally into the uterine vessels could also lead to excessive blood loss. Hemorrhage during delivery may then lead to the need for blood product transfusion, which itself has risks of complications. Sheehan syndrome is a known complication of hemorrhage at delivery ¹³. Approximately ten percent of maternal mortality in the United States is secondary to obstetric hemorrhage ¹³.

As previously discussed, there is a significant risk of infection after cesarean delivery. In addition to postpartum hemorrhage, wound infection and endometritis are the other most common complications that occur after a cesarean section. In a study ¹⁴ examining the efficacy of vaginal cleansing, postoperative endometritis was reduced from 8.7% to 3.8% with cleansing. A study ¹⁵ investigating adjunctive azithromycin saw a decrease in wound infection from 6.6% to 2.4% with the additional antibiotic, and serious adverse events decreased from 2.9% to 1.5%. However, given that over a million women have a cesarean every year, these percentages still represent a significant number of women suffering from infectious complications.

In data reported in 2010, the overall risk of infectious morbidity was 3.2% in elective repeat cesarean deliveries as compared to 4.6% in women undergoing a trial of labor ¹⁶. This same data reported elective repeat cesareans to have a blood transfusion rate of 0.46%, a surgical injury rate of 0.3 to 0.6%, and a hysterectomy rate of 0.16% ¹⁶. Thromboembolism and anesthetic complications can also occur.

While the cesarean section often has the perception of being safer for the fetus, there are risks to fetal delivery in this fashion. The risk of fetal trauma during cesarean is approximately 1%, including skin laceration, fracture of the clavicle or skull, facial or brachial plexus nerve damage, and cephalohematoma ¹⁷. Overall, these risks are lower than in vaginal deliveries. With regards to the neonate, there are risks of respiratory complications as well as higher rates of asthma and allergy in those born via cesarean compared to vaginal delivery ¹⁶. In 2010 transient tachypnea of the newborn was reported in 4.2% of elected repeat cesareans, and the need for bag-and-mask ventilation was 2.5% ¹⁶.

In addition to short-term and surgical risks, cesarean delivery also confers long-term risk, both to the patient and to her subsequent pregnancies. As stated previously, the presence of a vertical scar on the uterus requires a woman to delivery subsequent pregnancies via cesarean. As the number of cesarean sections increases, so too do the surgical risks. Adhesion formation can make each subsequent cesarean more difficult and increase the risk of inadvertent injury. The risks of abnormal placentation also increase with each subsequent surgery. For a woman who has had one cesarean section, the risk of placenta accreta is 0.3%, while the risk increases to 6.74% with five or more cesarean deliveries ¹⁸. A morbidly adherent placenta carries with it a risk of significant hemorrhage and possible loss of fertility if a hysterectomy becomes necessary.

Risks to you

Some of the main risks to you of having a cesarean section include:

• infection of the wound (common) – causing redness, swelling, increasing pain and discharge from the wound
• infection of the womb lining (common) – symptoms include a fever, tummy pain, abnormal vaginal discharge and heavy vaginal bleeding
• excessive bleeding (uncommon) – this may require a blood transfusion in severe cases or possibly further surgery to stop the bleeding
• deep vein thrombosis (DVT) (rare) – a blood clot in your leg, which can cause pain and swelling and could be very dangerous if it travels to the lungs (pulmonary embolism)
• damage to your bladder or the tubes that connect the kidneys and bladder (rare) – this may require further surgery
• reaction to medications or to the anesthesia that is used

Women are now given antibiotics before having a cesarean, which should mean infections become much less common.

Risks to your baby

A cesarean doesn’t affect the risk of some of the rarest and most serious birth complications, such as an injury to the nerves in the neck and arms, bleeding inside the skull, or death.

But a cesarean section can sometimes cause the following problems in babies:

• a cut in the skin (common) – this may happen accidentally as your womb is opened, but it’s usually minor and heals without any problems
• breathing difficulties (common) – this most often affects babies born before 39 weeks of pregnancy; it will usually improve after a few days and your baby will be closely monitored in hospital

If you think your baby is experiencing breathing difficulties after you’ve left hospital, contact your doctor straight away.

Risks to future pregnancies

Women who have a cesarean will usually have no problems with future pregnancies.

Most women who have had a cesarean section can safely have a vaginal delivery for their next baby – known as vaginal birth after cesarean. But sometimes another cesarean may be necessary.

