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Reviewed by the Faculty of Harvard Medical School

The Postpartum Period: Your "Fourth" Trimester

By Mary Pickett, M.D.
Harvard Medical School

When I was pregnant, I confided to my friend and mentor Phyllis that while I was excited I would have a baby, I was at times even more excited that I would have the entire length of my maternity leave to rediscover hobbies, reach out to friends, complete deferred projects and indulge in the testing of new recipes and decorating ideas. "I am going to take up the classical guitar, Phyllis!" I gushed.

Phyllis was wise from experience. She gave me a wry smile and she laughed kindly. "You will be doing well," she said, "if you make it out of your pajamas and into real clothes on most days of the week."

I was amused by her answer but I secretly vowed I would prove Phyllis wrong. Later, I was grateful to think back to her words. Without Phyllis as my reality check, I might have felt like quite the female failure during my postpartum period.

When I was first pregnant, I was given unlimited information about what to expect during pregnancy and delivery. I attended classes about how to care for my new arrival. But no one told me what to expect after delivery, or how to care for myself in the months that would follow. The postpartum period, described by some as the "fourth trimester," is a magical time, but it is also a period of guaranteed fatigue, anxiety and physical discomfort for new mothers.

Since many women leave the hospital in the first 24 hours after delivery, we can feel very much alone as we take stock of our own bodies and health in the weeks that follow childbirth. Typically, a doctor does not re-examine women until six weeks postpartum. Here are some things that no one told me before delivery, that I would like to have known:

Pelvic Symptoms
  • Vaginal bleeding (renamed "lochia" during the postpartum months) normally continues for a full three to eight weeks after delivery. Between the seventh and 14th day after delivery, it is normal for this bleeding to increase as the placenta's initial scar dislodges.
  • It is expected that you will have pain when urinating for at least several days after delivery, whether or not you had an episiotomy (a surgical cut to widen the vaginal opening during delivery). A warm water squirt bottle can be used to dilute the urine as it comes into contact with your skin surface and vagina.
  • It is normal for your uterus to cramp during the baby's first breastfeeding sessions. Brief episodes of pelvic or abdominal pain that occur during breastfeeding can occur for as long as a week.
  • A large fraction of women have urine or bowel incontinence, or both. In some women, this is caused by muscle stretching, tears or tone problems. In most women, however, the cause of the problem is stretching with temporary damage to the pelvic nerves. Coughing, sneezing or lifting the baby can cause abrupt urine leakage because of increased abdominal pressure, a problem known as "stress incontinence." Some women with pelvic-nerve stretch injuries also have "urge incontinence." With urge incontinence, urine leakage can be triggered by the power of suggestion. In this case, you may wet yourself when you turn on running water to wash dishes or to wash your hands after a diaper change. You may wet yourself just at the time you arrive at the bathroom. Incontinence stays around for many women for a surprisingly long time, particularly when nerve healing must occur. One survey found that three months after birth, 15% of women still had urinary leakage and 5% percent had loss of stool.
  • Hemorrhoids are common in the postpartum period and may cause itching or bleeding from the rectal area.
  • If you have a Caesarean section (C-section), abdominal pain can be severely limiting in the first week after your surgery. Remember that you have had a major surgery. Having a surgical incision will make it difficult to sit, stand, walk and lift your baby or change his or her diaper. The soreness is related to the incision but also to the stretching of ligaments during surgery. The postpartum blues and the pain can make you feel especially bad about being unable to care for your baby immediately, but keep reminding yourself that it will get better each day. You need to take care of yourself to take care of your baby. In most cases, women spend at least three to four days in the hospital after the surgery. Plan on getting help when you go home with your baby, because it will take you at least two to four weeks before you feel strong again. On a positive note, you usually will have less bleeding and fewer problems with incontinence or vaginal pain and swelling.
Your Beauty And Your Sexuality
  • Many women have dramatic hair thinning that occurs two to six months after delivery. The hair loss continues for weeks to months, and then the hair grows back (always).
  • It will take time for your weight to return to normal. Although most women lose between 10 and 20 pounds during the first four weeks after delivery, weight loss varies greatly among individual women. Breastfeeding helps with weight loss. Studies have shown that women who are breastfeeding their babies lose on average slightly more than 1.5 pounds per month in the second to sixth months after delivery.
  • Breasts are sensitive to all stimulation, and they will let down (and leak) milk if they are caressed. They may also leak milk in a warm shower, when you bend over, or if you hear your baby cry. Breast infections can occur in the postpartum period and you should be on the watch for red or sore areas.
  • Sex is not possible soon after delivery for most women. Six weeks is a typical amount of time that women wait before resuming sexual intercourse. At six weeks, about half of women will have some pain with intercourse when they first have sex again. Many new mothers have a low libido — three weeks after delivery, about 40% of women describe having little desire for sex, complete loss of desire or an aversion to sex.
Your Emotional Health
  • Hormone shifts in the first days after delivery frequently cause dramatic mood swings. Some doctors estimate that up to half of women (and the people around them) notice these "baby blues." Mood swings from these hormone changes should not last more than a week or two at the most.
  • Postpartum depression is a common problem that begins weeks to months after delivery. About one out of every six or seven women develops this more serious depression. Postpartum depression can make a new mother weepy, easily upset, and unable to sleep. It can cause her to be less attentive to her infant or more worried and preoccupied with her baby's care. Depression is a problem for the emotional health of both the mother and the baby, and it is important that a depressed mother receive medical attention.
  • Ten percent of women are found to have at least mild abnormalities in thyroid function in the months after delivery, and thyroid abnormalities can cause symptoms of anxiety or depression. For most new mothers thyroid abnormalities are temporary, but if they occur after childbirth they may recur later in your life.
  • Fatigue is universal to new mothers, and headaches are common. These problems can make you less emotionally resilient.
Your New Job
  • Babies are all different, and none comes with an instruction manual. Despite prenatal classes and infant-care advice guides, mastery of motherhood is born of trial and error. Motherhood is humbling, and it provokes anxiety. Do not be hard on yourself if it takes you time to feel like an expert.
  • As you may expect, newborn babies lead a simple life: They coo, cry, eat, sleep and fill diapers. You may not have anticipated that babies cycle through these functions rapidly, leaving you little break time in between feedings and changes, and they cycle at this speed through both the day and the night. As a new mom you will sleep, but your sleep will always be interrupted. Give in to your fatigue, and take a nap whenever you can claim one in the early days after delivery. Arrange to have a lot of support at home, especially in the first two weeks after you have delivered.
  • Breastfeeding is not easy for most women who are new at it. However, it is valuable to your baby's health and to your own bond with your baby if you are able to continue this form of feeding. It will be well worth your efforts if you seek nursing assistance when you develop any problems or concerns about breastfeeding. Most obstetrics offices can arrange for a nurse to visit you in your home in the case of breastfeeding difficulties. If you are given the chance to schedule such a visit at the time of your delivery experience, accept the opportunity without waiting for problems. Even if breastfeeding is going well, you will have collected some questions by the time of the visit.
  • Your nutritional needs will be increased in the postpartum months, particularly if you are breastfeeding. Women who breastfeed also need extra fluids. Your diet should include supplemental calcium, protein and total calories. Extra fluids are particularly important during and after breastfeeding sessions.
The Bottom Line

Falling in love with your new baby may happen immediately. Like any infatuation, your love and adoration can and should consume hours out of each day. You will be amazed at the passing of time, and you will find it remarkable how little you appear to "get done" in your postpartum months. I myself am proud that I got out of pajamas and into real clothes on most days of the week. In your postpartum months, don't lose sight of the immensity of your accomplishments: having and nurturing a newborn.

Mary Pickett, M.D. is an Associate professor at Oregon Health & Science University where she is a primary care doctor for adults. She supervises and educates residents in the field of Internal Medicine, for outpatient and hospital care. She is a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.

Last updated July 27, 2008