Birthing as a surrogate comes with unique feelings, challenges, and health concerns (1). You may find it comforting that despite its complex nature, many surrogates report experiencing a sense of purpose and joy (2, 3). There are still large gaps in research about how surrogacy affects the person carrying the pregnancy, children born through surrogacy, and the people who will parent the child (3).
Your health – both mind and body – are important as a surrogate. There are things that can be done to care for your whole self throughout this process. In this article we’ll cover what surrogacy is, to what to expect after giving birth as a surrogate.
What is surrogacy?
Surrogacy is a form of family building that is also a legal arrangement between a person with a uterus that becomes pregnant for another person(s) who will be the parent(s) after birth, usually called the intended parents (2, 4).
To conceive sperm, ovum (immature egg), and a uterus are needed (5). Artificial reproductive technology (ART) is often used during surrogate pregnancy (2). This means that either the sperm or sperm and egg are handled in some way by a healthcare provider during the process of trying to conceive (6).
There are two types of surrogate pregnancies. Traditional surrogacy is when a healthcare provider places sperm in the uterus of the surrogate (pregnancy carrier) to join with an egg from the surrogate’s own body (2). Gestational surrogacy involves healthcare providers joining sperm and egg in a lab and placing the fertilized egg in the surrogate’s uterus (2). Sperm and egg could be from the intended parents or from donors (2). This is the more common surrogate process (2).
Protecting your physical and mental health as a surrogate
The laws and regulations around surrogacy vary widely around the world and even in individual states in the USA. The amount of people seeking a gestational carrier outside of their country is growing (2). Cross-border reproductive care is healthcare provided to someone outside their own country focused on conceiving or the organs responsible for becoming pregnant (2). This can include surrogacy (2).
No matter where you are or where the person(s) you are partnering with is from, it is important for you to protect your physical and mental health as a surrogate. Talking with and receiving advice from a lawyer is one way of doing this (2).
A legal document (contract) that includes what you and the intended parent(s) have agreed to during pregnancy, birth, and after the birth is important (2). It should cover as many details as possible about anything that could happen and what you all agree should happen in those situations (2).
Your body after birthing
Body changes during pregnancy are obvious, but the changes postpartum (the time after birth) are often missed. There is no time limit on how long these changes last. Most people find that instead of returning to how they used to be, their body is adapting to a new normal.
There are many physical changes happening in the first few days after birthing, including hormone changes (7). There are a few things you can expect from your body postpartum:
Cramping, sometimes called “afterpains” is common in the first few days especially with breastfeeding (8). Heat and over-the-counter pain medications can help (8).
You may notice your belly takes a few weeks to decrease from its pregnant size (9).
During pregnancy, your abdominal muscles may have separated. This separation is in the middle of your abdomen and can be felt in a line starting a few inches above your belly button, moving down through your belly button to a few inches below your belly button (10). This separation (diastasis recti) can remain for months after giving birth (10). Exercises can help decrease this separation (11, 12).
If you had a c-section surgery, your incision on your skin should heal within two to three weeks (9). It is common to have some numbness or feel sore near the incision (9).
Vaginal bleeding after birth is called lochia (7). You can expect this to be like a heavy period the first few days (9).
A few clots can be occasionally expected, especially if you were sitting a long time and breastfeeding (9). Bleeding that soaks through one large pad in less than an hour or passing large blood clots is a reason to call for help (9, 13).
Bleeding should get lighter by 2-3 weeks and will slowly stop by 4-6 weeks (9). It is also possible to have light bleeding or spotting for up to 8 weeks (9).
It is best to not put anything in the vagina during the first weeks to help prevent infection (14).
After a vaginal birth, you may have tears in the skin or muscle of the vagina (7). No matter if you have a tear or not, your vagina may feel sore for a few weeks.
Using a warm water spray bottle (peri bottle) to clean after going to the bathroom can help with pain and prevent infection (8, 15).
Sitz baths or shallow very warm water soaks help with pain and decrease swelling (8).
Cushions, ice packs, over-the-counter pain medications, and numbing spray can increase comfort (8).
Vaginal tear pain should decrease over about two weeks(15). It can take up to six weeks for tears to completely heal (15).
Because of changes in the hormone estrogen your vagina may be more dry (9).
It might hurt when you pee the first few days postpartum (8).
Some postpartum people leak urine when they cough, sneeze, or with certain activities like running and jumping (16). This is called stress incontinence and is common in the first few months after birth (9).
You can do exercises to strengthen the pelvic floor muscles that support your bladder. These exercises are sometimes called Kegels (9).
Let your healthcare provider know if you continue to notice leaking beyond 4-6 weeks when you have your postpartum visit.
Your digestion may change after birth. Constipation is common, but most people poop by day four (17). There are a few things you can do to help decrease constipation:
Drink plenty of water, at least 8 large glasses a day (9)
Eating foods high in fiber like whole grains, leafy green vegetables, and fruits may help you avoid constipation (9, 8).
Stool softeners are often recommended to help prevent painful bowel movements in the first days postpartum (8)
Laxatives may be used, but talk to your healthcare provider first (17, 8)
Following up with your healthcare provider about your physical recovery is important after you give birth (18).
