A Mother’s Guide to the Fourth Trimester

The fourth trimester — the 12 weeks after giving birth — is just as important for a mother’s health as the first three trimesters. Yet this is often when mothers have the least interaction with their healthcare team, a time when, some experts argue, they need it the most.

The American College of Obstetricians and Gynecologists (ACOG) recommends that mothers have initial contact with their OB-GYN within three weeks after delivery, followed by ongoing care as needed, and a comprehensive postpartum visit no later than 12 weeks after delivery. They also recommend that a postpartum care plan be developed during pregnancy, so that birthing parents are better prepared when they go home.

“Those 12 weeks after giving birth are a critical time to focus on Mom and make sure that she is healthy moving forward,” says Dr. Mary Rosser, an OB-GYN at NewYork-Presbyterian/Columbia University Irving Medical Center. “We want to make sure it is not just a one-off checkup, but that we’re giving mothers holistic care and support for their growing family. Postpartum care sets the stage for lifelong health and well-being.”

Health Matters spoke with Dr. Rosser, who helped develop post-birth recommendations as a member of ACOG’s Presidential Task Force on Redefining the Postpartum Visit, about what mothers need to know during these critical 12 weeks.

According to Dr. Rosser, just 40% of moms attend their postpartum follow-up visit. “It’s an overwhelming time, so what often happens is this visit gets pushed aside, but it absolutely should not,” she says. “It impedes the management of chronic health conditions, discussing family planning and contraception, assessing mental health and well-being, and physical recovery.”

Rather than the traditional single checkup at around six weeks, Dr. Rosser says that “postpartum care should be an ongoing process, with tailored services to support each mother’s individual needs.”

According to ACOG, postpartum visits are recommended:

• Within 1-3 weeks: Mothers should be in contact with their maternal care provider within the first three weeks after delivery; those who are considered high-risk should check in within the first week or two, says Dr. Rosser. This first check-in — which often can be done over the phone or via telehealth — is to make sure Mom is doing well (physically and emotionally) and baby is doing well (feeding properly and gaining weight). It is important to discuss with your healthcare provider whether this initial visit can be done via video or should be in person.
• Within 12 weeks: Mothers should have an in-person, comprehensive care visit to discuss any medical concerns during pregnancy that may need addressing, as well as the mother’s physical health, infant care and feeding, and the mother’s mental and emotional health. This is also a time when practitioners and patients can develop a road map for future health.

It is important to note that, depending on a mother’s personal history and individual needs, they should receive ongoing postpartum care as needed. “It really is no longer a one-size-fits-all approach,” says Dr. Rosser.

1. Physical recovery
After delivery, there is a lot of soreness and healing that takes place. It is important for patients to have a full physical exam during their postpartum visit. If a patient had a tear during a vaginal delivery, they’ll need a thorough exam to make sure everything is healed. For C-section deliveries, the stitches need to be looked at to ensure they’re healing. “I’ll listen to the heart and the lungs, especially if they have had hypertension, do an abdominal exam, check to see if their thyroid is OK,” says Dr. Rosser. “You’re going from top to bottom, just like you would for any comprehensive exam, but you are targeting and individualizing it to that individual woman.”

2. Infant care and feeding
Postpartum appointments are also a chance to assess how a baby is doing and whether they are feeding properly. Breastfeeding is healthy for both infants and moms, but not everyone has instant success. If, after two or three days, there is a lot of pain, Mom is unable to breastfeed, or the baby is not gaining weight, seek support from a lactation consultant.

3. Sleep and fatigue
Mothers will be very fatigued in the first few weeks after delivering their baby. Experts advise fitting in sleep whenever you can, such as when the baby is sleeping. Resist the urge to do chores around the house when your newborn is sleeping and take a nap yourself. Consider enlisting your partner in nighttime feedings so that you can get a good night’s sleep. Perhaps a family member or friend can help with babysitting once or twice a week or running errands while you get some much-needed rest. Don’t be afraid to ask for help if you are not getting enough sleep to function. This sleep deprivation should slowly get better over time. If it does not get better and instead gets worse, call your doctor.

4. Mental health and well-being
It is normal to feel a bit of sadness seven to 14 days after birth — as many as 80% of women experience these “baby blues.” After all, a mother’s hormones are shifting, there is lack of sleep, and they are adapting to a new baby. “But if it’s beyond 10 to 14 days and people feel an overwhelming sadness, hopelessness, or a mother has so much anxiety or worry that they even think about not existing anymore, that may be a sign of postpartum depression,” says Dr. Rosser. “Those are reasons to get help immediately.”

