And So They Lived Happily Ever After: Planning for a Smooth & Successful Fourth Trimester

For many families, the focus during pregnancy is keeping themselves feeling their best and preparing for the birth of their baby. Often times, we forget that planning for the first 6-to-8 weeks postpartum is just as or even more important than the birth itself. The reality is that no matter how much planning you do, you don't have any control over the way your birth will ultimately unfold. But you can do SO much to guarantee that you have a smooth and enjoyable postpartum with your baby!

Now what IS the The Fourth Trimester exactly? This refers to the first 12 weeks or 3 months, following the birth of your baby. But truthfully, this is a significant time that extends well beyond 3 months, specifically distinguished by acclimating to new physical and emotional fluctuations. Baby is also going through (what feels like) unending growth spurts that come with fluctuating sleep & feeding patterns.

Understanding Postpartum Physiology

One main point we must drive home here, is that your body just went through the extremely strenuous event of childbirth - no matter how your baby exited your body - and now, needs to recover.

Postpartum is no easy feat... so prepping for this to be harder than labor & childbirth (truthfully, it will be and lasts a hell of a lot longer) and setting yourself up for all of the challenges this period will bring you, will only leave your future self very thankful.

Lochia

Immediately following the delivery of your baby, you'll experience postpartum bleeding, called "lochia". The lochia contains active, fresh bleeding, from the placental site (in which the postpartum contractions are meant to constrict the vessels of to control your bleeding!). This wound, being as large in diameter as your placenta (roughly the size of a dinner plate) requires SOLID rest to heal. The more you move around, bend or lift, push or pull things, the longer the site will take to scab over and heal. So you have this bleeding from your placental site, plus all the tissue from that extra thick decidual lining of the uterus that sustained your growing baby through the entirety of your pregnancy.

Think of your lochia as not only bleeding from where your placenta was attached, but also a gigantic period, which is what causes the different stages of lochia.

1st stage: Lochia Rubra. This is the heaviest your bleeding should be as it contains the active bleeding from the placental wound, plus mucous & uterine lining. It'll be dark red & thick, like the peak day of your period. Should only last up to 5 days, but typically will lighten significantly with the onset of milk.

2nd stage: Lochia Serosa. This is the longest cycle of lochia, lasting up to 3 weeks, is much more watery and scant in flow and can vary between pink-brown and can be easily disrupted, adding to length of recovery. It's the most important time to monitor this bleeding and make sure you're not doing too much!

Placenta Scab: You could also experience a very large clot, up to the size of your fist, or lots of small clots, with an increase in bleeding flow for up to 2 days, somewhere between day 10-14 postpartum. THIS IS NORMAL! The placenta wound forms a scab and eventually it will slough off, even without any added or new activity. Don't be alarmed, just continue to take it easy through this time and after you'll notice the lochia decreases further to a brown spotting flow.

3rd stage: Lochia Alba. This is a yellowish to off-white discharge, indicating you're in the final phase, typically lasting around 7 days. So once you're clear of any spotting for 7 days, you're in the clear to resume normal exercise, activities, intercourse, etc as they feel comfortable for you!

Getting Back to Ourselves

Uterine involution (reduction in uterine size and the evidence that postpartum uterine cramping/after pains really are doing something productive!) occurs at a rate of roughly 1cm

per day from a fundal height of umbilicus at 48hrs through up to 8 weeks postpartum. Between 6-8 weeks postpartum, the uterus should be back to "pre-pregnant" size. Though your uterus will always be a titch larger than it was before it was ever gravid. These afterpains are most intense during the first 5 days postpartum. And the more babies you've had, the more fierce those contractions will be. Many people, who've had more than 5 babies, often describe these afterpains as worse than their actual labors.

Now that we understand what your body is doing PHYSICALLY, it's time we review extremely realistic expectations for rest in the postpartum period and how & when to begin introducing daily activities or exercise. While the first 2 weeks are so euphoric, they are also fleeting. We highly encourage our freshly postpartum clients to stay in bed for at least 5 days, then near the bed for minimally another 5 days, with very limited activities until after your placenta scab has sloughed off. These timelines will allow for proper uterine involution to occur, but lets not forget that you have a delicious new baby to soak in too!! Enjoy this time together!! Once that scab has sloughed, you can begin to add in one new light activity per day, so you may monitor your bleeding depending on the type of activity you've tried. If your bleeding increases ever, that new activity was too much and you'll need another day or two of rest. When you've gone 7 whole days without any pink or brown spotting, you're safe to resume normal daily activities, chores, exercise & intercourse (as these feel desirable of course)!