Health Emergencies after birth
Seek emergency medical care if you have any of the following (9, 13, 19):
Chest pain or shortness of breath
Heavy bleeding (soaking more than 1 pad per hour)
Fever (temperature above 100.4 F)
Incision not healing
Bad headache with vision changes or a headache that won't go away
Red or swollen leg that is painful or warm to touch
Thoughts of hurting yourself or someone else
Breastfeeding/chest feeding after surrogacy
How you care for your breasts/chest after birth depends on the plans you made with the intended parents before birth. After birth, your body is prepared to produce milk. Breasts can become large or swollen and full of milk 3-5 days after birth (9). This is called engorgement (8). If not managed, this experience can be emotionally and physically painful.
Without a baby feeding at the breast or removing milk with a pump, the body will eventually stop making milk (20). Medications can help suppress milk production, but might not always work any better than doing nothing (20). Some people find that cold ice packs, cabbage leaves, or binding breasts tightly can help with discomfort from engorgement (21).
Some surrogates choose to provide milk to the newborn by using an electric or hand breast pump. For more information on how to pump milk, La Leche League is a resource both online and in many local areas.
It is important to recognize signs of a breast infection, called mastitis (22). Breast infections are more likely to occur when milk stays in the breast for a long time (22). Milk may stay in the breast too long if you are not breastfeeding or pumping milk, or if you are not able to empty your breasts regularly (22). If you notice any fever or your breasts are red or hot, call your healthcare provider right away (22).
Breast infections often need to be treated with antibiotics (22). If left untreated they can develop into a breast abscess (22). Breast massage with pumping or feeding may help the pain and swelling go away faster (8, 23).
Returning to work after surrogate birth
Your body will be recovering from an intense physical process, even more so if you had surgery. The American College of Obstetricians and Gynecologists (ACOG) supports having six weeks of leave after birth (24). Generally a birthing person will be entitled to the same leave regardless of whether you are caring for the newborn.
Lost wages or unpaid time off after birth are often factored into surrogate contracts. However, these can be hard to predict. If you experience health problems after birth that require additional medical expenses or time off work, this could present challenges if your contract doesn’t cover unexpected problems postpartum (2).
Exercising after surrogate birth
When to start physical activity and how much is recommended often depends on the type of birth and what your previous exercise routine was before (25).
Exercising soon after birth is safe for most people (11). If exercise wasn’t a part of your pregnancy routine, gradually increase your activity rather than jump in too quickly (11).
It is recommended that people get 150 minutes of moderate activity per week postpartum (11). Ideally this would be spread throughout the week, for example 30 minutes of exercise, five times per week (25). Keep in mind, the goal for exercising post-birth is to feel well balanced and care for your body, not to achieve an unrealistic goal to get a “pre-pregnancy” body.
Sex and conceiving after surrogate birth
Healthcare providers commonly recommend waiting to have sex until after six weeks postpartum (26). This gives time for vaginal or surgical wounds to heal. Most people have a postpartum follow-up appointment with their healthcare provider by this time (26) and this is a good chance to talk to your provider about how your body is healing.
There is no set amount of time you have to wait to have sex (27). Once you feel physically and mentally ready and postpartum vaginal bleeding has stopped, it’s up to you when to have sex (9, 27). Some people may feel ready to have sex again before 6 weeks while others may not feel ready for much longer, and that is okay too.
Vaginal dryness due to changes in hormones, especially if you are breastfeeding or pumping, and tenderness while the vaginal tissues heal may impact your sexual desire (26). Don’t feel pressured to have sex before you or your body is ready. Talking with your partner about going slow the first time. Lubrication is helpful in making sex more comfortable (28).
It is possible to become pregnant within the first few weeks of postpartum (18, 29). This is why talking with your healthcare provider about birth control methods that are right for you is important (29). If you are considering becoming pregnant in the future, it is recommended to wait 18 months between pregnancies (29). Pregnancies less than six months apart increase the chance of complications like low birth weight and preterm birth (30).
Recovering from surrogate birth is more than just physical
Healing from pregnancy and birth is complex for every person, including the surrogate. You may experience many different emotions during the postpartum period (3). After giving birth it’s possible to experience depression and anxiety even if you are not parenting (4). The American College of Obstetrics and Gynecology (ACOG) recommends surrogates and intended families seek out mental health counseling separately (2). Your healthcare provider should screen you for postpartum depression at follow up visits, but if you have concerns don’t wait to get help (18).
If you haven’t been helped by your provider, tell someone you trust about what’s going on. Talking to a mental health provider after birth can help you process your feelings. It can be helpful to find a specialist in postpartum mood disorders or surrogacy.
If you have feelings of emotional distress, like intense sadness or hopelessness or thoughts of hurting yourself, call your healthcare provider immediately, seek emergency medical care, or reach out to a National Emergency Hotline (9). Having support from people in your life is important, support from other surrogates or joining a support group may work just as well as therapy for some people (31).
It is our goal to provide real resources that can offer help tailored to people’s specific circumstances. In the case of Surrogacy, we have been unable to find helpful online resources that are of a high quality and do not attempt to promote a service.
Books to read
Everything Conceivableby Liza Mundy
Labor of Love: Gestational Surrogacy and the Work of Making Babiesby Heather Jacobson