The first few months after birth are essential for establishing family wellbeing.

For mothers, the first 12 weeks postpartum, also known as the fourth trimester, should be seen as a continuum of pregnancy and an important period of recovery and family adjustment (Verbiest et al. 2018).

Typically a time of great joy, the early postpartum period is also a time of significant challenge as new mothers adapt to hormonal and physical changes, recover from delivery, endure sleep deprivation and adapt to shifting family responsibilities (Spelke & Werner 2018).

Given the significance of all these changes, Goldfarb (2021) asks why monitoring, support and anticipatory guidance are not offered with the same intensity as during the antenatal period, as most women would benefit from much closer follow-up during the fourth trimester.

Postnatal Advice and Assessment

The fourth trimester can be a time of great vulnerability, especially for new mothers who tend to focus all of their attention on their newborns, often to the detriment of their personal health and wellbeing. It’s said that excellent postnatal care needs to start in the antenatal period, where mothers with special needs and vulnerabilities can be identified in time for additional support and education to be set in place. It’s also been argued that a six-week postnatal visit that focuses mainly on physical health doesn’t provide a sufficient level of care for more vulnerable mothers and should be replaced by a continuous conversation that emphasises support and early intervention.

The key considerations when assessing early postnatal health include:

Bleeding

This should diminish in the weeks following birth, gradually changing in colour from bright red to a brown lochia before ceasing entirely. Mothers should be advised to report the presence of any blood clots and reassured that afterpains might be more noticeable, and bleeding heavier, in the early days whilst breastfeeding.

Elimination

For mothers who have had a vaginal birth, grazes or tears to the skin around the vagina can cause pain when passing urine. Reassurance should be given that this is normal, and simple self-help techniques should be suggested, such as drinking plenty of water to dilute the urine and pouring warm water over the perineum to reduce any stinging sensation whilst urinating. Advice should also be offered at this time to help the mother avoid constipation, especially if haemorrhoids are present.

Stitches

Basic wound care advice should be given to mothers who have stitches following a caesarean birth, perineal tear or episiotomy.

Breastfeeding

Many women find the changes in their breasts in the early postnatal days to be concerning, whether they are breastfeeding or not. For mothers who choose to breastfeed, this is one of the most important areas where ongoing skilled support is needed.

Pelvic Floor Exercises

Stress incontinence is a common problem in the immediate postnatal period. Although most women learn how to perform pelvic floor exercises in antenatal classes, encouragement should be given for regular practice in the early days following delivery.

Sex

Physical recovery, exhaustion and hormonal changes can affect sexual desire after childbirth and mothers often need reassurance that it’s entirely normal to ease back into a sexual relationship at their own pace. This is also an important time to discuss future methods of contraception.

Managing Expectations

Supporting the entire family as they adapt to change and encouraging realistic expectations about the challenges of early motherhood is another vital, though often overlooked aspect of fourth-trimester care.

(RANZCOG 2017)

Improving Fourth Trimester Care

Spelke and Werner (2018) suggest that even though physical checks are of the utmost importance, there can be a disconnect between clinical considerations such as signs of infection, and the concerns of mothers, who may experience significant distress from symptoms that are considered to be a ‘normal’ part of motherhood, such as sleep deprivation, discomfort and emotional changes.

Many researchers, including Tully, Stuebe and Verbiest (2017), have been exploring this practice gap. Their suggestions for improving postpartum care include enabling more convenient, holistic care that is culturally appropriate, and which addresses the interrelated health issues that are most important to women.

Written or multimedia aids such as handouts, videos or websites can also be helpful postpartum resources after discharge. As Spelke and Werner (2018) note, this is a request that is often voiced in focus groups, reflecting the need for additional support for new mothers.

The fourth trimester is also a period of healthcare transition, as mothers shift from pregnancy-centred care to interpregnancy and then primary care services. However, this transition can be marked by poor coordination of care between providers, which can leave new mothers feeling unsupported.

Creating a Postnatal Plan

Creating a postnatal plan can be just as valuable as creating a birth plan, especially for single or first-time mothers. As Goldfarb (2021) describes, there are many online resources available to help mothers do this. Just as with a birth plan, actively planning for optimal postnatal care can be an efficient way of helping mothers express their concerns and get the support they need.

As Savage (2020) says, if planning for birth is good practice, then planning for the fourth trimester is also good practice, and the more specific or detailed the plan is, the more helpful it is likely to be.

Ideally, mothers should start to formalise their plan no later than the third trimester. Their plan should be meaningful, realistic, achievable, action-specific, anticipate barriers and include reinforcement. Perhaps most importantly, a fourth trimester plan should also include information on how to access additional resources such as community support groups. Social support within the mother’s local community is essential in the fourth trimester, as it can make the transition into motherhood easier, less stressful and more enjoyable. It’s also a topic that in the view of Cornish and Dobie (2018), warrants further research, as there can be significant differences in the need for social support between inexperienced primiparous, and experienced multiparous women.

As Savage (2020) says, the fourth trimester is characterised by a myriad of profound changes that affect the physical, emotional, social, and spiritual needs of the woman as she adjusts to motherhood. Perhaps the reason why the fourth trimester is often called the ‘silent’ trimester is that it is under-represented and poorly understood, leaving many mothers feeling forgotten as they embark on the most challenging transition of their life.