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What is the Fourth Trimester?
Dr. Jones: So you had your baby, and hopefully it all went well. You're home with your newborn and maybe your two other kids, and you're just a little sore, exhausted, and your body isn't your old body. And the last thing on your mind is your postpartum checkup. But I hope you make that visit. This is from Obstetrics and Gynecology at , and we're talking about the fourth trimester on the "7 Domains of Women's Health."
There isn't really a fourth trimester. But the six weeks after the birth of a child are critical for repair and restructuring of your pelvic floor, getting your blood count back up, adjusting to the hormonal swings of the postpartum state, and establishing a breastfeeding pattern. And this period of adjustment, which may take more than six weeks, is medically called the puerperium. But that's a big word. There's a lot going on for new moms, and they should really try to make that postpartum visit.
So with me in The Scope studio is Meredith Grady. She's a physical therapist and a perinatal health specialist. Welcome to the "7 Domains of Women's Health," Meredith.
Meredith: Thank you.
Dr. Jones: And thanks for helping us with this.
Meredith: You're very welcome.
Many Moms Skip the Postpartum Visit
Dr. Jones: So, number one, why is this phase crucial in healthcare and public health?
Meredith: Most medical events after birth will happen within the first six weeks. Postpartum hemorrhage, preeclampsia, endometritis, mastitis, postpartum depression, and other things as well. But close to 40% of moms will not attend their first postpartum visit because they're simply too busy with baby or with family, with life. Maybe they've already returned to work.
Dr. Jones: Right. It's really tough. But there's so much going on, and we need to sometimes check things out.
Meredith: Yes.
What Happens to the Body After Birth?
Dr. Jones: What happens to a woman's body after a vaginal birth?
Meredith: Everything. It's the biggest hormone shift in the shortest amount of time. I have yet to meet a mom who felt like their birth plan went exactly as they thought it would.
Dr. Jones: Oh, that's true.
Meredith: You know? I think most moms, especially first-time moms, are like, "What the heck just happened to my body?" Their expectations did not meet reality. So a lot of times when I see a patient who delivered vaginally, there's that debriefing, like, "What just happened? Is this normal?" And that's when I sit down with them and show them the pelvic model and explain how they tore, how to pee, how to poop, and how to take care of themselves vaginally and vulva-wise for the rest of their life.
Pelvic Floor Symptoms That Deserve More Attention
Dr. Jones: Oh, absolutely. So what are the common symptoms from the pelvic floor, the muscles and the skin, and the tendons that the baby pushed their little heads through or big heads through?
Meredith: Yes, big heads. Probably the most common symptom is difficulty emptying the bladder. I also see pain with sitting, pain with movement, feeling constipated, and, of course, afraid of that first poop. There are so many variables with childbirth that can determine which symptoms you might experience.
For instance, how long did they push, what's the severity of the tearing, and the position of the baby at the time of delivery? That can make a huge difference. Some moms can have a lot of pelvic floor edema if they were pushing for an extended period of time, think more than one and a half or two hours. This alone can lead to difficulty urinating after delivery.
Dr. Jones: But one and a half to two hours is a pretty normal push for a first-time baby. So that means a lot of first-time babies who are coming out vaginally have left a path behind them.
Meredith: Yes, they sure have.
Yes, C-Section Recovery Is Still Postpartum Recovery
Dr. Jones: Is there a difference with the cesarean section? one out of five births in this country are by cesarean, and . . .
Meredith: So, yes, a C-section is a major abdominal surgery. And I feel like a lot of moms forget that. They try to be a hero in all of this. But it's a huge surgery. They go through seven layers to get to the baby, skin, fat, fascia, the muscle, peritoneum, uterus, and amniotic sac.
But with everything, recovery varies from person to person. Some moms will be on their fifth C-section and walking laps around the unit. Others will have so much gas pain or incisional pain and have such a hard time getting out of bed.
I think it also depends on whether it was a crash C-section or an emergency C-section. Sometimes moms will have already been pushing for hours and then have to have a C-section because the baby needs to get out quickly. So this can make recovery a lot longer.
Dr. Jones: Well, I remember a woman I know quite well who went home on day two after a section and just walked right up a big flight of stairs all on her own. And I thought I had a section, and I couldn't do that or power . . . It was her first and . . . Oh, my goodness.
Meredith: Oh, wow.
What’s Normal and What’s Not After Delivery
Dr. Jones: So what's normal? With regard to the pelvic floor, what's normal, and what needs medical attention? If you're thinking, "Oh, I guess this is just normal. I don't have to go in for my checkup."
Meredith: Normal . . . that makes me think of OASI tears, too. An OASI tear, for people listening and not knowing what that means, it's an obstetric anal sphincter injury, and that is more into the third and fourth-degree tear. That's into the sphincters.
