Postpartum: 4th Trimester

Newborn babyAround the world, the postpartum period is considered a special time—a time in which a mother is born, as well as a baby. Many cultures have special practices and customs that serve to recognize this very special time in the life of a woman: the postpartum period.

In many cultures, women are not expected to carry on their usual lives, but are revered and recognized for the new journey they are beginning.

POSTPARTUM TRADITIONS AROUND THE WORLD

In the Indian Ayurvedic tradition, new mothers stay at home and are pampered for 22 days after birth. This period of rest is considered vital to protect the delicate nervous systems of both mother and infant. Few visitors are allowed, and mother and child are protected from wind and bad weather.

In Japan, a new mother is treated as if she were the baby—she’s put to bed for 30 days, waited on, and indulged while she recuperates from the birth.

In parts of Southeast Asia, a father begins to collect wood during the pregnancy, stacking it in a special place, and reserving it for a practice called “mother-warming.” After the birth, the house is closed up and a sign on the front door announces the new arrival, letting the community know that the new family needs quiet time. The father lights a fire next to or beneath the mother’s bed, and she and the new baby are wrapped in warm blankets. Mother and baby are kept inside this womb-like environment, removed from the demands of daily life, and kept safe from wind and rain for several days or weeks, depending on the culture.

While Western countries do not have ceremonies or rituals quite like these, many do pay special attention to a new mother’s needs, particularly in Europe and Scandinavia. In Holland, for example, where many births take place at home, a specially trained live-in maternity nurse stays with the mother for the first 8 to 10 days. She reports directly to the midwife and keeps her posted as to the mother and baby’s progress. She also cooks, cleans, and helps take care of other children in the family. Until recently, women in the United States were encouraged to remain in bed for at least ten days after giving birth. Even the poorest women had friends and family to help around the house during the postpartum period.

POSTPARTUM ADJUSTMENTS

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The postpartum period needs to be treated as a special time, a time when women deserve extra care. Your mind and body are engaging in important work right now, whether or not you are consciously aware of it, including:

  • Physical Healing: It takes your body approximately six weeks to heal. During that period, postpartum bleeding completely stops. This is a time of unparalleled change in your body as your reproductive tract returns to its nonpregnant state. In addition, your cardiovascular, respiratory, musculo-skeletal, urologic, gastrointestinal, endocrine, and nervous systems all also return to a nonpregnant state. If you experienced perineal tearing or had an episiotomy, you may be experiencing pain that makes it difficult to sit down. If you required a cesarean, you need additional time for muscular healing, and may be recovering from loss of blood. Some practitioners think of the postpartum period as a “fourth trimester.” While some mothers feel “back to normal” at six weeks, others may require up to three months.
  • Learning to Breastfeed: If you’re breastfeeding for the first time—or even if you’ve breastfed several babies, it can take time to master this practice, and it can be emotionally frustrating.
  • Bonding: Most people still believe that mother/infant bonding happens immediately and completely, right after birth. Some lucky women do experience “love at first sight.” For others, bonding can take a week or more. In any case, bonding is an ongoing process that requires a tranquil postpartum period.
  • Hormonal Changes: While your hormones are hard at work helping every cell and organ in your body to return to their pre-pregnancy state, the fluctuating levels may leave you feeling vulnerable and fatigued. Until your body recovers, you may cry at the drop of a hat or feel an overwhelming sense of joy.
  • Dealing With New Emotions: Even if you have other children, you’re now faced with a completely new experience. The new sense of responsibility, your protective love for your new baby, and your fears for his health and safety can seem overwhelming—and you need time to adjust to these new emotions.
  • Adjusting to Relationships: No matter how well you’ve planned things, your relationship with your partner will undergo changes. Until you both adjust to the new situation, it can be stressful. If you have other children, you may feel guilty for taking attention away from them, or you may mourn the loss of the exclusive relationship you once had with an older child.
  • Starting the Process of Separation: For many months, you and your baby have been functioning as one. The postpartum period is the first step in a long and gradual process of separation that will carry on for many years. It may feel strange at first, and takes getting used to.
  • Learning New Things: While changing a diaper is not intrinsically difficult, it is new. So are a hundred other things about a new baby. How do you answer the telephone while breastfeeding? How do you bathe a baby? How can you schedule anything¾even reading the newspaper—when you don’t know when the baby will be sleeping? Unfortunately, you’ll be learning these new skills “on the job,” and it will take time to develop your own methods.