Lactation - Part 1

We've split lactation up into a couple of different sections, here as it pertains to your recovery and later for additional tips & tricks. The first milk is known as colostrum. This is a thick, starchy, golden fluid that acts as a laxative for the baby, to help them eliminate that meconium! But it does NOT contain a lot of water, so it's not as hydrating as milk is. Colostrum is a fluid of pregnancy, so everyone has this initially. They have to work super hard to get this fluid out of the breast, so they may get tired as those new little muscles in the mouth, jaw and neck are developing and getting stronger! Meaning they may pop off frequently in the first few days, cluster feed small amounts more frequently, etc.

A healthy timeframe for full milk onset is roughly 3-5 days postpartum, but minimally it will take 24 hours from the time the placenta sheers away from the uterine wall. Milk contains a higher water content and more fats & proteins. Your body uses a let down reflex to shoot milk out of your body and can fill a baby's tummy QUICKLY, leading to a "milk drunk" affect in the baby! Milk onset is also an inflammatory response. So you'll notice night sweats, hot flashes, slight fatigue and possibly an elevated temp (but not quite a fever, between 99-100 degrees).

FUN FACT: Oxytocin is released when you latch your baby, because it is responsible for contracting the alveoli in the mammary ducts, which also promotes uterine contractions for involution... is the body not incredibly designed?!

Nipple sensitivity with initial latch, that lasts about 10-30 seconds or so and will occur with each feed through the first 1-2 weeks, is completely normal. However, if you're experiencing pain & discomfort throughout the entire feed, this would be abnormal. Please gently break the baby's suction and readjust before attempting to latch again. However if the baby consistently has a poor latch, causing you pain and/or tissue trauma, please call your provider. Later we'll cover feeding, pumping and storage!

And one more thing in regard to lactation before we move on. There are several neuropeptides & hormones involved with lactation, that are all working together in a feedback loop to keep your supply adequate. These main players are Growth Hormone, Leutenizing Hormone, Gonadotropin Releasing Hormone, Prolactin, Estrogen & Progesterone. Increased levels of Dopamine and/or Seratonin may actually decrease milk volume as they are inhibitors of the lactation feedback loop.

Full time, on-demand and frequent bodyfeeding will allow your body to experience a cool phenomenon known as Lactational Amenorrhea - a fancy way of saying you won't ovulate or have a period for a while! The levels of these invidual hormones will ultimately determine how long your body will experience Lactational Amenorrhea. Which is why some will report beginning menses again around 8 weeks postpartum and others can go as long as 18 months without a cycle. During this time however, due to the influence of these hormones, you may experience decreased libido and you won't produce as much of your own natural lubrication. So it's DIRE to remember lubrication during intimacy, for added comfort and to not be too hard on yourself!

It's a hell of a lot to give your body over to your baby all day, experiencing a decreased libido and being quite touched out at the end of the day. This is super normal and common and you're not alone! Some people just need a little more time to feel back to themselves.

Postpartum Mood Disorders

And because there are so many hormones involved with lactation, plus the crashing levels of hormones from pregnancy & birth, it can be common as well to experience emotional disturbances postpartum in the first 10 days or so. We encourage all of our newly postpartum clients to immediately start on a regimen of 10,000iu Vitamin D and 3,500mg Omega-3's every single day to help stave off more problematic manifestations of mood disorders. But occasionally, pharmaceuticals may be helpful for you to feel healthy and back to normal. These can be really scary to read about, but early intervention is KEY! Just please, PLEASE call your provider if you are not feeling like yourself beyond 2 weeks postpartum.

Baby Blues is a mild & temporary postpartum mood disorder characterized by random weepiness, desire to be close to baby, insomnia, anxiety, depression and more. While this is the least severe variation of postpartum mood disorders, it's highly recommended that you continue to reach out to your providers if it's extending beyond 10 days postpartum.

Postpartum Depression is more intense than Baby Blues and lingers beyond 2 weeks postpartum. You may lose interest in caring for the baby, or for yourself as the thought of brushing your teeth or showering is just too overwhelming.

Postpartum Anxiety/OCD also extends beyond that 2 week period. You may feel overly energized, buzzy and restless. While you can tend to your baby, you're not so much paying attention to your own needs. After a full day of vacuuming the curtains and cleaning the vents & high shelves, it's suddenly 3pm and you haven't had anything to eat or drink. Or your intrusive thoughts become your reality, as in not letting the baby be near a window because it'll shatter suddenly or you won't cut vegetables because the knife will fly out of your hand and hurt your baby.

