4Th trimester symptoms

The ‘fourth trimester’: Why women need health care after delivery | Your Pregnancy Matters

Prenatal care appointments can make it feel like you live at your Ob/Gyn’s office, especially in the third trimester as your due date approaches. Starting from the moment you find out you’re pregnant, you’re encouraged to see the Ob/Gyn regularly – and then some. Women typically are seen every four weeks for most of the first and second trimesters, then every two weeks for a period, and then every week in the later third trimester.

But for many women, after baby comes, the doctor-patient relationship becomes a vacuum. If you have a normal vaginal delivery, the standard post-delivery checkup is six weeks after your discharge from the hospital. After a C-section, which is a major medical procedure, it’s typically two weeks before women see the doctor again.

My colleagues and I call the postpartum period “the fourth trimester.” In this time, your body is healing from childbirth and trying to return to its pre-pregnancy state. Though a break from doctor appointments might sound like a good thing, it’s actually quite the opposite: The absence of health care after childbirth can lead to serious health implications, even death, for new moms.

Recent data has raised concerns regarding the maternal mortality rate in Texas. Fourth-trimester maternal care, also known as interconception care, can help reduce the risk of tragic medical issues after delivery and can be the first step towards optimizing your health, including for future pregnancies.

Health concerns we address in fourth-trimester health care

So many body transformations occur in new moms in the weeks and months after childbirth. The body’s adjustment from pregnancy to healing can cause uncomfortable side effects, including:

• General discomfort
  
• Hormone fluctuations
  
• Swelling for two to three weeks
  
• Postpartum bleeding for two to three weeks
  

Often, women either are unprepared for these side effects or perhaps expect that managing them will be easier than it turns out to be. Complicating recovery further, many women are diagnosed during pregnancy with health problems, such as diabetes or high blood pressure, that can last long after delivery. Depending on weight gain during and after pregnancy, women might face obesity-associated health risks. Some women are diagnosed with depression either during or after pregnancy. Depression that occurs after pregnancy is called postpartum depression.

These ongoing issues can be compounded by the sleep deprivation and stress that can accompany bringing home a newborn. In this sometimes-stressful time, it’s easy for women to overlook subtle emotional and physical signals that something more serious is wrong. This is especially true if the doctor sends you home with your newborn and says, “See you in six weeks!” without a thorough discussion of what to expect during recovery and what symptoms should alert you that something is wrong.

Gaps in fourth-trimester care

Unfortunately, even when a conversation about fourth-trimester health occurs, some women still don’t get that vital care. A study published in 2016 by the American College of Obstetricians and Gynecologists indicates that as many as 40 percent of women don’t go to their six-week postpartum exam. In Childbirth Connection’s Report of the Third National U.S. Survey of Women’s Childbearing Experiences, 44 percent of women surveyed who experienced depression symptoms had not met with their provider since giving birth.

Statistics like these indicate a disconnect in doctor-patient relationships and communication. Doctors can’t expect overwhelmed new moms to know what should be expected and what could be a problem. That’s unreasonable.

We must explain that even if a woman experiences no unusual symptoms postpartum, attending the six-week appointment still is vital for her health. And a woman shouldn’t wait until her six-week checkup if symptoms or questions arise, or if something just doesn’t feel right. She should call an Ob/Gyn or primary care doctor and be seen, even if her six-week checkup is weeks away. This is a partnership.

Red flags during the fourth trimester

Seeking care from a doctor prior to the six-week checkup can help reduce the risk of complications. These symptoms might indicate that something is wrong, and you should seek the care of your Ob/Gyn immediately:

• Excessive fatigue
  
• Headaches
  
• Dizziness
  
• Extreme sadness or mood swings
  
• Thoughts of harming yourself or your baby
  
• Swelling or postpartum vaginal bleeding that lasts longer than two weeks
  
• Any sharp, persistent, or intense pain in the abdomen, particularly if you’ve had a C-section
  

During the fourth trimester, enlist the help of your partner, loved ones, and friends to not only help with the baby but also keep an eye on you. Pay attention to their thoughts regarding your health and behavior, and let them check in on you from time to time and ask how you’re feeling.

I recommend that every woman see a doctor annually to continually optimize her health and monitor health concerns. This is especially important to manage or resolve chronic health conditions diagnosed during pregnancy. If a woman chooses to get pregnant again in the future, going into the pregnancy healthy can decrease the risk of complications for both her and the baby.

How primary care helps you in future pregnancies

A primary care doctor can help you achieve and maintain an ongoing healthier lifestyle, which can improve the chance for healthier pregnancies in the future. Ongoing primary care and healthy lifestyle choices can decrease the risk of complications such as birth defects, growth restriction, hypertension, diabetes, and other health concerns with your next pregnancy.

