The Fourth Trimester
Molly Jarchow, ND, LM
Around the world, the Fourth Trimester has been acknowledged as a special time for both mom and baby that requires extra care and attention. Most often, the Fourth Trimester has been defined as the first 3 months after birth, particularly for babies, but for mothers it really encompasses the first year. In some cultures the mother-in-law moves in for at least 1 month to care for mom and baby (Gabon); in others, pots of seaweed soup bubble away on the stove for several months (Korea); and still others observe a full lunar cycle of rest, support, and nourishment called the Sitting Moon (China). These traditions are rooted in respect for just how special this time is and how vulnerable it can be for both mom and baby.
The common theme among these traditions is prolonged support and nourishment from friends or family members; this enables the mother to focus exclusively on healing, breastfeeding, and bonding with her new baby while all household and childcare responsibilities are taken care of by others. Although this is far from the norm here in the United States, our mothers are also in need of this pause to rest, fully heal, and be nourished during the early Fourth Trimester before returning to their busy lives. This can be created in our culture, but it requires moms to advocate for themselves and orchestrate the support during the Third Trimester to ensure a proper foundation for a healthy Fourth Trimester. As doctors, asking moms about their support plans for the Fourth Trimester helps bring attention to this overlooked but critical time that many mothers are unaware of.
Thriving in the Fourth Trimester – The First 3 Months
Have an experienced Lactation Consultant visit the mother at home within 24-72 hours after leaving the hospital, especially for first-time mothers. Moms who give birth at home or a birth center often receive ongoing lactation support from their midwife; however, it’s always helpful to have the name and number of a Lactation Consultant in case challenges arise in the first week. Early lactation support is essential to preserve a mom’s milk supply and to prevent pain and discouragement – factors that moms often cite for why they stop breastfeeding.
A new mother shouldn’t be alone with her baby for extended hours during the first few weeks after birth. If her partner or family aren’t available for appropriate support, hiring a Postpartum Doula can be worth its weight in gold. Postpartum Doulas help decrease the “overwhelm” factor for a new mother (and her partner) by helping with breastfeeding, newborn care, cooking and cleaning, and by offering physical and emotional support. This is one of the most important times in a woman’s life for extra support, as many women are unprepared for just how much care a newborn requires. Encourage her to secure a house cleaner, a personal chef or meal delivery service, and extra childcare for older children prior to the birth. Creating a “How to Help” list for family and friends to post on the front door or the fridge provides guidance for those unfamiliar with the family’s needs during the Fourth Trimester. Include washing the dishes, walking the dog, taking out the trash, throwing in a load of laundry, taking an older child out to play for a couple hours, sweeping the floor, and making/purchasing food.
A mother usually needs to talk about her delivery, especially if it was traumatic, long, challenging, or included unexpected interventions that strayed from her birth plan. This may not be immediately after the birth, as it can take time for a mother to process her feelings; so it’s useful to check in on how she’s feeling about her delivery as the weeks and months pass. Holding a safe and nonjudgmental space that is focused on acknowledging her feelings around her experience can be very healing. Avoid responses such as “At least you have a healthy baby,” which minimize a mom’s birth experience rather than validate it. Homeopathy and flower essences are very helpful in supporting a woman process a tough birth experience. Refer to a perinatal therapist experienced with birth trauma if necessary.
Nutrition & Supplements
Reminding moms to have healthy snacks next to the places they breastfeed can often do wonders for stabilizing blood sugar and, therefore, mood and energy. Drinking a glass of water each time the mom nurses will help prevent constipation and subsequent hemorrhoid aggravation, as well as fatigue from dehydration. A diet rich in colors, protein, healthy fats, and complex carbs supports the needs of a breastfeeding mother. In the first 2 months after birth, dairy, soy, the Brassica family vegetables, onions, garlic, and beans can be common food culprits in causing extra gas in babies, and therefore should be avoided if colic is an issue for the baby. Partners can help restock snacks and refill big bottles of water near the nursing areas before leaving for the day. Foundational supplements of 2000 mg total omega-3 oils, 4000 IU vitamin D3, a prenatal vitamin, and 25 billion organisms in a multi-strain probiotic can also help support mood, energy, and immune health while a mom is getting less than ideal sleep and transitioning to motherhood.
