The Fourth Trimester: A Postpartum Guide to Life with a New Baby
Your baby is here! You may be on cloud nine but also a bit overwhelmed with your new responsibilities. Medically, you’ve entered the postpartum period, or the time after birth. And regardless of whether you gave birth vaginally or had a cesarean section delivery, you’re still recovering and adjusting physically and mentally, which is why the first few months after birth are known as the fourth trimester.
“The big picture of the fourth trimester of pregnancy is that it represents the transition from pregnancy back to the ‘normal’ nonpregnant state,” says James L. Whiteside, M.D., professor and chair of the Department of Obstetrics & Gynecology at the Brody School of Medicine at East Carolina University.
He adds that even though much attention tends to be on caring for a newborn baby during this time, it’s also an important time to pay attention to your own health.
Here, we discuss what you might be feeling physically and mentally during the fourth trimester, what postpartum doctor appointments you’ll likely attend (for both you and your baby), and what life with a newborn may be like.
Common Postpartum Symptoms
Everyone has varying types, intensity, and duration of symptoms after giving birth. The following are some common postpartum symptoms to watch for:
You’ll have a discharge that resembles a very heavy period, called lochia, after delivery. Lochia usually lasts for four to six weeks, and should decrease in amount over that time. It can be normal for postpartum bleeding to be a bit heavier after increased activity and breastfeeding. Don’t use tampons or anything else that must be inserted into the vagina; instead, use maxi pads, changing them every few hours.
Tell your doctor immediately if you lose enough blood to soak through a pad within an hour more than once in a row, if you pass a blood clot bigger than a golf ball, or if you still have bloody discharge more than four to six weeks after the birth.
It’s normal to have some pain and swelling in your perineum (the area between the vagina and anus) after a vaginal birth. Pain may be more severe and heal slower if you had a tear or an incision. You can relieve discomfort by applying witch hazel pads or an ice pack to the perineal area. You may also want to put a pillow beneath you if it’s uncomfortable to sit.
You can also take an over-the-counter pain reliever, but check with your healthcare provider first if you’re breastfeeding. Ibuprofen (Advil) and acetaminophen (Tylenol) are generally safe for most patients during the fourth trimester, says Abe Shahim, M.D., a board-certified ob-gyn at Manhattan Women’s Health in New York City. Follow the dosing on the bottle, adds Whiteside.
It can be scary to experience pain and bleeding after giving birth, so you may need to remind yourself that your body has experienced a major transition and that this is a sign of healing.
If you’re experiencing excessive pain or postpartum bleeding, especially while also having a temperature of 100.4 F or higher, contact your doctor, Whiteside says.
It’s common to strain intensely during labor and delivery, which can make the veins in the anus and/or rectum swollen and sore. You can relieve your pain with medicated numbing sprays, topical ointments, or cold witch hazel compresses.
Hemorrhoids should improve after delivery but generally take several weeks to months to completely resolve.
Swollen Breasts and Sore Nipples
As breast milk comes in, the breasts or chest may feel hard, full, and tender. If you experience this, feeding your baby can reduce the pain, and you can also use cold packs in between feedings. If you’re not breastfeeding or chestfeeding, you can try to stop milk production by wearing a snug-fitting bra.
It’s very common to have sore nipples when breastfeeding, especially in the first few weeks of the fourth trimester, as your body is adjusting to it. You can use a nipple cream like lanolin or even rub some expressed breast milk into the nipple after each feeding to help with healing.
If you’re really struggling with soreness, it may be helpful to have a consultation with a lactation consultant to evaluate your baby’s latch and also give you some breastfeeding help and tips.
Postpartum Mental Health
Postpartum mental health can be complex. You probably expected to be excited and joyous once your baby arrived, but it’s also common to feel negative emotions after birth as well. This is sometimes known as the “baby blues” and can include mood swings, anxiety, sadness, irritability, difficulty sleeping, lack of appetite, and anxiety. These blues tend to start two to three days after giving birth, and may last about two weeks into your fourth trimester.
More intense or more severe negative feelings after birth are known as postpartum depression (PPD). With PPD, symptoms are stronger than typical baby blues and last longer than two weeks. They can get in the way of you being able to care for your baby.
Signs of PPD include excessive crying, difficulty bonding with the baby, withdrawal from friends and family, severe mood swings, depressed mood, overwhelming fatigue, feelings of worthlessness or hopelessness, and thoughts of harming yourself or your baby.
“Depression is problematic if it affects your daily life or daily functions,” Shahim says. “Any thoughts about harming yourself or the baby require immediate evaluation.” You can find mental health professionals that have special training in pregnancy and postpartum mental health at Postpartum Support International.
Postpartum psychosis can happen too. This is a rare form of extreme mood disorder. Symptoms include confusion, hallucinations, delusion, paranoia, and disorientation.
If you’re experiencing any symptoms of postpartum depression or psychosis, get help from your doctor or a mental health professional as soon as possible.
Help for PPD and Postpartum Psychosis
If you’re having thoughts of harming yourself or your baby, speak to someone you trust and call 911.
“Acknowledging a woman’s depressed mood and sense of loneliness can be transformative,” Shahim says. Although it may be hard to admit if you’re having trouble, know that you’re not alone. It’s common to struggle with postpartum mental health, and help is available.
A mental health professional can help you decide how to manage your symptoms and treat PPD if you have it. Treatments can include counseling, medications, or both.
