Fourth Trimester What to Expect

Overview

During pregnancy, you focus on your health, baby, and planning for birth. Many expecting moms often overlook what happens after birth and what they may experience postpartum. Your body needs time to recover after nine months of pregnancy, giving birth, and establishing breastfeeding. Many things happen after you have your baby that no one talks to you about beforehand. Let’s normalize talking about the regular changes you go through after birth. Rather than wondering if what you are experiencing is normal, I want you to know what to expect. Plus, know the warning signs you can keep an eye out for to make sure you are recovering well after birth.

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Hospital or Birth Center Stay

If you give birth in a hospital, you will likely be there for 1-3 days, depending on whether you had a vaginal or cesarean birth and how you and your baby are recovering. If you have your baby at a birth center, you often head home the same or the next day. You are likely solo with your baby the same day with home birth. This will vary depending on your care provider, routine, and how you and your baby are doing. Ask your doctor or midwife what you can expect so you know the timeframe and when you will be on your own.

Postpartum Instructions

You should be given instructions for your care from your doctor or midwife. This typically happens just before your doctor discharges you from the hospital before you go home from the birth center, or before your midwife leaves following a home birth. When your care provider reviews instructions, please ensure your partner or another support person is present. This gives you an additional person to hear care instructions and look for warning signs. Often, instructions aren’t incredibly detailed. If you have any questions, do not hesitate to ask. Trust your gut. If something feels like it isn’t right, contact your doctor or midwife. It is always better to err on the side of being safe. Catching or correcting a minor issue early on may prevent a more significant problem later.

Postpartum Visits

In the past, it was common practice that you do not have a postpartum visit until six weeks after you give birth. In 2018, the American College of Obstetricians and Gynecologists updated their guidelines to state that postpartum care should become an ongoing process rather than a single encounter, with services and support tailored to each woman’s individual needs. ACOG recommends that all women contact their care provider within the first three weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth.

You may have appointments more frequently, depending on your care provider. My midwife for my last pregnancy did postpartum visits at one day, three days, two weeks, six weeks, and three months. If you want an appointment sooner, please ask. You should also have contact information if something happens outside regular office hours.

As many as 40% of women do not attend a postpartum visit. Many new moms must bring their newborns, and getting out of the house with a new baby can be challenging. Not only do you need to bring all the things, but you also need to time everything right with naps, feeding, and diaper changes. Please prioritize attending postpartum visits with your provider. Even if you feel great, it is nice to know everything is okay and healing well; plus, it allows you to ask questions about anything you are experiencing postpartum, any questions about breastfeeding, or your baby.

Be Prepared for Medical Bills

You will have medical bills coming in the weeks after your birth. You may receive a lot of mail from your insurance company or the venue where you gave birth. If you receive a bill that you do not understand, please reach out to ask questions, make sure you know the charges, and verify the statement is correct. If you are concerned about paying medical bills, please inquire about payment plans with your provider or insurance company. Insurance and medical bills are confusing and can be a huge pain. Understanding your insurance and how to take advantage of tax breaks if you are eligible will pay off and prepare you for upcoming expenses.

Physical Changes You Should Know About

Many physical changes happen after birth and during the recovery process. You likely have never heard about many of these changes or symptoms. You have a lot going on in the weeks after having a baby. The last thing you need to do is worry about whether something you are experiencing is normal or stress out over finding relief. Let’s examine some of the common physical changes postpartum and how you can treat them and recover better.

Fatigue

You will probably be exhausted after birth. Your body goes through more physical exertion during birth than any other event. Plus, in the first few weeks, your baby is adjusting to life outside the womb, and it will take time for them to adapt to any schedule. While feeling tired may be typical or expected, you should rest as much as possible. The advice to sleep when the baby sleeps is a good idea. This is especially important early on when they sleep a lot and you are recovering from birth.

Sleep

Sleep is essential for your physical recovery and mental health. You should know that researchers see a baby sleeping through the night as six hours of continuous sleep. Many babies are not physically capable of sleeping even six hours, especially if you are exclusively breastfeeding. If you value your sleep, it can be stressful to think about existing on a few hours of sleep one night. Adjusting your sleep expectations can make a big difference in how you feel when you don’t get enough sleep. While naps are not the same as getting a quality eight hours of sleep per night, they help.