Although uncommon, having a cesarean can increase the risk of certain problems in future pregnancies, including:

• the scar in your womb opening up
• the placenta being abnormally attached to the wall of the womb, leading to difficulties delivering the placenta
• stillbirth

Speak to your doctor or midwife if you have any concerns.

Vaginal birth after cesarean section

If you’ve delivered a baby by C-section and you’re pregnant again, you might be able to choose between scheduling a repeat C-section or attempting vaginal birth after C-section (vaginal birth after cesarean section).

For many women, vaginal birth after cesarean section is an option. In fact, research on women who attempt a trial of labor after cesarean shows that about 60 to 80 percent have a successful vaginal delivery.

Vaginal birth after cesarean section isn’t right for everyone, though. Certain factors, such as a high-risk uterine scar, can make vaginal birth after cesarean section inappropriate. Some hospitals don’t offer vaginal birth after cesarean section because they don’t have the staff or resources to handle emergency C-sections. If you’re considering vaginal birth after cesarean section, your health care provider can help you understand if you’re a candidate and what’s involved.

Why vaginal birth after cesarean section is done?

Women consider vaginal birth after cesarean section for various reasons, including:

• Shorter recovery time. You’ll have a shorter hospital stay after a vaginal birth after cesarean section than you would after a repeat C-section. Avoiding surgery will help your energy and stamina return more quickly, as well as reduce the expense of childbirth.
• More participation in the birth. For some women, it’s important to experience a vaginal delivery. Your labor coach and others also may be able to play a greater role.
• Impact on future pregnancies. If you’re planning a larger family, vaginal birth after cesarean section might help you avoid the risks of multiple cesarean deliveries.

The chances of a successful vaginal birth after cesarean section are higher if:

• You’ve had only one prior low transverse uterine incision — the most common type for a C-section
• You and your baby are healthy and your pregnancy is progressing normally
• The reason you had your prior C-section isn’t a factor this time
• Your labor begins naturally on or before your due date
• You’ve had a previous successful vaginal delivery

The chances of a successful vaginal birth after cesarean section are lower if:

• Your pregnancy continues beyond your due date
• You have an unusually large baby — suspected fetal macrosomia
• You’ve had two or more cesarean sections

You’re not a candidate for vaginal birth after cesarean section if you had a uterine rupture during a previous pregnancy. Similarly, vaginal birth after cesarean section isn’t recommended if you have had a vertical incision in the upper part of your uterus (classical incision) due to the risk of uterine rupture.

Vaginal birth after cesarean section risks

Vaginal birth after cesarean section poses potentially serious risks, including:

• Failed attempt at labor. Labor can results in a repeat C-section.
• Uterine rupture. Rarely, the uterus might tear open along the scar line from a prior C-section. If your uterus ruptures, an emergency C-section is needed to prevent life-threatening complications, including heavy bleeding and infection for the mother and brain damage for the baby. In some cases, the uterus might need to be removed (hysterectomy) to stop the bleeding. If your uterus is removed, you won’t be able to get pregnant again.

How you prepare for vaginal birth after cesarean section

If you choose vaginal birth after cesarean section, boost your odds of a positive experience:

• Learn about vaginal birth after cesarean section. Take a childbirth class on vaginal birth after cesarean section. Include your partner or another loved one, if possible. Also discuss your concerns and expectations with your health care provider. Make sure he or she has your complete medical history, including records of your previous cesarean section and any other uterine procedures.
• Plan to deliver the baby at a well-equipped hospital. Close monitoring can decrease the risk of complications. Look for a facility that’s equipped to handle an emergency cesarean section.
• Allow labor to begin naturally, if you can. Drugs to induce labor can make contractions stronger and more frequent, which might contribute to the risk of uterine rupture — especially if the cervix is tightly closed and not ready for labor.
• Be prepared for a cesarean section. Some complications of pregnancy or delivery might require a cesarean section. For example, you might need a cesarean section if there’s a problem with the placenta or umbilical cord, your baby is in an abnormal position or your labor fails to progress.

What you can expect

If you choose vaginal birth after cesarean section, your prenatal care will be just like the care you’d receive during any other healthy pregnancy.

When you go into labor, you’ll follow the same process as any woman expecting to deliver vaginally — although you and your baby will be more closely monitored during labor. Your health care provider will be prepared to do a repeat cesarean section if needed.

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