UT Southwestern maternal fetal medicine specialists (MFMs) like me are available on an outpatient basis to consult with women who have had or anticipate having complicated pregnancies. We will meet with you to create a plan to help optimize your health and potentially reduce preventable health risks to you and your baby. We also offer preconception counseling if you have a pre-existing condition that might make getting pregnant or having a healthy pregnancy difficult. 

In addition to seeing an Ob/Gyn, it’s important to see a primary care or family medicine doctor on a regular basis. These doctors often have training in a variety of areas, including pediatrics and women’s health concerns. These doctors can help you with questions about birth control, breastfeeding, and managing chronic concerns such as diabetes and high blood pressure.

Just as we encourage women in the third trimester to think about getting diapers and a car seat prepared, we encourage adding “find a primary care doctor” to the pre-baby to-do list. You can look on your own or request references from friends and family members, or we can recommend providers we know and trust who can take care of you going forward.

If you have medical conditions that made your pregnancy difficult, such as a heart problem, diabetes, obesity, or high blood pressure, your primary care doctor can help you optimize your health and straighten out your medications after pregnancy and as your health improves over time. Think about bringing your new child into the world as a chance to reset your own health as well.

The better your chronic conditions are controlled, the healthier you will be and the more energy you will have to care for your newborn – and the healthier you will be if you choose to get pregnant again.

Looking for a primary care doctor? Find a UT Southwestern doctor online or call 214-645-8300.

A Mother’s Guide to the Fourth Trimester

The fourth trimester—the 12 weeks after giving birth—is just as important for a mother’s health as the first three trimesters. Yet this is often when mothers have the least interaction with their health care team, a time when, some experts argue, mothers need it the most.

The American College of Obstetricians and Gynecologists (ACOG) recommends that mothers have initial contact with their OB-GYN within three weeks after delivery, followed by ongoing care as needed, and a comprehensive postpartum visit no later than 12 weeks after delivery. They also recommend that a postpartum care plan be developed during pregnancy, so that mothers are better prepared when they go home.

“Those 12 weeks after giving birth are a critical time to focus on Mom and make sure that she is healthy moving forward,” says Mary Rosser, MD, PhD, assistant professor of obstetrics & gynecology at Columbia University Vagelos College of Physicians and Surgeons and an OB-GYN at Columbia University Irving Medical Center/NewYork-Presbyterian. “We want to make sure it is not just a one-off checkup but that we’re giving mothers holistic care and support for their growing family. Postpartum care sets the stage for lifelong health and well-being.”

Postpartum Visits

Just 40% of moms attend their postpartum follow-up visit, says Rosser, who helped develop post-birth recommendations as a member of ACOG’s Presidential Task Force on Redefining the Postpartum Visit. “It’s an overwhelming time, so what often happens is this visit gets pushed aside, but it absolutely should not,” she says. “It impedes the management of chronic health conditions, discussing family planning and contraception, assessing mental health and well-being, and physical recovery.”

Rather than the traditional single checkup at around six weeks, Rosser says that “postpartum care should be an ongoing process, with tailored services to support each mother’s individual needs.”

ACOG recommends a postpartum visit within one to three weeks and another within 12 weeks of giving birth.

Those who are considered high risk should check in within the first week or two, says Rosser. The first check-in—which often can be done over the phone or via telehealth—is to make sure Mom is doing well physically and emotionally and baby is feeding properly and gaining weight. It is important to discuss with your health care provider, Rosser says, whether this initial visit can be done via video or should be in person.

Within 12 weeks mothers should have an in-person, comprehensive care visit to discuss any medical concerns that may need addressing, as well as the mother’s physical health, mental and emotional health, and infant care and feeding. This also is a time when practitioners and patients can develop a road map for future health.

It is important to note that, depending on a mother’s personal history and individual needs, they should receive ongoing postpartum care as needed. “It really is no longer a one-size-fits-all approach,” says Rosser.

A Comprehensive Postpartum Checklist

1. Physical recovery

After delivery, there is a lot of soreness and healing that takes place. It is important for patients to have a full physical exam during their postpartum visit. A patient who had a tear during a vaginal delivery will need a thorough exam to make sure everything is healed. For C-section deliveries, the stitches need to be looked at to ensure they’re healing. “I’ll listen to the heart and the lungs, especially if they have had hypertension, do an abdominal exam, check to see if their thyroid is OK,” says Rosser. “You’re going from top to bottom, just like you would for any comprehensive exam, but you are targeting and individualizing it to that individual woman. ”

2. Infant care and feeding

Postpartum appointments also are a chance to assess how a baby is doing and whether they are feeding properly. Breastfeeding is healthy for both infants and moms, but not everyone has instant success. If, after two or three days, there is a lot of pain, Mom is unable to breastfeed, or the baby is not gaining weight, seek support from a lactation consultant.