HIRE A POSTPARTUM DOULA

iStock_000006459298SmallThe benefits of hiring a doula to help you during labor and birth are well-documented and doulas can also help you in the critical postpartum period. If you used a labor doula, she might also be able to work with you after the birth—or you might decide to hire a specialized postpartum doula to complement the help of friends and families, or compensate for their lack of availability.

A postpartum doula is hired to care for the mother. She may change occasional diapers or give the baby a bath, if you need that kind of help (if you are recovering from a cesarean, for example), but her primary focus is to help you so that you can care for your new baby. Doulas range in experience and skills, but here is a short list of the basics you can expect from one:

  • Emotional support and encouragement.
  • Help with baby care and breastfeeding.
  • Advice on self-care, nutrition and postpartum healing.
  • Screening calls and visitors.
  • Light housekeeping, laundry, meal preparation, and errands.

If your partner is taking time off, you may feel you don’t need the services of a doula. While this may be true, partners may also need time to adapt to the new situation, and may not be experienced at caring for others while juggling the demands of a new baby.

It is best to line up the services of a doula ahead of time. However, if you realize that you need a doula during the postpartum period, don’t hesitate to call a doula service or ask a friend for a reference. Try to find a doula with skills that match your needs, for example, familiarity with vegetarian cooking or knowledge of your neighborhood.

Doula services vary in their fee arrangements. Some offer a package of postpartum care, while others require that you pay for a minimum number of hours. Ask for doula care as a shower gift.

EASING THE POSTPARTUM PERIOD

Newborn baby with motherYou may be on an adrenaline high right after the birth and may feel like you can conquer the world! This is not likely to last, however, and when your energy levels plummet, you may be discouraged. For this reason, it may help you to think of the first few days after the birth as your “lying-in” period, just as women did in olden times. Consider staying in bed for most of the first week. Dress in your pajamas to remind yourself to take it easy, and if you feel more energetic and are able to get up and do more, then you’ll be pleasantly surprised. Remember the adage: 5 days in the bed; 5 days on the bed; 5 days around the bed.

Here is a potpourri of tips to consider during the postpartum period:

  • Keep visitors to a minimum: Limit visitors to people who will help you or make you feel good, and set time limits on visits so you won’t be tired out. This may not be easy—you may be worried that you will insult others. This is the time to put your own needs first. Ask your partner or doula to screen calls and visitors if you’re not up to the task.
  • Stock up on nutrient dense food: Good choices include yogurt, eggs, beans, tofu, fish, chicken, sweet potatoes, leafy green vegetables, avocados, sunflower seeds, nuts, butter, hard cheese, whole grains, and fresh fruits. And, make sure you get plenty of good quality protein. You will need 500 to 700 calories more per day than when you were pregnant. Fat stored during pregnancy will provide for 200 to 300 calories daily for the first 3 months; the rest must come from your diet. You’ll also need more fluids. Plan on drinking ten 8-ounce glasses of water each day. Leave a glass of water of water bottles near the areas where you are likely to nurse during the day.
  • Redefine time: Jennifer Louden, author of The Pregnant Woman’s Comfort Book, refers to this period as living in “baby time,” This means that you’re now on the baby’s schedule, and will need to gradually re-learn time management. You’ll need to take life one moment at a time, and set realistic expectations for what you can accomplish. Resist the temptation to get too much done until you’ve had time to adapt to your new life.
  • Move around: While it’s important to get adequate rest, it’s also important to exercise once you feel ready. Exercise will speed healing and improve your mood. While you are still in the lying-in period, you can start to do simple movements in bed that will get your circulation going. Try rolling your ankles and wrists around. Stretch long like a cat, and then stretch each limb out, one at a time. Sit up in bed and let your head drop forward, like a heavy ball. Gently roll it from side to side to stretch out your neck muscles.
  • Don’t become isolated: Isolation is a problem most new mothers face. Once the deluge of visitors and the household helpers are gone, many women find themselves virtually alone. If you’ve been accustomed to adult company, this can be difficult. This is the time when a support system is critical. Breastfeeding support groups, mothers’ groups, and postpartum exercise classes can be terrific social outlets.
  • Communicate: Communication with other people is critical. So talk—talk to your partner, your girlfriends, your mother, other mothers, or a therapist. There’s a lot going on in your life now, and it’s important to communicate with others.

HEALING YOUR BODY

iStock_000016228020SmallIt isn’t just emotional changes that create postpartum strain and fatigue. Amazing physical changes have taken place as well. Your body went through an awesome transformation for nine months, culminating in the dramatic experience of birth. It will take some time for your body to return to its earlier state. In the meantime, you may experience the following symptoms:

Bleeding

You will continue to bleed for two to six weeks after the birth. This bleeding, or lochia, is the shedding of the lining of the uterus which built up during pregnancy. Bleeding should be moderate to heavy during the first three to five days after birth. You may also pass a few clots, some as big as an egg. As you near the second week postpartum, the bleeding will lighten to a watery brown color, and gradually over the next few weeks, it will become lighter and eventually stop.

