My first child was born six years ago, and I remember that labour and birth well. It was empowering and exhilarating. It was also long, physically exhausting, and resulted in some tearing to my pelvic floor. I loved my baby instantly but, in the days and weeks after he was born, I remember accumulating a huge sleep debt, wincing with movement as my perineal tears were healing, dreading every feed as I struggled with breastfeeding, being shocked at the shape of my new body, and feeling lost as to how to care for myself without being able to use what I was used to: sleep and exercise. Going through postpartum rehab for my own body, and navigating the system to find resources for my struggles in breastfeeding and mental health, I quietly, then loudly, became an advocate for change in the maternal healthcare system. The greatest contribution that I could think to make was opening a centre with a multidisciplinary team of health professionals to provide specialized support to women through pregnancy, postpartum and parenthood.
What is the fourth trimester?
The fourth trimester is the time between birth and 12 weeks postpartum. It is a time of incredible change and marked vulnerability for mothers and their new-born babies. During pregnancy, a woman is followed closely by her birth care provider with a standard four appointments in the last month of pregnancy, alone. After birth, this intense following is continued for the new baby, with close monitoring for them during the first days, weeks and months of life. Contrarily, in this time, care for the new mother drops off and rather than being checked in with about how she’s managing physically, mentally, emotionally, nutritionally, environmentally, or otherwise, the burden falls to her to raise any of these issues to a care provider.
The fourth trimester is also the time when a woman is physically recovering from pregnancy, labour, and birth. The amount of cellular energy it takes for grow a human, a placenta, and all other fetal structures is incredible. Pregnancy also impacts every single system in the mother’s body including blood volume, lung function, metabolism, digestion, even memory. But no other system is more impacted by pregnancy than the musculoskeletal system. Pregnancy changes the shape of the abdominals and strains the pelvic floor. It also changes a woman’s posture and loads her body with extra weight.
In addition to recovering from pregnancy, a woman must also recover from labour and birth, which can be physically exhausting. If she birthed vaginally, a woman’s pelvic floor and perineum are recovering from an incredible amount of stretch, and possible tearing or episiotomy. She may be experiencing, pain, swelling, hemorrhoids, and pelvic floor dysfunctions such as urinary or fecal incontinence, and pelvic organ prolapse. If she birthed by Caesarean section, she is recovering from major abdominal surgery and the effects of anaesthetic medications. Some moms of multiples are recovering from both at the same time.
It takes a certain amount of time for a pelvic floor to recover after a birth where little to no injuries were sustained. It takes a different amount of time to heal from a birth where a woman experienced significant injury. These are both different than how much time it takes for someone to heal from a Caesarean section.
The fourth trimester is also the time when a new mother is climbing the steep learning curve of breastfeeding. She may be experiencing nipple and/or breast pain, and may certainly be experiencing the self-doubt that comes along with breastfeeding difficulties. With very little prenatal education on the mechanics of breastfeeding, and how to trouble shoot difficulties, many new mothers who have every intention of exclusively breastfeeding their babies discontinue in the fourth trimester. In fact, in Alberta, 96% of pregnant women plan to exclusively breastfeed their babies. By 3 months, only 50% are and by 6 months, only 15% are.
It often happens that a woman’s first experience with childbirth, breastfeeding, and postpartum is her own first-hand experience. This is in contrast with what happened in generations passed. Because we are so isolated from birth and postpartum at a community level, a multidisciplinary approach to fourth trimester support from a group of health care providers is very important.
What is a Multidisciplinary approach?
Multidisciplinary care is divided into primary care and allied care. Primary care team members are Doctors, Midwives and Nurses. Allied care team members can include Pelvic Health Physiotherapists, Psychologists, Registered Dietitians, Lactation Consultants, Acupuncturists, Chiropractors, Occupational Therapists, Naturopaths, and more. There is also non-medical support that comes in the form of friends and family, birth doulas, postpartum doulas, exercise specialists, spiritual support, and more.
Everyone who gives birth is attended by either a Doctor or a Midwife. Very often, this primary care provider attends a woman at the time of birth, but then doesn’t follow up with her until six weeks postpartum – or half way through the fourth trimester. Then, care is transferred to a different Doctor so continuity of care is lost. Six weeks is a long time to go for someone who is struggling to breastfeed, or who’s mental health is deteriorating, or who cannot control their bladder or bowels, or who is in a lot of pain.
The American College of Obstetricians and Gynaecologists (ACOG) released new guidelines in 2018 to reinforce the importance of the fourth trimester. Rather than a single encounter at six weeks, ACOG now recommends that the first postpartum follow up should be no later than three weeks and should continue as an ongoing process that eventually transitions to wellness.
The expectation that a single heath care provider could be an expert in the assessment and treatment of postpartum concerns related to pelvic health, mental health, breastfeeding health, nutritional health, fertility, etc. is illogical. There are professionals dedicated to each of these areas.
How to feel supported in the fourth trimester?
The first step in ensuring that a woman is adequately supported through the fourth trimester starts with her prenatally gathering a team of support. She will probably know who her support network of family and friends will be. She may not know who should be on her team from the medical world. In my opinion, there is a minimum of 3 allied health professionals that every woman needs on her team: someone to support her mental health, someone to support her physical and pelvic health, and someone to support her in breastfeeding.
Establishing a relationship with these key individuals prenatally will ensure that if a new mom runs into issues, she doesn’t have to try to find help in a period of time when problems are already present, stress is high, and sleep is interrupted. These key players will also have other helpful referrals to direct women towards, when needed.
Knowing that the best predictor of family health and well-being is the health and well-being of the mother, appropriate postpartum care in the fourth trimester should be prioritized just as highly as care for our new-borns. With the right supports in place, a multidisciplinary team of primary and allied health care professionals can really change the trajectory of a whole family’s experience.
About the Author
Jillian Palmer is a Pelvic Physiotherapist, Mother of 4 children, and the co-founder of Pine Integrated Health Centre. She is passionate about helping women recover from issues related to their abdominals and pelvic floor after pregnancy and birth. She is enthusiastic about helping women feel great in their bodies, no matter what stage of life they’re in.
Note: This blog is a condensed version of an article originally published in Birth Issues Magazine -FALL/WINTER 2019 — Postpartum Care: The Fourth Trimester. https://birthissues.org/