Afterpains

You will have some postpartum contractions, often called afterpains. These are particularly noticeable when you breastfeed, which triggers the production of oxytocin, the hormone that causes contractions. These contractions are part of your uterus, minimizing blood loss and shrinking in size. The good news is that afterpains are short-lived, with the most noticeable contractions subsiding within a week. Think of these cramps as a reminder that your uterus and body are returning to normal.

Afterpains tend to be stronger with subsequent births. This is because your uterus has less muscle tone, and the contractions tend to be more intense to prevent postpartum bleeding. If your afterpains are uncomfortable, use any labor coping technique, like breathing, meditation, or visualization. Cuddling your baby is an excellent distraction from the discomfort of afterpains.

Soreness

Giving birth is a marathon of a workout for every muscle in your body. Your muscles will probably be sore and feel better within a few days. You may also have soreness in your vagina if you had a vaginal birth or around your incision if your baby was born via cesarean. The best remedy for recovery is rest. There are medications that are safe for breastfeeding if you need them.

Over-the-counter and Homeopathic Medicine

There are over-the-counter pain medications that are safe to take after you have your baby. These can be helpful if you are experiencing pain from birth, a cesarean incision, or afterpains. Always check with your doctor or midwife before taking any medication. You can also reference LactMed, a database with information on drugs and breastfeeding. This includes evidence on whether you pass medications through breast milk and how they affect your baby.

According to LactMed, ibuprofen is preferred as an analgesic or anti-inflammatory agent in nursing mothers. This is due to its extremely low levels in breastmilk, short half-life, and safe use in infants in doses much higher than those excreted in breastmilk. Acetaminophen (Tylenol) is a good choice for analgesia and fever reduction in nursing mothers. Amounts in milk are much less than doses usually given to infants. Adverse effects in breastfed infants appear to be rare.

There are also “natural” and homeopathic remedies available. My midwife recommended AfterEase tincture. This is an herbal tincture by a company called Wish Garden Herbs. Anecdotal information from my personal experience is that it was nice to have something to take, so I felt like I was doing something for afterpains. I didn’t notice a big difference in the pain or intensity of afterpains when I took the AfterEase and when I didn’t. Arnica Montana is a homeopathic remedy to help with swelling, pain, and muscle soreness. From my personal experience, I don’t know how effective it was. I don’t think it was the same as taking an OTC painkiller, but if you are avoiding acetaminophen or ibuprofen for any reason, it may be worth a shot.

Hemorrhoids

Technically everyone has hemorrhoids, also called piles, and these are clusters of veins lining the lower part of your rectum and your anus. We refer to the condition of these being swollen (they are actually varicose veins) as hemorrhoids, and there are two types. Internal hemorrhoids are swollen veins in your rectum, and external hemorrhoids occur in your anus. Both can cause bleeding, but internal hemorrhoids tend not to be bothersome. External hemorrhoids can be very painful and can also come with itching and burning. People often described them as a small cluster of grapes, which is reasonably accurate. They tend to be soft and very tender.

Hemorrhoids are estimated to affect around 40% of pregnant women. Even if you escape your pregnancy without hemorrhoids, you could get them after birth. Hemorrhoids are a possibility after birth. You are straining during the pushing stage, very much like you would if you were trying to make a bowel movement. One study found a significant predictor of hemorrhoids after birth is straining during delivery for more than 20 minutes. The pushing or second stage of labor typically lasts more than 20 minutes, especially for a first-time mom. Depending on many factors, it could be anywhere from a few minutes to several hours.

The downside to any hemorrhoid treatments is that none of them will make hemorrhoids go away, but they will help make you more comfortable. The only cure for hemorrhoids is time. 

If it is uncomfortable to sit down, there are cushions specifically for hemorrhoids; these look like a donut with a hole in the middle. Another option is a Boppy pillow or a breastfeeding pillow. Sitting on any cushion instead of a hard chair or surface may be helpful.

You can try applying ice or an ice pack to the area to decrease swelling and give you some relief. A warm bath may give you some relief from hemorrhoids. You could try a sitz bath, a small plastic tub that you can put over your toilet, fill with warm water, and then sit in it.  You can add herbs or anything you would add to an ordinary bath. Baking soda applied to hemorrhoids may help with itching. You can also add some to a warm bath or a sitz bath. Witch hazel is something you can use to make hemorrhoids feel better and potentially alleviate some swelling. You can buy Tucks pads that already have witch hazel in them. You can use other topical treatments to treat hemorrhoids. These usually contain an astringent, steroid, anesthetic, or some combination.