Postpartum Rage is much less common and not often discussed. But you don't feel depressed, just very easily angered and typically this may be directed at only one or two people close to you. Unfortunately this means it could be aimed towards your partner or children.

Postpartum Psychosis is the most rare & most urgent mood disorder. Characterized by complete lack of sleep, hallucinations or delusions, disorganized thoughts or speech, erratic changes in mood, catatonic state or feeling like you're not in your own body, thoughts of self-harm or of harming your baby. It's imperative to seek emergency medical help if you or your loved ones begin to notice any of these signs.

Recovery & Support

Recovery from birth, even a non-complicated delivery at home, requires a crucial amount of support. Remember, you're going to experience a serious disturbance in sleep, heavy bleeding & uterine cramping, a baby that wants to eat roughly every 2 hours (sometimes more frequently!), sore nipples from such frequent feeding, perineal/vaginal tenderness or pain, possibly even sutures, frequent pees & poops from baby, milk onset & engorgement, hormonal swings that highly affect mood & ability to cope... really, the list goes on. To complicate things further should you deliver by cesarean and the mental & physical trauma that comes with a surgical birth, could highly impact the healthy and ease of your recovery. It would be insanity to expect a person to do this all alone. What happens when your partner has a short baby-bonding leave or if you don't have friends or family nearby with the freedom to assist you while you're healing? How do we ask for help, in a society that judges you and forces you to feel inadequate if you don't just bounce back immediately while moving through parenthood with the grace & fluidity of a ballerina?

Not everyone will have family or friends nearby to help, or maybe will only have limited time, but not to fret, there are other options! Depending on resources, the following can be incredibly helpful:

"Little Helper" - a local teenager interesting in babysitting, typically advertising in their neighborhood, for an affordable hourly fee as they gain experience. The role provides support while you're home to help you with older children so you can tend to your baby, may be able to help with very light chores such as, switching laundry, making snacks, etc. May only come for 1-3 hours a few days per week.
Meal Trains - a friend or family member could begin a meal train for you, where people sign up to bring your family a meal on specific days. Can be shared across social media for higher reach.
Nanny or House Keeper - hiring someone, if within your financial means, may keep you feeling emotionally healthy. Knowing your house will be cleaned to your liking however many times per month. But even having one house cleaning done at 1-2 weeks postpartum can be so refreshing & reduces stress! On the flipside, having the peace of mind of a nanny in the house to help out with your children so you can focus on work or other tasks is certainly priceless as well. Outsourcing to people you trust and/or hire, when you don't have additional support available is beyond reasonable. We cannot be expected to do everything ourselves, maintain our homes and take care of all of our children at the expense of our physical and emotional health, as fragile as it is in the first 6 months postpartum.
Postpartum Doula - just as having a doula during labor and birth is immensely helpful, postpartum doulas specifically have the tools to assist you for postpartum. They'll generally have a CLC or some kind of background & knowledge in lactation, will help in any capacity you need for the time blocks you hire them for. Including chores & cleaning, assisting with older kids, prepping meals, sitting with baby while you nap or shower, whatever you need!
Pre-Delivery Meal Prepping - during the last couple of weeks of your pregnancy is the perfect time to stock your freezer with prepped meals that you can just pop into the crock pot or oven. Our favorite healing foods to recommend would come from The First 40 Days. Remember, you'll need a steady intake of proteins & healthy fats to encourage an abundant milk supply! Meal prepping, meal trains, etc are wildly helpful to ensure that when your partner or family support need to get back to work & life, you'll have easy and nutritously dense meals already to go. This will reduce the stress of planning, prepping and clean-up, while managing the unknowns of a blow-out, need to eat or interrupted naps.

Your midwives are here for you, babe! Literally. The way visits just cease to occur after the birth & 48hr visit, is shocking to everyone. But your provider won't know there's a problem if it's not being communicated. Don't skip calling if you're struggling with explosive and/or up & down type emotions or moods, ill-coping, lactation, mastitis, latch issues, baby's feeds & outputs infrequent or insufficient, lochia concerns, OR ANYTHING! With our practice as with many other midwives, we'd rather hear from you and put your mind at ease, review remedies or tips for whatever your concern is, and come see you as needed, than to find out at our final visit you've been struggling alone, have stopped nursing, etc!! Or on the flip side, should something actually require escalated care, let us review those recommendations with you and help you establish your next steps. Your midwives are what again?? HERE. FOR. YOU.