5. Sex and family planning
Returning to sex should be a personal decision. “Usually, it’s OK at six to eight weeks if everything is healed, or whenever Mom feels ready,” says Dr. Rosser. “What is important is that partners have open communication. Sex may be a bit different, so it is good to be open to it being different and take your time.”

When it comes to contraception and family planning, Dr. Rosser urges patients to have a plan in place before the baby arrives. Do not consider breastfeeding a form of contraception. “Before you become sexually active again, talk with your provider about birth control. Many patients will opt for an IUD right after delivery so that they don’t have to worry about an unplanned pregnancy immediately after birth.”

6. Diet and exercise
It is important for new moms to nourish their bodies with healthy, whole foods (lots of fresh fruits and veggies, lean protein, and whole grains), drink plenty of water, and begin moving their bodies as they feel ready. Whether you have had a vaginal delivery or a C-section, an excellent place to start is simply walking: Go outside and walk around the block. Ease into it and build up your physical activity. For those who have had a C-section, check with your doctor about when you can resume more strenuous physical activity.

By eating well and moving your body, you are helping yourself heal and recover. Healthy babies need healthy, well-adjusted mothers. After all, “If Mom is not well, then she is not going to be able to care for her baby and her family the way that she might want,” says Dr. Rosser.

7. Chronic disease management
Postpartum visits are an opportunity to recognize risk factors for conditions like heart disease or obesity and to check that complications during pregnancy such as high blood pressure or diabetes are resolving. “We can provide risk reduction strategies and early intervention,” Dr. Rosser says. “It’s about educating, empowering, and motivating the patient and encouraging a healthy lifestyle that is consistent.”

8. Know the warning signs
More than half of pregnancy-related deaths occur up to a year after the birth of the baby, according to the Centers for Disease Control and Prevention (CDC). And Black women are about three times more likely to die of a pregnancy-related cause than white women. It’s a sobering statistic that OB-GYN experts are working diligently to change by raising awareness of certain warning signs.

Seek medical attention immediately if you have any of the following symptoms:

• Fever or chills — This could indicate an infection vaginally (if there was a significant tear), in the womb, or of the C-section. Urinary tract infections can also be very common.
• Heavy, brisk, bright red bleeding — Postpartum women may bleed up to 4-6 weeks; however, if it is heavy all at once, it could be postpartum hemorrhage. “I tell women, if you saturate a pad every hour and that’s consistent for several hours, we want to see you,” says Dr. Rosser.
• Dizziness — A symptom associated with loss of blood.
• Shortness of breath or chest pain — This might signal a blood clot like deep venous thrombosis (DVT) or a pulmonary embolism.
• Severe headache — Sometimes associated with preeclampsia, which is a pregnancy complication characterized by high blood pressure or stroke.
• Swelling of the legs and feet — May be a sign of preeclampsia.
• Deep sadness, thoughts of hopelessness, or thoughts about death, suicide, or harming oneself or the baby — Postpartum depression affects about one in eight mothers and is very serious.

“These symptoms can be life-threatening,” explains Dr. Rosser. “Don’t ignore them or chalk them up to just being tired and postpartum. If it’s something that is out of the ordinary, please contact your doctor or go to the emergency room.”

Mothers who are considered high risk — they have diabetes, high blood pressure, obesity, or another chronic health condition — should be extra vigilant about any signs and symptoms that are not normal.

“Just as babies need care and attention during the fourth trimester, so too do mothers,” says Dr. Rosser. “Postpartum care is a crucial time to make sure Mom is safe and healthy so that the baby can be supported in the best possible way.”

Mary L. Rosser, M.D., Ph.D., is an OB-GYN at NewYork-Presbyterian/Columbia University Irving Medical Center. She is also an assistant professor of obstetrics and gynecology at Columbia University Vagelos College of Physicians and Surgeons, where she is Director of Integrated Women’s Health and Director of the Columbia Women’s Postpartum Health program. Dr. Rosser is co-chair of the New York State Expert Panel on Postpartum Care and is a member of the American College of Obstetricians and Gynecologists’ (ACOG) Presidential Task Force on Redefining the Postpartum Visit. Primary care and heart disease in women are areas of focus for Dr. Rosser. She served as chair of the Women & Heart Disease Physician Education Initiative for ACOG’s District II. She has published numerous clinical studies and lectured on heart disease and well-woman care. Dr. Rosser has served on the Medical Leadership Team of Go Red for Women, the American Heart Association’s signature women’s initiative, and is ACOG’s liaison to the American College of Cardiology.