All of these remedies should give you some relief. Unfortunately, the only way to completely get rid of hemorrhoids is to give them time. In rare cases, they can be surgically removed, although they will most likely go away on their own within a few weeks. See this episode for more information on hemorrhoids.

Healing an Incision or Tear

If you have an incision from a cesarean birth, episiotomy, or a perineal tear, you want to follow your doctor or midwife’s instructions on how to treat it to ensure it heals properly. Any tear or incision is bound to be sore and healing after birth. You want to keep it clean and watch for a sign of infection, which could be redness, swelling, or oozing.

If you do not feel you are healing well or as you expect to be, please bring it up with your care provider. There is something called granulation tissue when the tissue gets stuck in the healing process. If you are not consistently healing, contact your doctor or midwife. You have so much going on with your new baby that you do not want to procrastinate seeking help if you are not healing correctly. If this does happen to you, your care provider can treat it with silver nitrate, which will help to speed up the healing process and stop the tissue from being granulated.  

During birth, it is very common to tear your perineum. Research shows the rates of tearing with your first baby are 90% and decrease to 69% in subsequent births. According to the American College of Obstetricians and Gynecologists, the rate of some laceration during all vaginal births is between 53-79%.

If you have an episiotomy or a tear during birth, the wound will probably be sore for a few weeks, and this is especially true when you walk or sit. If the incision or tear is extensive, the tenderness can last longer. Thankfully, there are many things you can do to give yourself some relief and promote healing. There is an in-depth episode on vaginal tearing, episiotomy, and recovery that goes into detail on healing.

Lochia

After birth, you will experience a vaginal discharge called lochia. This is excess blood, mucus, and tissue from the lining of your uterus. Even if your baby is born via cesarean, you will still have lochia. Bleeding is most heavy in the first three to ten days postpartum and will taper off over several weeks. Early on, you may notice sudden gushes of blood or blood clots. Your lochia should start a bright red, go to a brownish-red or light pink, and eventually a white or yellow. If you feel like it starts to get a bit heavier, you may be overdoing it. For example, if you go on a long walk and find that your bleeding increases, you may be pushing it too much, which could signify that you need to cut back on your activity.

Following your birth, you should not insert anything into your vagina, and you should use pads, not tampons or menstrual cups. I wouldn’t stock up initially with a pad you haven’t used before. After my first baby, I went out and bought the bulkiest pads ever, and they were so uncomfortable. I switched to much thinner pads, which made a big difference.

You may feel gushes of blood when you are breastfeeding because that causes the release of oxytocin, which causes your uterus to contract. You may also get a gush of blood when standing up from a sitting or lying position. You could have blood clots, which are like thick chunks of blood. If clots are bigger than about the size of a golf ball, you should let your doctor or midwife know. If you are suddenly bleeding a lot and not stopping, that is a sign to call your care provider. Contact your doctor or midwife if you are soaking a pad in under an hour. If your lochia or discharge is foul-smelling, that could be a sign of infection. You are always best erring on the side of caution. If you ever have any concerns, please get in touch with your doctor or midwife. 

Postpartum Hemorrhage

Postpartum hemorrhage is heavy bleeding, most commonly within the first 24 hours after birth, and is the number one cause of maternal mortality worldwide. The rate of postpartum hemorrhage is between 1-5% of pregnancies. It is more common in low-income countries where access to care is limited. However, the rates of postpartum hemorrhage have been on the rise in developed countries, and researchers have not been able to pinpoint the exact cause.

Late or delayed hemorrhage occurs between 24 hours following your birth, up to 6 weeks. Call your doctor or midwife if you ever have a concern about how much bleeding you have while you are still at the hospital or once you are home. Some red flag warning signs include blurred vision, chills if you feel like you may faint or feel weak, nausea if your skin goes pale, swelling, or pain around your vagina or perineum. If this happens, you should contact your doctor immediately or call 911.

There is a full episode with in-depth information on postpartum hemorrhage, bleeding, and the return of your period.

Going to the Bathroom

After birth, it can be uncomfortable to go to the bathroom. This could be due to a tear or an episiotomy, hemorrhoids, or because lochia can be messy. To make using the toilet more comfortable, you can utilize a peri bottle. This is a small plastic bottle. You can gently squeeze the water on your vagina and perineum after using the bathroom. If you have your baby at a hospital or birth center, they should send you home with one. Using a peri bottle will prevent a tear or incision from stinging if it comes into contact with urine. Plus, this is a great way to rinse and keep the area clean without aggravating it by wiping it with toilet paper. You need to be careful wiping during the beginning of your healing, so after you rinse with warm water, you can use the tissue to pat dry or air dry if that feels better.

