An Obstetrician's perspective: Five Focus points for the Fourth Trimester - Scott Shemer

An Obstetrician's perspective: Five Focus points for the Fourth Trimester - Scott Shemer

Five Focus Points for the Fourth Trimester: An Obstetrician’s Perspective
Scott Schemer


So much preparation goes into birth itself, yet less guidance is offered in preparing for “The Fourth Trimester”. While new parents rightfully look forward to meeting their newest family member, it is crucial to recognise that this initial postpartum period is just as physically and emotionally taxing as pregnancy. As with pregnancy, some parents will navigate these weeks with ease, while others will struggle –  there is no singular experience and all experiences are valid. My best advice is to avoid comparisons with others. Instead, direct energy towards supporting yourself with the resources you need to bond with your new baby and physically recover from birth. Here are five important aspects of care to focus on during the first twelve weeks postpartum:


Mental & Physical Health and Wellbeing

This will always be my number one focus! Taking care of your general well-being and mental health is paramount and a key factor in bonding with your newborn. It is very common for new mums to experience 'baby blues' with episodes of teariness, anxiety and feeling overwhelmed a few days after birth. This commonly happens three to five days after your baby is born and is most likely due to rapidly changing hormone levels, alterations to your sleep cycle and potentially the birth experience itself. Reassuringly, these major symptoms usually go away after a few days, but if these feelings are prolonged or severe then please reach out to your Obstetrician, GP, Midwife or Maternal Child Health Nurse. Mental heath concerns can be triggered by birth and the postpartum period in people who have never experienced symptoms before - there is absolutely no shame in vocalising your worries and receiving the care and support you deserve.  

With a new baby and the resulting exhaustion, it is easy to de-prioritise your physical health. Focus here on the basics: hydration, regular snacks/meals, some fresh air and – when you feel up to it – a short walk per day.  When you feel ready to participate in further exercise, it’s ideal first to see a Women’s Health Physiotherapist who can assess your pelvic floor and discuss the best way to support your postpartum body in movement. Remember – it took nine months for your changing body to grow your baby – it is normal for it to take at least this long to re-gain your pre-pregnancy strength. If something doesn’t feel right – mentally or physically – consult a trusted medical or allied health professional. Early intervention is often the key to a speedy recovery.


Wound Care

Caring carefully for any wound allows optimal healing and reduces the risk of complications, such as infection. 

If you have a perineal tear or episiotomy (a small cut) that required suturing, the stitches used will be self-dissolving. That area of your body is generally very quick to heal, but your vagina, vulva and perineum may feel tender for up to a few weeks. Ice packs in maternity pads or your underwear for the first 24-72 hours post-birth are a helpful way to not only reduce swelling, but also to relieve pain and discomfort. A great way to care for your perineum is with gentle washes with warm water, ideally using a peri-bottle (available from pharmacies), after urinating or opening your bowels. Salt baths at home are also very effective. It is then critical to keep your wound dry after cleaning - this can be achieved by gently patting the area with a towel, or using a warm hairdryer. 

For those of you who have given birth via caesarean section, your wound will most likely feel quite tender to touch, numb and/or itchy for the first few weeks. Early mobilisation (gentle walking) is critical and should be encouraged within 24 hours of delivery at the latest. Having said that, avoid strenuous exercise, excessive bending over and heavy lifting for the first six weeks (try not to lift anything heavier than your baby). Your wound should be kept clean and dry (my patients will have dissolvable stitches and a waterproof dressing on for the first ten days). Wear loose, comfortable high-waist underwear and soft clothing. I suggest scar massage to begin only after your six week obstetric, GP or physiotherapist review.

Please look out for early signs of infection - these include, but are not restricted to, fever and chills, redness, ooze, offensive smell, increasing pain, abnormal bleeding or discharge. It is important to seek medical advice with any concerns as early treatment is the key to preventing severe infection.

Regardless of your type of wound, support garments (such as specialist post-natal compression tights/leggings) will provide excellent scar support and can be worn from the time you leave hospital.


Bladder and Bowel Care

Following birth, a small proportion of women have difficulty with bladder emptying or decreased awareness of a full bladder. This can lead to accumulation of residual urine, which if left untreated, can cause infection, incontinence and in very rare cases permanent damage to the bladder.