Use disposable, unbleached menstrual pads, as these are the most hygienic. Avoid tampons, cloth menstrual pads or menstrual sponges during the first month.

Be cautious about doing any strenuous lifting, pushing or exercise, as these can cause bleeding to resume and postpartum hemorrhage can occur up to 30 days after birth.

Eat iron-rich foods during the first few weeks postpartum to compensate for any blood loss. Include red meat, dark-meat turkey, red beans, lentils, kale, collards, broccoli, raisins, black mission figs, apricots, and cherries.

Perineal Soreness

Whether or not you had an episiotomy or experienced tearing, your perineum will be sore from the stretching of the birth and you may experience some stinging pain. Here are a few techniques that will encourage healing of the area:

  • Sit on a doughnut or half-moon shaped pillow to avoid placing more pressure on the area.
  • Apply an ice pack to the area as often as you like. Leave it on for no more than 20 minutes at a time and take a break of at least 20 minutes.
  • Prepare a convenient, soothing sitz bath. Run warm water until the bath is just deep enough to cover your hip bones. Add 3 drops lavender essential oil and 3 drops cypress oil, and mix vigorously. Sit and enjoy! You can also double the amounts in this formula for a regular bath.
  • Keep some witch hazel or aloe, or a mixture of the two, in the refrigerator. Use a plastic squeeze bottle to apply to the perineal area as often as you like. This mixture will ease discomfort and encourage healing of the perineal tissues.
  • Apply some tea tree oil to the perineal area with a cotton ball or swab. You can dilute the tea tree oil with ¼ teaspoon almond or olive oil. Then sprinkle on a mixture of equal parts of goldenseal, comfrey, myrrh, and echinacea powders. Hold a warm washcloth on the area. This will help to reduce swelling and redness after a few applications.
  • When wiping after urination, you may want to just rinse with water or your plastic squeeze bottle solution, and dab or drip dry.
  • Do kegels. The kegel muscles are the support system for the muscles of the lower pelvis. Contracting them tones the muscles that support your uterus. Put one hand on your abdomen and one hand on your perineum. Contract your kegel muscles in the same way you do when you hold your urination. Contract these muscles carefully and slowly. Repeat 3 times a day the first week, adding two kegels each week until you’re up to 15. Don’t force yourself, and do less if that feels better.

Weight Loss

The birth of the baby, as well as the loss of placenta and fluids will result in an immediate (though relatively small) weight loss. At first, you may be discouraged to learn you’ve only lost 10 or 12 pounds, especially when your still-large belly, rather than being firm, as it was during pregnancy, is now soft and jelly-like. Don’t despair—you will begin to lose weight relatively quickly, especially if you are breastfeeding. Producing breastmilk will consume about 30 percent of the calories you take in. In any case, it’s healthiest to lose the weight gradually, just as you gained it gradually, and this will occur naturally over the first nine months of your baby’s life.

Energy Levels

Your body needs plenty of rest in the first few weeks after birth. Your energy levels will return gradually after the six-week mark. Until then, consider the fatigue a message from your body saying “Rest.”

For more on the postpartum period, see Ayurvedic Postpartum and Tips for Postpartum Blues.

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PEGGY-headshotPeggy O’Mara is the editor and publisher of peggyomara.com. She founded Mothering.com in 1995 and was its editor-in chief until 2012. She was the editor and publisher of Mothering Magazine from 1980 to 2011. The author of Having a Baby Naturally; Natural Family Living; The Way Back Home; and A Quiet Place, Peggy has conducted workshops at Omega Institute, Esalen, La Leche League, and Bioneers. She is the mother of four and grandmother of two.

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About Peggy O'Mara

Editor and Publisher of peggyomara.com. Longtime natural living advocate, award winning writer, and independent thinker.

38 thoughts on “Postpartum: 4th Trimester

  1. Alisa

    I had the most horrific experience in the fourth trimester, my husbands mother came to “help” us after the birth. She came with her old school belief system and nearly drove me insane, I couldn’t find peace and eventually I asked her to leave, this caused a huge problem between my husband and me, the whole month after my son was born was a disaster, except the first three wonderful days before she came. I still regret thinking that I would not be able to handle it alone, especially after making it through a home birth without even a tear. I would sit and cry and not let them in to the room where I was breastfeeding, otherwise she would stand over me and stare and tell me I was holding him to long and that babies suffocate sometimes during breastfeeding, I mean crazy stuff. it was a nightmare I still cringe when I think of that time. I wish I could take it all back and enjoy the amazing experience of motherhood without that paranoid woman next to me.