Many new mothers are intimidated to have their first bowel movement after birth. Constipation is prevalent after using pain medications in labor. There is an episode of constipation with a breakdown of over-the-counter remedies. You can take a stool softener to make your first bowel movement easier. If you are concerned about aggravating your perineum, you can press a clean, round, flat cotton pad against the wound when you are passing a bowel movement.

Body Image in the Postpartum Period 

One thing that surprises some new moms is that they still look pregnant after their baby. While you lose a lot of weight at birth with your baby, the placenta, and amniotic fluid, you won’t lose all the weight you put on instantly. There is such a focus on getting back to your pre-pregnancy weight, and many new mothers struggle with changes to their bodies after having a baby. Your focus after having a baby needs to be on your overall health and your baby’s health. This is a significant life change as you step into your new role as a mother or a mother of multiple children; it is easier when you are not preoccupied with your body. If it is important for you to return to your pre-pregnancy weight healthily, I applaud you. If this is not your priority, that’s okay too. It took you nine months to get here; don’t expect to bounce back right away.

A review that included 19 studies looked at body image and how it affected postpartum depression. The majority of studies found that body image dissatisfaction is consistently but weakly associated with the onset of prenatal and postpartum depression. Some studies even looked at the reverse and found that depression contributed to negative body image. It makes sense that when you are unhappy with your body, it can affect your mood. Remember how hard your body has worked to build and birth a human, and have patience with the recovery process.

Postpartum Hair Loss 

Many new moms fret about postpartum hair loss. This study shows that hormones can affect your hair’s growth cycle during pregnancy. The increase in estrogen makes the growth phase longer, so less of your hair enters the resting phase or shedding. The less you shed, the fuller and thicker your hair seems during pregnancy. After your birth, as the estrogen levels drop and return to normal levels, the growth phase isn’t prolonged, and more of your hair than usual enters the resting or shedding phase. This usually happens between 3-6 months postpartum. 

The technical term for this excessive shedding is postpartum alopecia. It may seem like your hair is falling out. It is more likely you are shedding the hair you should have shed during your pregnancy. As you shed excess hair and new hair grows, it may seem like you have a lot of short hair. This can be particularly noticeable around your face. These newer hairs will grow out, and by 9-12 months postpartum, your hair growth cycles should return to normal. 

Postpartum Mood and Emotions

Another thing you want to be aware of after you have your baby is hormonal changes that can cause changes in your mental health. Postpartum depression is one of the most overlooked symptoms and can have the most significant impact on your mental and emotional health, both short and long-term.

After the birth of your baby, your hormone levels drop quickly. A significant drop in estrogen and progesterone after birth leads to chemical changes in the brain that trigger mood swings. Other hormones produced by your thyroid gland also may drop sharply, which can make you tired, low energy, and depressed. Changes in the thyroid are common after pregnancy. If you have had any thyroid issues or a family history of them, get it checked after you have your baby. When you combine drops in hormone levels with a lack of sleep, your body working to recover from labor and birth, and the stress of caring for a newborn, you have the perfect storm to be bummed out.

Baby Blues

Many new moms will experience what is often referred to as “baby blues” after their baby arrives. This generally includes mood swings, crying spells, anxiety, and difficulty sleeping. Some other signs are sadness, irritability, feeling overwhelmed, reduced concentration, and a reduced appetite. Baby blues typically begin within the first two to three days after birth and last about two weeks. The good news is it generally disappears pretty quickly on its own.

Postpartum Depression

Postpartum depression lasts longer than the baby blues and can be more serious. You need to know that baby blues and postpartum depression are not due to anything you did wrong. It is just a complication of birth. If you are struggling with signs of depression, you do not need to be embarrassed or ashamed and know that you are not alone. So many women deal with this, and very few openly discuss it. The sooner you seek help, the better. Please speak to your doctor or midwife about how you feel and seek professional assistance if you are struggling mentally or emotionally.