Thriving in the Fourth Trimester – Months 3 to 12
Quarterly Visits in the First Year
Giving birth brings incredible physical and emotional changes for women that don’t always arise or resolve within the first 6 weeks after birth when the OB or midwife care is complete. By scheduling quarterly visits in the Fourth Trimester rather than the usual annual exam, moms have more regular check-ins during a time when they can have a hard time keeping up with their own needs, since those of baby often take priority. Inevitably, a mom’s hemorrhoids will be flaring, she’ll be fatigued during a sleep regression, she’ll have caught the first cold going around and not know what she can safely take while breastfeeding, or she’s feeling down or anxious by the time that next scheduled visit comes around; she’ll be grateful that it’s already on the calendar. Basic reminders about eating enough protein and healthy fat, eating frequently enough, having food before caffeine, and taking foundational vitamins of a multivitamin, omega-3s, vitamin D, and a probiotic can make a big difference for moms. These regular check-ins remind moms about the small daily acts of self-care that can have big effects on their overall health and wellbeing.
Mental Health Assessment
Approximately 10% of women report symptoms of postpartum depression, which can occur any time during the first year after birth. Mothers respond best when asked directly if they have concerns about postpartum depression or anxiety, as they may not always feel comfortable bringing it up or may be minimizing it as “not that bad” in their own head. It’s best to ask at each visit during the first year, as feelings and outlook can change month to month. Mild-to-moderate anxiety and depression often respond beautifully to stabilizing blood sugar with dietary modifications, adding nervines, adaptogens, and B vitamins, and creating a plan to get the mom more support so that she can do something fun or relaxing without her baby at least once a week. Asking a woman about what she really enjoyed doing before she became a mother can be a good place to start for bringing the joy back. If a mother feels her anxiety or depression is becoming the new normal and affecting her daily life, lab assessment for anemia, vitamin D deficiency, and/or thyroid issues, along with a referral to an experienced perinatal therapist, are warranted.
Women’s Health Physical Therapy
Every mother, whether she’s just had her first or fifth baby, can benefit from an assessment by a skilled women’s health physical therapist (WHPT). These unique practitioners assess women from the breasts to the knees, encompassing the main areas that get compromised during pregnancy and birth. Diastasis recti is very common after pregnancy and should be addressed before a mother starts her exercise routine, since some exercises can actually make it worse. Pelvic floor muscle hypo- and hypertonicity is also extremely common, even after a Cesarean-section birth, and although Kegel exercises may be enough for some, many women need more specific exercises to help strengthen or relax the muscles. In France every mother gets government-subsidized physiotherapy after birth – an excellent form of preventive care, since it’s a lot easier to rehabilitate weak pelvic floor muscles during the childbearing years than after menopause when symptoms like incontinence often worsen. At a minimum, every mother should be assessed for diastasis, pelvic floor tone and incontinence, perineal healing and dyspareunia, and pelvic pain at the 6-week postpartum visit. Sadly, with both OB and midwifery care these are often missed or overlooked during the final visit, leaving many women to assume that the new symptoms are their new normal and “just part of having a baby.” This is far from the truth. Ask mothers specifically about these issues and help them on the road to recovery by referring to a WHPT.
Community & Connection
One of the most important aspects of the Fourth Trimester is for mothers to find their tribe, whether online or in person. Around the globe, motherhood is rarely a solo journey, but rather one that involves multigenerational support and wisdom to help weather the ups and downs. Preventing a mother from feeling isolated during the Fourth Trimester is one of the most important tools for preventing postpartum depression and anxiety. There is an abundance of classes available for moms and babies for yoga, music, baby signing, stroller strides, swimming, and parenting philosophy, as well as La Leche League and moms’ groups that help create community and connection during the Fourth Trimester. There are many common experiences and emotions shared among moms, and it can be reassuring to hear that a mom isn’t alone and that “this too shall pass.”
The 1-Year Birthday
The first year is a big one for babies, mothers, and their partners. Often a big birthday celebration is planned for the baby, but the parents may be too exhausted to celebrate that they have survived (and hopefully thrived) during the first year. Encourage the couple to go on a date (morning or afternoon dates work if they’re too tired at night) and to schedule something that they enjoy, whether together or alone. After all that both partners have given to their baby during the Fourth Trimester, they don’t want to miss this opportunity to pause and give a little something back to themselves.
Image Copyright: <a href=’https://www.123rf.com/profile_garosha’>garosha / 123RF Stock Photo</a>
Molly Jarchow, ND, LM, is a naturopathic doctor and licensed midwife who graduated from Bastyr University. Dr Molly splits her time between an integrative pediatric practice in Los Angeles and her women’s health practice in Santa Monica. Although no longer attending births, she has the pleasure of continuing to work with women during the childbearing years, offering fertility, prenatal and postpartum care, and primary care for their children. Dr Molly enjoys sharing her love of food and herbal medicine with the families she serves, and uses them regularly in her prescriptions. Her website is www.sagenaturalmedicine.com.