    Reply
    • Nicole

      I understand exactly how you feel especially since I have much the same experience as you. My husband’s mother moved in in the name of “helping with the baby” and they both have driven me crazy about my decisions concerning my son and my best hurts so much that I could not truly enjoy the first few weeks of being a first time mom. I would hide in my room all day done days just to be away from them.

      Reply
  2. amy

    I love this….except for the examples of nutrient dense foods. I was a vegetarian and Mothering Magazine subscriber after the births of my first two children and tofu did not sustain me. In fact, it contributed to my getting kidney stones and extreme postpartum lethargy. I have since become a member of the Weston A Price foundation and have found their recommendation for nutrient dense foods extremely helpful. My third birth was a completely different story and I have never felt better eating these nutrient dense foods and no unfermented soy. Here is the link to their prenatal and nursing diet recommendations: http://www.westonaprice.org/childrens-health/diet-for-pregnant-and-nursing-mothers?qh=YToyOntpOjA7czo5OiJwcmVnbmFuY3kiO2k6MTtzOjExOiJwcmVnbmFuY2llcyI7fQ%3D%3D

    Reply
  3. Amanda

    I’m pretty tired of the myth of breastfeeding weight-loss being spread around. Before I was pregnant, I was 130 lbs and a size 4. I got up to 170 during 42 weeks of pregnancy and left the hospital weighing 182 (I got to have way too many IV fluids while I was there.) It has taken me two years just to get to 160 and a size 10. I’m still nursing and ravenous all the time. Even when I try to diet, the weight simply won’t move. I’ve spoken to many professionals about this and they all agree that it is due to my breastfeeding. I know I’m not alone as I have many mother friends and it’s far more common for them to be heavier while nursing than to drop weight from it.

    Reply
    • Lilie

      This happened to me. But after my second (my first breastfed until well into my second pregnancy) would sleep through the nigh immediately, my milk dried up. For a few weeks I lost a ton of weight and was back to a size 4 (never thought I’d get there again). But then I got pregnant and am back to a 6 or 8 now. I think I made it to a 10 during my second pregnancy. This gave me so much hope. It seems my body wants to keep the weight on because it knows I am sustaining another life. I never felt like my body was mine during these pregnancies and breastfeeding. Only for the 2 weeks after drying up and getting pregnant.

      Reply
    • Ann G

      Agreed! I’ve been nursing for six months and I still weigh the same as when I came home from the hospital. I eat a healthy diet and exercise.

      Reply
  4. Lucy

    I love this article. It´s really very nice and so true.

    I think losing weight while nursing is individual. I gained 10kilos during my second pregnancy, when I was leaving hospital I had only 3,5 and after one month of nursing I had the weight I had had before pregnancy. I did not do any exercises, nor was on any diet.

    Reply
  5. Patti Ashley

    Peggy, this is beautiful, informative and nurturing. I work with mothers and families in my psychotherapy and parent coaching practice in Boulder. I will definitely share this with them. I have just finished a book for mothers that helps open up the conversation about the truth of being a mom, entitled Living in the Shadow of the Too-Good Mother archetype, scheduled to be released by Wyatt-MacKenzie Publishing on March 17, 2014. I would love to share an advanced review copy with you if interested. http://tinyurl.com/TooGoodMotherSellsheet Patti

    Reply
  6. Lyn Stark

    Peggy, this is such a wonderful article full of excellent information and very practical advice. It thoroughly covers the topics essential for new families to know and understand over this very precious and often challenging time. As a practising midwife, having provided full case loading care for women for the last 17yrs, (antenatal/birth to 6wks postpartum, some home but most births in a small primary unit and ranging from 4-6hr to 2 day stays) I believe this is a ‘must read’ for women and families. It certainly summarises my thoughts, experience and advice, plus extra. Your wise words help explain, prepare, advise and offer understanding of the ‘invisible umbilical cord’ and 4th trimester experience very comprehensively. Thank you.

