The Fourth Trimester

All new parents are familiar with the concept of trimesters.  They have completed a pregnancy broken up into these three periods by their health care providers.  They have noted milestones and changes unique to each of these periods but how many are aware that there is a very crucial fourth trimester?  The word trimester actually does not mean 3 periods. It originates from the Latin word trimetris meaning three months.  The concept of a fourth trimester was introduced in the late 1970s and then popularized by the pediatrician Harvey Karp in 2002 to describe the 12 weeks that your newborn needs to adapt to being outside the womb.  It is also the time moms are going through significant physical and emotional changes and both parents are adjusting to their new roles.  Siblings are adjusting as well as we discussed in our previous blog “Bringing Baby Home.”

Human newborns are born in a state of complete dependence on others…. more so than any other mammals.  It has been estimated that to be born with the neurological and cognitive development of a newborn chimpanzee they would need to remain in utero for 18 to 21 months.  This reliance on caregivers is not only necessary for the infant’s survival but also is the foundation for social connections throughout the lifespan.   Newborns are emerging from a cocoon in which they have been ideally perpetually nourished, housed and comforted.  They always heard their mothers’ heartbeat and felt her warmth.  They were never hungry or alone.  Now they are bombarded with new smells, tastes and sounds.  They are seeking to communicate their need for sustenance as well as human contact.  They are extremely needy.  For the first 12 weeks, infants need frequent feeding and near constant human contact.  Despite all the books written to the contrary, they generally are not designed to sleep more than a few hours at a time. 

For moms, the fourth trimester is a period of significant emotional and physical transition.  For the first few hours after birth, they often experience an emotional high.  Baby is naturally awake and alert for the first two hours, as well, and this can be an opportunity for bonding.  Afterwards, babies are very sleepy in the first few days and may even need a little bit of coaxing to feed.  Between days 3 and 5 moms can experience an emotional rollercoaster.  It is often referred to as “baby blues.”  It is marked by intense emotional highs and low.  Your hormones are in flux and you are sleep deprived.  In most moms this period passes.  Do not be afraid to reach out to your primary care provider if it persists or you have other symptoms more indicative of postpartum depression.  After six weeks moms are usually experiencing growing confidence and emotional leveling.  By 12 weeks life finds a new normal as babies are beginning to sleep for longer stretches and are interested in their surroundings or simple toys when they are put down.  A routine begins to emerge. 

How can families navigate this fourth trimester?  We have a lot to learn from cultures around the world.  In many places, rituals are observed that honor this time.  Latin American cultures observe La Cuarentena a 40 day sequestered period in which new parents focus on healing and bonding with their baby.  In China, new mothers observe zuo yue zi or “sitting the month” as a period of rest and dietary and lifestyle restrictions.  A recent qualitative systematic review examined traditional postpartum practices from 51 studies in over 20 different countries.  Common themes focused on support for the mother, periods of rest and nutritional recommendations.  In the United States, corporate America is beginning to acknowledge this time.  I have seen a shift …albeit slow…. of maternity leave from six weeks to 12 weeks.  I have also seen many companies acknowledging the importance of parental leave for both parents.  We still have a long way to go to support new families.

How can your family navigate this crucial fourth trimester?  Give yourself grace and find your tribe whether it is extended family, friends or community.  Give yourself grace.  Cynthia Gabriel, PhD writes in The Fourth Trimester Companion  “Do NOT put yourself into a “bliss guilt vise.”  It is normal that most of your time taking care of a newborn in the first few weeks feels hard not wonderful. “  Acknowledge this and find ways to simplify your life.  Wear your pajamas…or comfortable sweats…for the first few weeks.  Make yourself a nest on the couch and follow the advice to not go up the stairs more than once a day. Sleep when baby sleeps.  This will be different than your usual pattern but mothering releases hormones that will make you sleepy at all times of day.  Take advantage of these hormones and SLEEP.   Get some sunshine. If you head out for a walk and get to the corner and it is too much allow yourself to turn around and head home.  Tell your partner what you need and how they can help.  Let them know that simply being there is worth more than they know.  Know that on your low day they are probably exhausted as well.  The focus should not be on infant sleep in the beginning.  Newborns are not wired to sleep.  It should be on parental sleep.  Find ways to tag team and give each other breaks.  Let people feed you AND encourage them to leave the meal on the doorstep.  Do not be afraid to limit visitors particularly in the first few weeks.  Feel free to say no to help that is not helpful. Surround yourselves with people who are supportive.   I cannot emphasize this enough…ask for help.  If a friend or neighbor can come hold your baby for a few hours while you shower or nap let them.  Honor this time as your baby adjusts to this big new world and you heal and find your way as a parent. 

by Laura Duke, C.P.N.P., I.B.C.L.C.