There are also many postpartum support groups (both online and in person) that may be able to help you feel less alone during this time.
Postpartum Doctor Appointments
In the fourth trimester, your checkup schedule involves two different doctors: yours and your child’s.
Your Postpartum Doctor Appointments
You’ll see your doctor for a postpartum checkup to make sure you’re healing and recovering properly. All patients usually get a follow-up around four to six weeks after delivery, Shahim says, adding that many physicians are now also doing a follow-up two weeks after delivery.
At postpartum checkups that take place two weeks after birth, you’ll have any tears and incisions checked to be sure they’re healing well. Your doctor will also check your blood pressure, weight, breasts, and belly. You’ll get a pelvic exam to examine your uterus, vagina, and cervix.
Your doctor will also ask you some screening questions for depression. It’s important to talk to your doctor about what you’ve been feeling or thinking. Tell them if you’re stressed, tired, or feeling blue or depressed. If you need treatment, they can help point you in the right direction.
Postpartum checkups four to six weeks after delivery will be similar, but your doctor will also likely ask you to have a contraception plan, Whiteside says. If you want to use contraception, you can decide whether you want to go back to a birth control method you’ve used before or whether you’d like to try something new. You’ll also talk about returning to your physical and sexual activity at this visit.
If you had gestational diabetes (GD), you’ll get your blood sugar levels retested at six weeks postpartum. “Retesting glucose control is important to determine if you need longer-term diabetes management,” Whiteside says. Women who had GD during pregnancy are seven times more likely to develop Type 2 diabetes in the future, even if they have reassuring postpartum test results, he says.
Remember to take care of your own needs during the fourth trimester as well as your baby's. Try to eat nutritious meals and find ways to move your body gently.
Your Baby’s Checkups
The American Academy of Pediatrics (AAP) recommends all babies be seen by a doctor when they’re 3 to 5 days old. This is called a checkup or a well visit. Bring along your baby’s hospital paperwork so the doctor can review the details of the birth as well as the results of hearing and blood tests that were done in the hospital.
At this first office visit, your baby will be weighed and measured, and they’ll get a physical exam. You’ll discuss how the baby is eating and sleeping and ask any questions you have. Your baby will likely get the hepatitis B vaccine if one wasn’t given in the hospital.
“If you have concerns, especially after the first-week visit, additional visits may be scheduled before one month,” says Jennifer Trachtenberg, M.D., a board-certified pediatrician in New York City.
At 1 month, your baby will likely have another checkup to see if growth and development is on track and to see if they appear healthy. They may get the second dose of the hepatitis B vaccine either at this visit or at the following month’s visit. “When you get it depends on the doctor’s office,” says Jarret Patton, M.D., a board-certified pediatrician in eastern Pennsylvania.
At 2 months, your baby will likely get their third postpartum checkup, along with more vaccines, including hepatitis B (if not received the previous month), DTaP (diphtheria, tetanus, and acellular pertussis), rotavirus, Hib (Haemophilus influenzae type B), PCV (pneumococcal conjugate vaccine), and IPV (inactivated polio vaccine). “Don’t worry,” Patton says. “Many of them are available as combination vaccines so there won’t be so many shots at once.”
Since you may be seeing your baby’s pediatrician before you see your own doctor for a follow-up, the pediatrician will likely ask how you’re feeling at these visits, Trachtenberg says.
“It is important to know how Mom is doing,” Patton says. “When Mom is doing well, the baby can do well.” So, it’s common for pediatricians to screen for postpartum depression, too, he says.
After that, your baby should have checkups at 4 months, 6 months, 9 months, 12 months, and 15 months, according to the AAP schedule. Then, your baby should have checkups every six months until they’re 3 years old. After that, the well visits should happen once per year.
Your Newborn Baby’s Development in the Fourth Trimester
“[A newborn] baby mainly eats, sleeps, cries a lot, poops, and pees,” Trachtenberg says. Your baby will have a lot of growth and changes throughout the fourth trimester.
By the time they’re one month old, most babies can:
- Move their hands near their faces
- Hold their hands tightly in fists
- Gaze at items that are 8 to 12 inches away
- Turn their heads to each side while lying on their stomachs
- Prefer to look at human faces most and also enjoy looking at contrasting or black-and-white patterns, too
- Hear and remember some sounds including their parents’ and/or caregivers’ voices
By the time they’re three months old, most babies can:
- Lift and hold up their upper bodies with their arms when on their bellies
- Kick their legs when lying down, and push down with their legs when held upright on a flat surface
- Open and close their hands and move them to their mouth
- Grab, hold, and shake toys, such as a rattle
- Watch faces and follow moving objects with their eyes
- Remember objects, people, and surroundings
- Babble and repeat sounds; smile when they hear their parents’ or caregivers’ voices
- Delight in playing with others and may cry when playtime is over
- Start to smile
- Be better able to self soothe a bit and may sleep longer stretches
Note that not all babies will develop at this same pace. For example, babies who were born prematurely may hit milestones a bit later, and other babies can experience developmental delays too. If you have any concerns about your child’s development, talk with their doctor, who can recommend interventions that could help.
The fourth trimester may be a magical time for you and your baby, but it’s also a huge adjustment for you both. Remember to try to rest when you can—and talk to someone if you’re having any difficulties. It’s okay to ask for help.
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