3. Sleep and fatigue

Mothers will be very fatigued in the first few weeks after delivering a baby. Experts advise new mothers fit in sleep whenever possible, such as when the baby is sleeping. Resist the urge to do chores around the house when your newborn is sleeping; instead, take a nap yourself. Consider enlisting your partner in nighttime feedings so that you can get a good night’s sleep. Perhaps a family member or friend can help with babysitting once or twice a week or running errands while you get some much-needed rest. Don’t be afraid to ask for help if you are not getting enough sleep to function. Sleep deprivation should slowly get better over time. If it does not and instead gets worse, call your doctor.

4. Mental health and well-being

It is normal to feel a bit of sadness seven to 14 days after birth—as many as 80% of women experience these “baby blues.” After all, a mother’s hormones are shifting, there is lack of sleep, and mothers are adapting to a new baby. “But if it goes beyond 10 to 14 days and people feel an overwhelming sadness or hopelessness, or a mother has so much anxiety or worry that they even think about not existing anymore, that may be a sign of postpartum depression,” says Rosser. “Those are reasons to get help immediately.”

5. Sex and family planning

Returning to sex should be a personal decision. “Usually, it’s OK at six to eight weeks if everything is healed, or whenever Mom feels ready,” says Rosser. “What is important is that partners have open communication. Sex may be a bit different, so it is good to be open to it being different and take your time. ”

When it comes to contraception and family planning, Rosser urges patients to have a plan in place before the baby arrives. Do not consider breastfeeding a form of contraception. “Before you become sexually active again, talk with your provider about birth control. Many patients will opt for an IUD right after delivery so that they don’t have to worry about an unplanned pregnancy immediately after birth.”

6. Diet and exercise

It is important for new moms to nourish their bodies with healthy, whole foods (lots of fresh fruits and vegetables, lean protein, and whole grains), drink plenty of water, and begin moving their bodies as they feel ready. For those who have had a vaginal delivery or a C-section, an excellent place to start is simply walking: Go outside and walk around the block. Ease into it and build up your physical activity. Those who have had a C-section should check with their doctor about when to resume more strenuous physical activity.

Eating well and moving helps the body heal and recover. Healthy babies need healthy, well-adjusted mothers. “If Mom is not well, then she is not going to be able to care for her baby and her family the way that she might want,” says Rosser.

7. Chronic disease management

Postpartum visits are an opportunity to recognize risk factors for conditions like heart disease or obesity and to check that complications during pregnancy such as high blood pressure or diabetes are resolving. “We can provide risk reduction strategies and early intervention,” Rosser says. “It’s about educating, empowering, and motivating the patient and encouraging a healthy lifestyle that is consistent.”

8. Know the warning signs

One-third of maternal deaths occur after the birth of the baby, from one week through one year after delivery, according to the Centers for Disease Control and Prevention. Black women are three to four times more likely to die of a pregnancy-related cause than white women. It’s a sobering statistic that OB-GYN experts are working diligently to change by raising awareness of certain warning signs.

Seek medical attention immediately if you have any of the following symptoms:

• Fever or chills. This could indicate an infection vaginally (if there was a significant tear), in the womb, or of the C-section. Urinary tract infections can also be very common.
• Heavy, brisk, bright-red bleeding. Postpartum women may bleed up to four to six weeks; however, if it is heavy all at once, it could be postpartum hemorrhage. “I tell women, if you saturate a pad every hour and that’s consistent for several hours, we want to see you,” says Rosser.
• Dizziness. A symptom associated with loss of blood.
• Shortness of breath or chest pain. This might signal a blood clot like deep venous thrombosis or a pulmonary embolism.
• Severe headache. Sometimes associated with preeclampsia, which is a pregnancy complication characterized by high blood pressure or stroke.
• Swelling of the legs and feet.  May be a sign of preeclampsia.
• Deep sadness, thoughts of hopelessness, or thoughts about death, suicide, or harming oneself or the baby. Postpartum depression affects one in 10 mothers and is very serious.

“These symptoms can be life-threatening,” says Rosser. “Don’t ignore them or chalk them up to just being tired and postpartum. If it’s something that is out of the ordinary, please contact your doctor or go to the emergency room.”

Mothers who are considered high risk—those with diabetes, high blood pressure, obesity, or another chronic health condition—should be extra vigilant about any signs and symptoms that are not normal.

“Just as babies need care and attention during the fourth trimester, so too do mothers,” says Rosser. “Postpartum care is a crucial time to make sure Mom is safe and healthy so that the baby can be supported in the best possible way.”