Breastfeeding

Breastfeeding is a big part of your postpartum period and can be challenging as you and your baby navigate your breastfeeding relationship. We assume that breastfeeding will come naturally; if it does for you and your baby, that is fantastic. It certainly doesn’t feel easy for a lot of new moms. I recommend attending a breastfeeding support group in those early days and weeks. Also, seeking the help of a lactation consultant preventatively or the second you are having trouble can make a world of difference. You can also get free help after birth while still in the hospital. If you plan a home or birth center birth, your midwife may assist or recommend a lactation consultant. For more resources on breastfeeding, click here.

Warning Signs Related to Breastfeeding

A few things can be warning signs related to breastfeeding. The sooner you get help and correct the underlying issue, the quicker you can return to breastfeeding without disrupting your milk supply. If you do not take care of a minor issue, it can quickly grow into a more significant issue that can potentially derail your breastfeeding relationship.

Sore or cracked nipples

You likely hear that breastfeeding is not supposed to hurt. It isn’t supposed to, but it is common to have sore and sensitive nipples in those first few days. This is a part of your body that isn’t always used to this much stimulation. Sore nipples are often related to a poor latch. As with anything breastfeeding, you always want to fix or correct the underlying problem, not just treat symptoms. As you are correcting the underlying issue, you want to give yourself some relief if you damage your nipple.

The first thing you can do is start your baby off on the other side. Their sucking tends to be more intense at the start. After breastfeeding, you can use a saline solution on your nipple. This is easy to make with 8 ounces of warm water and ½ teaspoon salt. Soak your nipples for about a minute. You don’t want to do it too long. Afterward, pat them dry and then put breast milk on your nipple. Your breast milk has anti-inflammatory and anti-bacterial properties that can help promote healing. Nipple cream can also provide some relief and may speed up recovery. This isn’t something you should be using every day for your entire breastfeeding life. Nipple cream should be short-term to help heal while you fix the problem causing the damage.

When you are not nursing, try giving your nipples exposure to air, and you can use mild soap once a day on your nipples if they are chapped or cracked. Damaged nipples are uncomfortable, but they will heal and get better. The more proactive you are in correcting latching issues as soon as possible, the more you can prevent problems like cracked nipples. You can visit the Kelly Mom blog for more info on Healing Tips for Nipple Cracks or Abrasions.

Plugged Duct

Your breast has many ducts that send milk to your nipple. When one of those ducts gets plugged, it doesn’t get emptied, and it can get hard, swollen, red, and feel warm or hot to the touch. This is usually due to ineffective milk removal if your baby isn’t eating well and getting engorged. You can also cause a plugged duct with a bra that is too tight or doesn’t fit well. Wear comfortable bras and tops that are too tight or not digging into your skin. The best method to treat a plugged duct is to empty the milk from your breast, drink plenty of fluids, and eat well. Before you breastfeed, you can apply heat to your breast with a warm compress or a warm shower and massage it. While you are nursing, you want to massage from the plugged duct towards your nipple to try and help get it unclogged.

Mastitis

If you do not resolve a plugged duct, it can turn into mastitis. The symptoms are similar but often more intense, including a fever and flu-like symptoms like aches and chills. Mastitis may be an infection due to bacteria entering through a point of damage on the nipple. To treat mastitis, you want to follow the same treatment as for a plugged duct, but you also want to rest, preferably in bed, with your baby. Your care provider may prescribe antibiotics to treat an infection. If you are running a fever and have flu-like symptoms, contact your doctor or midwife to talk to them about their suggested course of action and whether or not you should consider antibiotics.

Plugged ducts and mastitis are very similar, and an excellent article on Kelly Mom compares and explains the two.

In my most recent breastfeeding journey with my daughter, I got mastitis, and it turned into a full-blown abscess that landed me in the hospital. This was not a fun experience, and you can visit this episode if you want to hear more about my experience and the lessons learned breastfeeding the second time around. It is critical to take great care of your health at any time, but definitely when breastfeeding, especially when mastitis is most common in the first few weeks. If you have anything you do to strengthen your immune system, now is the time to do it. My go-to is AG1 and lots of rest.

When to Contact Your Doctor or Midwife

Your care provider is an expert at recognizing symptoms of more severe conditions, but they are not with you 24/7 after birth and during your recovery. Please pay attention to any instructions for your care and recovery after birth. Some basic warning signs should prompt you to contact your doctor or midwife immediately. Some signs of an infection are fever or flu-like symptoms. If you have swelling or are vomiting, those are also signs to reach out to your care provider. If you are experiencing something that doesn’t feel right, always bring it up. It could be no big deal, but at least then you would know you don’t need to worry about it. Please do not hesitate to contact your doctor or midwife.

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