    Reply
  7. Denise Hynd

    I saw that it really does ‘take a village to raise a (happy, confident) child ‘ when I worked in provincial Papua New Guinea in 1980! So I agree with much of what you say and love the practical ideas and loving intent, though it is sad that we need to talk about hiring a doula as other nations have not followed the Dutch maternity system approach and most people no longer live in a village (or aco-housing community) We need to acknowledge that bonding starts even before a woman becomes pregnant as she day dreams about her future mothering! But sadly all the testing in pregnancy (and the interventionist deliveries today makes even healthy women question their bodies ability to grow or nurture a child disturbs this early connection. Especially Ultrasound though presented as a means to connect with the baby, is really a disturbing (for mother as well as baby), invasive tool which original research said should only be used when there is clinical indication. Midwives and others need to promote and protecte physical and emotional connection between mother and baby during the pregnancy as it is essential for an instinctive birth and the foundation for ongoing relationship. Also an understanding of physics and bodily mechanics says that sitting on a doughnut or half-moon shaped pillow can place greater pressure on parts of the perineal region.

    Reply
  8. Krit

    I don’t believe the thing bout breast feeding nd weight loss…. I breast fed both my girls second I was 140-150 pounds nd went up to 170-180 or so at end of pregnancy… She is now 17 months nd I am bout 130 or just under….

    Reply
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  20. Emilie McVey of Mothercare

    Yes! You expressed so well what I’ve been trying to help mothers (fathers, friends, family, the world!) understand! The postpartum period is more than just a few days getting back to normal after being pregnant; it’s a very special-though-hectic several weeks for the mother to recover, bond, and find her ‘new normal’. In America we don’t appreciate nor support this time, which can have long-lasting negative effects for both mother and child. I love helping new mothers get a great start, and my desire is for every woman to get the care and support she needs to recover gently, bond with her baby, and adjust to the new role she has taken on.

    Emilie McVey
    Certified Postpartum Doula (CAPPA)
    http://www.mothercaring.com
    Serving Hershey, Harrisburg and the surrounding areas
    717-343-3204

    Reply
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  23. Eva Zasloff MD

    I am a family medicine doctor in the process of opening a practice where I will nurture and care for moms and babies at their homes during this period of time. It is called Tova Health in the Boston/Cambridge area. I would love to chat some more with you 🙂

    Reply
  24. Marie Peacock

    Dear Peggy – I would really like to reproduce this excellent piece on our Mothers at Home Matter website – would that be possible? Many thanks – Marie Peacock MAHM

    Reply
  25. T

    In El Salvador woman are taken care of by relatives for 40 days. There are many rules to follow, watch what to eat, when to shower, no sandals, can’t go out, keep your head and ears covered, no lifting, if breastfeeding they will make special drinks to help the mothers. Etc. With all these not many new mothers suffer from post partum depression, that is a term i learned in the United States.

    Reply
  26. Christie

    Just putting it out there, cloth pads are much more comfortable than disposable pads, and every bit as sanitary. Disposable pads left me with a horrible, painful rash during my first postpartum time and I’ve had absolutely no problems with painful rashes since switching to cloth pads.

    Reply
  27. Diana Barron

    This article is excellent and much-needed. Thank you, Peggy. I don’t see any mention of grandma coming to help in the first few weeks. This is traditional in most cultures with good reason. My friends and I, whether mothers or mothers-in-law, have all been asked – and willingly, joyously accepted the request – to help out after the birth of each grandchild. We cared for, protected, and encouraged mom & babe (& daddy, too!); cleaned, cooked, shopped, & did mounds of laundry. We helped soothe fears & teach our daughters to trust their maternal instincts; we calmly & joyously nurtured the formation of a new family. I completely support a 4th trimester paid doula in the absence of other options. However, grandmas have not become extinct, and many of us are available to take part in this joyous stage of womanhood – our daughters’ as well as ours. The cycle of life in a family calls for the elders to participate with love and joy. It strengthens the growing family, enlarging love and respect.

    Reply
  28. Joslin

    Other than the one comment below from the woman who apparently has a terrible m-i-l, you mention nothing about a loving Mother-Daughter relationship and the comfort and support that a Mother can lend to her daughter during this time. What a shame society has demonized that relationship to the point where a mother is not welcome to provide the wisdom of a sage and the comfort of experience.

    Reply
  29. Shannan Williams

    This is such a great article, but I feel like I need to clarify one tiny point. Postpartum doulas cannot drive any member of the family in any vehicle for any reason. Our insurance coverage does not allow it. And if she is a DONA trained doula, transportation is considered outside the scope of doula practice.

    Reply
  30. Shelly

    Awesome article! 🙂 ♡
    Just one thing though in relation to perineum comfort – my midwife, doctor and pelvic floor physio could not stress to me enough NOT to use donut as it encourages the pelvic floor to sag. They suggested to sit on a soft cushion or couch… Ice was my friend!

    Reply

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