Dr. Jones: That's just when the tear goes through the skin of the vagina and then the tissues around the vagina and into the muscles around the rectum and then sometimes into the rectum itself. And so, usually we make a big to-do in terms of teaching the patient that you had a third or a fourth degree. It went through the muscles, or it went through the rectal tissue. We tell them about it.
Meredith: Yes.
Dr. Jones: But sometimes things don't go well.
Meredith: Yeah. So then that's when we refer you to the Upward Clinic, which is run by urogynecologists. And they keep a closer eye down there. But we watch for any kind of complication, like a fistula or . . .
Dr. Jones: Fistula is a hole that kind of goes between the vagina and the rectum. Or it can be happening . . . All over the world, women who push for hours and hours and hours or who babies get stuck, put so much pressure between their bladder and their vagina that they actually wear a little hole in there, or they get kind of dead tissue there, and then it makes a little hole that causes a fistula, and there's a permanent hole between the bladder . . . Oh, this is so depressing. Let's not. Forget that. We'll go back. Yes. When that happens, it's really depressing.
Meredith: Babies do a number on you.
Physical Activity Supports Recovery
Dr. Jones: But the good news is, in this country, people don't push that long. And so we hopefully don't let those things happen.
Meredith: Yes.
Dr. Jones: But women all over the world do get up and go back to work after birth.
Meredith: They do.
Dr. Jones: Women with a new child and several other children are right back at it. Is there importance to physical healing?
Meredith: Yes, but there's a balance. I've never really been a fan of that phrase, "Five in the bed, five around the bed, five close to the bed. I think that things need to change a little bit just to prevent any secondary things from occurring. I love the idea of reading your body and adding a little bit every day. And that looks different for everyone, right? It depends on what you were doing before you were pregnant and while you're pregnant. It's just so important to walk every day. Incorporating little, short bouts of walking throughout the day can improve your mood, increase circulation, and decrease healing time.
Pelvic Floor Therapy Should Be Standard
Dr. Jones: If you were to add some instructions. So women, they only get 24 hours in the hospital sometimes, and they've got so much going on. And if you were to add some instructions for women leaving the hospital, what would you add?
Meredith: Well, I would add, "I hope you saw a perinatal specialist like myself while you were here. And please see an outpatient pelvic PT if you have any issues whatsoever." And that goes for C-sections, too. Pelvic PT is just as important for C-sections, even though you didn't deliver vaginally.
Returning to Sex After Birth
Dr. Jones: Well, what about a return to sexual intercourse? We did a study. They always say, "Well, you should refrain from intercourse for the first six weeks." And we did a study about how often people followed that instruction or advice. We've had people trying out their bottom parts in the hospital with their husbands.
Meredith: Really, in the hospital? Wow.
Dr. Jones: Yeah, yeah, yeah. Well . . . So what about returning to sexual intercourse? We don't advise that.
Meredith: I've never heard of that.
Dr. Jones: It's not very often.
Meredith: I say take your time. Also lube. Lube is helpful. It's funny that you said that because I'm saying it's not uncommon to wait longer than six weeks because you're so tired, or you simply don't know what day it is. If you have any issues with returning to sex because of pain or mobility, or anything else, please make an appointment with an outpatient pelvic PT. Don't live with pain down there. I know there can be pressure from partners, and just like societal things, but just please go and get help.
Long-Term Symptoms That Aren’t “Just Part of Motherhood”
Dr. Jones: Well, we've talked about some of this. But what should you know? What are some long-term problems? So after the first six to eight weeks, what kinds of things, if you're still having problems, should you see some pelvic physiotherapists and have an evaluation?
Meredith: Incontinence, whether urinary or fecal, or gas, needs to be addressed. Pain with intercourse. Pain with mobility. Pain could be from the pelvic floor or other parts of the body that just don't seem to be the same after delivery.
Honestly, I think going to pelvic PT six to eight weeks after delivery is great for everyone, so that you feel confident returning to exercise and returning to life again. It's a foreign land down there. So, going to your pelvic PT is so eye-opening. You discover a lot about yourself, about your pain. It could be a hip problem. You just don't know until you go.
Dr. Jones: Thanks so much for joining us, Meredith, and you've taught me a lot that I didn't know. And there's so much going on in the fourth trimester, this time after the birth of a child, including sleep and emotional issues, and following up on issues that came to light during your pregnancy, so maybe high blood pressure or diabetes. And then, of course, choosing a contraceptive method so you can plan your next baby. So, for your sake and for the sake of the new mother or the mother again that you might know, make sure to get the support you need and make that visit. And thanks for joining us on the "7 Domains of Women's Health."
More Answers and Resources for Your Women’s Health Concerns