Toxemia, Intestinal Problems, and Heartburn

Find out how pregnancy affects your digestive tract, which trimesters are more likely to cause indigestion and nausea, and what to do to manage them.

During pregnancy, the burden on the mother's body increases. The body needs more nutrients, the body produces additional hormones. And the growing fetus puts pressure on neighboring organs, including the stomach and intestines. We tell you what symptoms are observed in each trimester, how to cope with toxicosis and get rid of heartburn.

Contents:

• 2. Toxicosis and pregnancy
• 3. Causes, risks and treatment of diarrhea during pregnancy
• 4. Heartburn and stomach pain during pregnancy
• 5. Bloating, constipation and microbiota during pregnancy
• 6. Note

Changes in the work of the gastrointestinal tract by trimesters of pregnancy

The average duration of pregnancy is 40 weeks, which are usually divided into trimesters in accordance with the stages of intrauterine development of the child.

Each trimester is accompanied by a number of changes in the body, including in the gastrointestinal tract:

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Causes of gastrointestinal problems during pregnancy

Every pregnancy is accompanied by inevitable changes in the functioning of the digestive system. They are most often caused by hormonal changes and increased stress on the organs, but they can also be associated with lifestyle and health conditions, for example:

• Sedentary lifestyle and unbalanced diet;
• Certain drugs, including calcium or aluminum antacids;
• Viral and bacterial infections;
• Intolerance to certain nutrients and allergic reactions;
• Stress;
• Diseases of the thyroid gland.

If you have chronic diseases of the gastrointestinal tract and you are planning a pregnancy, try to consult your doctor in advance. Symptoms of conditions such as irritable bowel syndrome (IBS) or acid reflux are more likely to get worse during pregnancy. Your doctor will help prepare your body and create a prevention plan to help relieve symptoms during this time.

Irritable bowel syndrome, or IBS, is a functional bowel disease that causes frequent abdominal pain, impaired peristalsis, bloating, constipation, or diarrhea.

Morning sickness, vomiting and general malaise during pregnancy

Morning sickness and morning sickness during early pregnancy are common, because the body undergoes important changes necessary for the development of the child.

up to 90%

women experience nausea during pregnancy

Doctors find it difficult to say with certainty why pregnant women feel sick in the morning. The main theory is hormonal changes. But there are some patterns associated with an increased risk of morning sickness:

• Multiple pregnancy;
• Toxicosis during previous pregnancy;
• History of morning sickness during pregnancy in close relatives;
• Tendency to motion sickness in transport;
• Use of oral contraceptives containing estrogen before pregnancy;
• Frequent migraines;
• BMI 30 and above;
• Elevated levels of stress hormones

Risks of severe morning sickness and how to reduce nausea

Nausea and vomiting are usually not associated with a risk for mother and child and disappear by 16-20 weeks of pregnancy, but it is not necessary to wait so long - there are ways that can help reduce nausea and enjoy the process of waiting for a new person:

• Get plenty of rest - fatigue increases toxicosis;
• Avoid smells and foods that cause nausea;
• Eat something right after waking up. A toast or a slice of bread will help reduce nausea;
• Avoid hunger - empty stomach increases nausea. Eat small meals often, prefer low-fat, high-carbohydrate foods;
• Try ginger - studies show it helps with nausea;
• Sip as often as possible and prefer still water.

In rare cases, pregnant women may develop hyperemesis gestationis or excessive vomiting. This is a serious condition that can lead to dehydration, kidney damage, seizures, abnormal heart rhythms, and even death.

Signs of dehydration include dry mouth, dizziness, dark urine, infrequent urination and/or dizziness.

Symptoms of excessive pregnancy vomiting:

• frequent nausea for a long time and regular vomiting after meals;
• dry skin and lips;
• sudden weight loss;
• low blood pressure (below 90/60).

If symptoms of excessive pregnancy vomiting occur, do not wait until the condition resolves on its own. It is necessary to seek medical help as soon as possible - the doctor will prescribe treatment, help adjust the diet and lifestyle of the expectant mother.

0.5–2%

pregnant women experience excessive vomiting

Diarrhea in pregnancy

The word "diarrhea" comes from the Greek language and literally means "to flow through". This is a condition during which bowel movements or bowel movements occur three times a day or more often. This phenomenon is especially typical for the third trimester of pregnancy, but it can also occur earlier.

Symptoms of diarrhea:

• Three or more bowel movements per day
• Urgent urge to have a bowel movement
• Abdominal pain and cramps
• Bloating

Causes of diarrhea during pregnancy poisoning, dysbacteriosis, bacterial and viral infections: