It turns out that we have been missing a big piece of the pie in terms of maternity care. There is a keen focus on maternal and fetal health in the first, second and third trimesters with inadequate attention to the comprehensive needs of the acute post-partum period and almost zero attention to the later portion of the post-partum period, the fourth trimester.
The ‘fourth trimester’ is the period after the birth of the baby; the post-partum period. This is considered to last for three months, with some advocating it may actually last a full six months. The paradigm for American maternity care, and social constructs, has been that the post-partum period is six weeks long...
You have six weeks to physically recover, emotionally adjust, master breast feeding, fall in love with your baby, redefine your life and position in society, have sex again, learn to function on little sleep and then you’re thrown back into your working routine again. This has largely been generated by the insurance companies’ definition of the global obstetrics billing package to cover pregnancy, delivery and care for six post-partum weeks; not driven by science or compassionate patient-centered care.
Not only are the emotional adjustments enormous for many moms; it turns out that there is a lot of physical healing that extends well beyond six weeks in terms of tissue healing, cardiovascular changes, blood clotting risks and hormone levels to name a few. We are missing a lot of important pieces to maternity care when we expect six weeks to be uniformly the right amount of post-partum time that women need. Let me offer two examples why prolongation of the defined “post-partum” period is essential.
The Return to Work
Many working women in America are expected to return to work after six weeks maternity leave; some as soon as four weeks. Those protected by the FMLA legally can take 12 weeks (often without pay), but often are culturally or environmentally pressured to return to work much sooner. We advocate for exclusive breastfeeding and then expect mom to be separated from her baby for many hours a day in the first few weeks or months of life before her milk supply is fully established, leading to tremendous stress, guilt and failed lactation for many moms. Despite clear advocacy for breastfeeding, the biology and psychology of breastfeeding has been undervalued and modern society has placed many barriers to success; including rapid return to work.
The breast pump offers many moms opportunity for breast feeding success but falls short of being a miracle. The breast pump is often seen as justification for why women can ‘easily’ do both: work full-time and breastfeed exclusively. This is an incredibly disappointing misnomer for many women. The pump is not an equal substitute for a nursing baby and it is no wonder many women see a supply decrease, despite tremendous effort, when they transition to primarily pumping with the return to work. Many work places offer no welcoming set-up for pumping as well, and even fewer are accommodating to the baby coming to nurse. The fourth trimester is critical for establishing a milk supply that sets the narrative for the duration of breastfeeding; we need to be cohesive in our messages about breastfeeding’s benefits and the reality of achieving that for working moms.
Sex and the Six Week Check-up
I find that frequently husbands and partners have been misinformed and expect that their wife will return from her six week check-up “cleared” for sex again. Many women are not physically nor emotionally ready for sex by six weeks post-partum. Many women are not ready for sex for many months after a baby. This is normal! Unfortunately our current construct suggests something magical about a six week post-partum abstinent period resulting in disappointment, nagging, frustration, guilt and even long term negative effects on an otherwise healthy sexual relationship. We need to reassure new moms, and their partners, that returning to being sexually active after a baby follows no rigid timeline and stop suggesting that at six weeks she should be ready to resume sex. Sexual desire is complicated and far more than a few healed stitches plays in to when a woman is ready for sexual contact after birth.
These two examples of misguided expectations about the post-partum portion of maternity care demonstrate how poorly we have addressed and defined the post-partum period. Such misconceptions lead to disempowering perceptions of the weeks and months following birth for many families. Fully embracing the needs of the fourth trimester will take a culture shift; in our medical offices, in our homes, in hospitals and maternity wards, in our places of work and in our government.
So, yes, there is a fourth trimester. And it has always been there as an unnamed and under-attended to extension of our defined post-partum period. ‘Quadmester’ is unlikely to replace ‘trimester’ in our dialect, but hopefully ‘fourth trimester’ will become common place vernacular in the near future.
Rosanna Gray-Swain, MD, is a member of BJC Medical Group and a part of the West End OB-GYN practice. The practice is located at 1110 Highlands Plaza, Suite 280, St. Louis, MO and can be reached at 314-286-2620. Dr. Gray-Swain is accepting new patients, so BOOK today!