Afterpains and Postpartum Cramping

What afterpains are

Your womb spent nine months growing to many times its normal size. Now it has to shrink back, and it does that by contracting. Afterpains are those contractions, felt from the outside.

The HSE describes them exactly: "You may feel some painful cramps low down in your tummy as your womb gets smaller. They may feel like period pains. These are sometimes called after pains." ACOG uses the same framing: "After delivery you will feel your uterus contract and relax as it shrinks back to its normal size. This cramping also is called 'afterpains.' It may feel like menstrual cramps or even labor contractions."

The comparison to labour contractions is not an exaggeration. For some women, particularly after a second or third baby, afterpains are genuinely painful rather than merely uncomfortable.

Why they are worse when you feed

Because feeding is what triggers them. The HSE: "You may feel these pains are more severe when you breastfeed. This is because breastfeeding makes your womb contract, which helps it to return to a normal size." The NHS says the same from the bleeding side: "You may notice the bleeding is redder and heavier when you breastfeed. This happens because breastfeeding makes your womb contract. You may also feel cramps similar to period pains."

Suckling releases oxytocin, oxytocin makes the womb contract, and the contraction both hurts and shifts blood. So the cramp that hits about a minute into a feed, along with a gush onto the pad, is the mechanism working as designed rather than something going wrong.

What is normal

• Timing. The HSE says "these cramps should go away after a few days." ACOG notes afterpains "are more common during the first few days of breastfeeding."
• Worse with each baby. ACOG states it plainly: "Afterpains are more common in women who have given birth before." A womb that has been stretched several times contracts less efficiently, so it works harder and in bigger waves.
• Coming in waves. They tighten, peak and ease, rather than sitting as constant pain.
• Alongside heavier, redder bleeding during feeds. Expected, per the NHS.
• Other aches too. The HSE points out that after birth "you may feel pain in your joints, bones, muscles, ligaments and tendons," that your shoulder may hurt from feeding posture, and that your lower back or pelvis may feel tender. Not everything that aches postnatally is your womb.

Your midwife will be checking. The HSE: "Your midwife or doctor will examine you after the birth to check your womb is shrinking."

What is not normal

The distinction that matters is between cramping that comes in waves and settles over days, and tummy pain that is constant, severe, or getting worse. The second one is not afterpains.

The HSE's urgent list for postnatal tummy pain: contact a GP, midwife or public health nurse immediately if "the pain in your tummy is not getting better, is getting worse, or is severe — this could be a sign of infection." It puts severe muscle and joint pain on the same urgent list as a possible sign of sepsis, and calf pain that does not go away as a possible blood clot.

NICE's postnatal guideline (NG194) tells clinicians to treat "abdominal, pelvic or perineal pain, fever, shivering, or vaginal discharge with an unpleasant smell" as symptoms of potentially serious infection needing medical advice without delay.

When to call

Contact your midwife, GP or maternity unit the same day if:

• tummy pain is severe, constant, or getting worse rather than better
• you have a temperature over 38°C, or you are shivering
• your bleeding gets heavier, you pass large clots, or the discharge smells unpleasant
• you have pain in one calf that does not go away, or pain, swelling or redness in one leg

ACOG says to call 911 or seek emergency help right away for chest pain, coughing or gasping for air, seizures, severe pain in the lower abdomen, or pain, swelling and tenderness in the legs.

Book a routine appointment if aches and pains carry on for more than two months. The HSE flags that as the point at which they may be unrelated to the pregnancy and worth investigating.

What actually helps

The evidence here is modest and the advice is correspondingly simple.

• Heat. ACOG: "Applying a heating pad to your abdomen will help relieve this discomfort."
• Ibuprofen in preference to paracetamol. ACOG is specific for this symptom: "If you need to take an over-the-counter pain reliever, ibuprofen may work better than acetaminophen." On breastfeeding it says "ibuprofen is usually the preferred first step because little of it passes through breastmilk," and that paracetamol is also safe.
• Take it before a feed, not after. If afterpains peak during feeds, timing a dose so it is working when you sit down is more useful than taking it once the cramp has passed.
• Ask what you can take. The HSE: "Ask your midwife or doctor about what painkillers you can take to help with these cramps." The advice differs if you are on other medicines, so check with a pharmacist.
• Emptying your bladder often makes cramping easier, because a full bladder stops the womb contracting down properly.

NICE recommends that clinicians "consider using a validated pain scale" to monitor postnatal pain and discuss pain relief options taking breastfeeding into account. If your pain is not being taken seriously, that recommendation exists and you can point at it.

What to let go of

Afterpains being worse with a second or third baby is not a sign that something is wrong with this recovery compared with the last one — it is the expected pattern. Cramping during feeds is not a reason to stop feeding. And afterpains do not need to be endured silently: the fact that they are normal does not mean they should be untreated.