Preparation

Alright, let's talk supplies! We've compiled a checklist of all the fabulous things you can ask for on your registries or gather for yourself.

Disposable underwear for lochia/postpartum bleeding (such as Depends or Frida Mom - the latter being ultra premium, comfortable and highly recommended!!)
Long or overnight pads if desired over Depends/postpartum underwear or to make padsicles
Cold perineum packs (only enough for a couple of days)
Sitz bath herbal blend
Epsom salts
Perineal healing spray or foam (plenty of options from natural companies or Frida mom)
Dermaplast or lidocaine spray in the event you have had sutures
Arnica (homeopathic tablets)
Homeopathic Tinctures for cramping, lactation, or anything else you'd like
Sunflower lecithin (this is to ensure your milk fats glide through the ducts easily)
Haakaa (classic & ladybug style)
Silverettes - silver nipple caps for healing of tissue
Ibuprofen & Tylenol - for intense cramping, swelling & healing sutured tissues
Tiered roller cart, to keep all of the essentials for you & baby nearby easily!
The First Forty Days: The Essential Art of Nourishing the New Mother; a postpartum book that "revives the lost art of caring for the mother after birth".

Lactation - Part 2

Piggybacking off of the nutritional aspect above, many other factors go into a successful lactation & bodyfeeding journey. It takes fluids to make fluids and you should plan to have healthy electrolyte beverages each day plus plain water each time you need to nurse your baby. We'll also get into realistic expectations for when & why babies like to eat, how their bellies expand, storing milk, and pumping outputs & frequency/duration for pumping (should you need to bank for going back to work).

Feeding frequency is something that will be referred to often and is similiar to timing contractions; from the start of one feed to the start of the next. Ideally you should be feeding your baby about every 2 hours (with a little leeway built in). They could nurse anywhere from 15 or 20 minutes up to 45 minutes during each feed. Newborns may not understand when they're hungry and can begin to reserve calories & energy quickly.

So in the first few days, when you still have colostrum, it's important to wake your baby frequently before your milk comes in. Then, once your baby is back to their birth weight (by two weeks usually), you can allow the baby to dictate when and how long they want to feed for.

Expect increased feeding frequency and feeling empty when baby goes through a growth spurt! And these happen A LOT initially. As they grow, you'll notice cluster feeding around the clock. They may also spit up more than usual during these periods as the stomach capacity is stretching to accommodate more milk. Just nurse as needed and your body will increase your supply to meet baby's new growth demands. AND do not forget, your fluid intake needs to increase too!

Are you thinking you'll need to pump to store up milk so you can return to work? Please don't fall prey to the pictures on social media showcasing hundreds & hundreds of ounces of stored milk. Really you should only have enough stored for about 3-5 days. That's it. Because when you do finally return to work, the baby will need roughly 1 ounce per hour that you're gone and you will be pumping at work to replace the milk they drank! Easy peasy... let's not make this more stressful than it needs to be! But when it does come to pumping, we really only recommend the Haakaa while nursing, to passively collect your let down to build up your stores and keep you comfortable. If you're looking for a super big pumping sesh though, thyroid peaks increase prolactin and output production at its HIGHEST amount between 5-7am. So this is a pretty solid pumping session, if needed! Make sure you are using flanges that fit you appropriately and are comfortable. Ill-fitting flanges or too strong settings on your pump can cause tissue damage and sensitivity, but also decrease your output.

There are so many supplies and different pumps available, so do your research to find the best fit for you and your lifestyle. Storing milk is pretty straight forward however. You may collect your daytime milk throughout the day into one bag, mark the date, how many ounces and label "daytime". Any milk collected at night or after the sun goes down, will have melatonin, so we suggest you keep this separate and label "nighttime". Specifically if you or your baby become sick, you can mark any collected milk during that time as such so you have increased antibody milk if needed in the future!

All of this is so much work! So don't be too hard on yourself, reach out to your midwives if you need anything at all.

Please check out this article for our complete list of recommended home birth & postpartum essentials!!

As always, if you'd like to suggest additional topics or if you’re curious about our stance on things, such as common herbal induction methods, pre-labor release of membranes, newborn medications or anything else… Please drop us comment here or send your thoughts and suggestions through our website or emailed to: support{at}cloverleafmidwifery{dot}com