The Fourth Trimester:

Recovery and Development

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JULY 16, 2019, Harvard Health Publishing, Ilona T. Goldfarb, MD, MPH

 

We hear a lot about the three trimesters of pregnancy. But many women (and even some medical professionals) know little about a newly described and critical time period in women’s lives that desperately needs our attention: the fourth trimester.

As a practicing obstetrician-gynecologist, I know that the medical care of women before, during, and immediately after pregnancy has long focused on the goal of achieving a healthy pregnancy and a healthy baby. But too often, the fourth trimester — that time between birth and 12 weeks postpartum — is swept aside.

For example, we encourage all women to start taking prenatal vitamins before conceiving and meet with their primary care providers to optimize their health before conception. During pregnancy, women’s schedules are filled with appointments for prenatal care visits, ultrasounds, and lab tests, and perhaps even nutrition and social work consultations. Weekly visits in the final month of pregnancy provide opportunities for fetal heart checks, maternal blood pressure and weight evaluations, paired with slow and steady counseling and anticipatory guidance for the process of labor and birth. Though some attention is given to preparing pregnant women for the challenges of breastfeeding and the pitfalls of postpartum depression, women, families, and healthcare providers tend to focus on a healthy outcome at birth.

What happens during the fourth trimester?

After birth, the close attention given to mothers in the last few weeks of pregnancy is picked up with a similar intensity by pediatric providers caring for newborns. Usually, babies have their first pediatric visit within one week of birth. Their well-being is closely monitored over the first weeks and months of life.

And for the mothers? Well, your routine postpartum visit (yes — usually there’s only one) is scheduled for six to eight weeks after childbirth. Perhaps for many low-risk women, this long interval between giving birth and a postpartum visit with their obstetric provider is adequate. But let’s review: by the time they arrive at their office at six weeks, most women who give birth have survived the pain caused by tearing during a vaginal birth, a surgical incision after cesarean delivery, and/or hemorrhoids in the first two to three weeks. Many are coping with the physical and emotional challenges of breastfeeding. They’ve grappled with sleeplessness and may have overcome their initial baby blues.

While this early postpartum period is a time of great joy for many, it’s also a very vulnerable time. Women and their families experience substantial physiological, social, and emotional changes. Why, then, do we not offer careful monitoring, support, and anticipatory guidance with the same fervor as in the weeks before childbirth, in order to keep women safe? Most women would benefit from much closer follow-up during the fourth trimester.

Attitudes are changing

Fortunately, attitudes toward the fourth trimester are changing. The American College of Obstetrics and Gynecology (ACOG), which governs standards of care and guides practice, now recommends that medical professionals view postpartum care through the lens of maternal health. A committee report

• calls for closer follow-up of women after birth

• provides doctors with specific recommendations

• emphasizes that a change in reimbursement policies is needed to support individualized, continuous postpartum care for each woman.

Their focus on the fourth trimester clearly acknowledges that the goals of pregnancy care must go beyond achieving a healthy pregnancy and a healthy baby to include a healthy mother!

How can you gain support during the fourth trimester?

If you are pregnant, start by talking to your obstetric team to learn what sort of support they can offer you during the fourth trimester.

Online resources are available to help you and your family create a “postpartum plan,” such as this one created by Mara Acel-Green, LICSW. Having a plan can help you anticipate difficulties and be prepared to get the types of support you need, which can be very challenging to access from scratch during the sleep-deprived early weeks after childbirth.

It helps to add your own individualized medical section to any postpartum plan you fill out. Discuss these questions with your obstetric team and any other healthcare providers you typically see:

• Do you have medical or emotional conditions that are expected to change during the postpartum period?

• Will any medications you take need to be adjusted?

• What warning signs should you or your family look for?

• When is the best time for your first postpartum check-up?

Finally, pregnancy is a window into future health. Ask your providers about how best to maintain the medical discoveries made during pregnancy as part of your long-term health maintenance plan.

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