There are a number of simple measures that can be employed to minimise the risk of bladder dysfunction:

  • Adequate daily fluid intake: 1.5-2 litres of fluid per day is recommended. Ideally spread this throughout the day to avoid overloading the bladder 
  • Void regularly, as this will prevent your bladder from overfilling
    • Aim to pass urine every 2-3 hours during labour. If you have an epidural or spinal anaesthetic, you should have an indwelling catheter until it has worn off
    • After birth, try to void every 3-4 hours 
  • Ensure you’re using enough pain relief after delivery 
  • Use cold packs on the perineum after a vaginal birth to reduce perineal swelling
  • Take laxatives to prevent constipation
  • Do your pelvic floor exercises every day as advised by your physiotherapist/midwife.

In terms of bowel function, the key is to avoid constipation. This is very common and results from a combination of having been pregnant, medications, dehydration, pain and surgery (in the event of a caesarean section). Keep your stools soft by:

  • Drinking lots of water and pear juice
  • Eating food high in fibre - this may include pears, prunes and kiwi fruit (ideally with the skin on)
  • Adding psyllium husk to your food
  • Considering the additional use of laxatives - I regularly prescribe Coloxyl, with a low threshold for Movicol if bowels haven’t opened within 24 hours of birth

Employ optimal positioning when using the toilet. The best position is leaning forward with your feet flat and knees slightly higher than your hips – use a small stool for easy positioning. Have your legs comfortably apart with your elbows resting on your thighs.

Haemorrhoids are very common during pregnancy and may become worse following delivery, particularly after pushing during a vaginal birth. Reducing constipation is crucial in allowing haemorrhoids to resolve. Over-the-counter topical creams and ointments are completely safe to use and may reduce discomfort.


Pain Management

Pain following birth is both expected and normal. The amount of pain will vary depending on a number of factors, in particular the type of birth you have had. Pain can result from a wound itself (whether this is a caesarean section or perineal wound), with associated swelling and bruising contributing as well. Afterpains can also be extremely uncomfortable - after delivery the uterus will try to contract back down to its pre-pregnancy size. They may feel like menstrual cramps or even labour contractions. They tend to be worse with each successive baby and are more common during the first few days of breastfeeding.

I strongly recommend every patient takes pain relief as needed – there is no reason to remain in pain. Good pain control will not only make your postnatal experience much more enjoyable, but it will also allow you to better care for your newborn. My key tip is to not wait until your pain is unmanageable before medicating – our bodies respond more favourably to regular doses of pain relief rather than the larger doses needed to manage severe pain.   

Pain relief strategies may include:

  • Medications - regular Paracetamol and an anti-inflammatory (such as Ibuprofen) can be really helpful. In women who have had a caesarean section or those with moderate/significant perineal tearing, stronger prescription medications such as Tramadol or Oxycodone may be required for up to a couple of weeks
  • Heat packs
  • Sitting on a pillow or padded ring for women with perineal trauma
  • Using a pillow for abdominal support when coughing or laughing - after a caesarean section, it may be uncomfortable to do anything that requires your abdominal muscles. Therefore, we recommend taking a pillow and providing support to your abdomen at times where there is pressure on the abdominal cavity. 

If your pain is getting worse rather than improving after the first few days, this may be a sign of a complication such as infection or a haematoma. Please notify your care provider if you are concerned that this might be the case.


Vaginal bleeding

The vaginal bleeding experienced after birth is called lochia. Lochia will occur following all modes of delivery (vaginal and caesarean births). Whilst bleeding tends to follow a rough pattern in most women, it can in fact vary significantly from person to person. 

Lochia is bright red in colour for the first few days and will usually be quite heavy, like a period. After the first few days the blood usually changes colour to a darker red or brownish-red. It will then gradually slow down over the following weeks, becoming light in colour and eventually stop. It is not abnormal, however, for lochia to stop and then return as bright red blood for a short while before fading back again, especially during the early stages. I find this is common around day 10-14 following birth. Generally, lochia can last for up to six weeks following birth. 

If you are passing clots, soaking through a maternity pad hourly or more, or concerned with an offensive smell, I recommend that you contact your Obstetrician or midwife. This may be normal, but can potentially be suggestive of infection or retained pregnancy tissue. 


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