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The 4th Trimester

Have you heard of the 4th trimester?

As most of you know, 6 months ago I had my little boy Oliver. These past 6 months have been incredible. I have enjoyed every part of motherhood (well, maybe after that first month..haha). As I reminisce on my own pregnancy and postpartum experience, I am thrilled that the “4th trimester “is now a recognized term. Your 1st trimester you are sick and tired, your 2nd trimester you are happy, full of energy, and not that big, and your 3rd trimester you are huge and can’t wait for your little human to enter the world. Well, prior to the term “4th trimester” we just thought women went back to normal, right? You aren’t pregnant anymore so you are done….? This could not be more false! And for some women, the 4th trimester is the most difficult. That was the case for me.

My birth story was not what I expected, and I hear that from so many of my clients. I have a whole new appreciation for labor and delivery, which is funny because I grew up totally immersed in it with my mother being an OBGYN.

I will never forget the morning we came in to the midwives office on Wednesday June 20…I did not expect to have my baby that day. We put the bags in the trunk as a “just in case” measure. I truly thought that I just peed on myself and my water had truly not ruptured. That day sitting in the triage room and the nurse coming back around 11 am to tell us that we were being admitted because my water had ruptured tears came to my eyes because I knew that my birth was not going to be what I expected. Working as a pelvic health physical therapist I hear horror stories about inductions and all of them were swarming my brain. At that moment Mitch said to me, it will be okay, we are having our little guy today.

No contractions and not dilated, I was induced at about 12 pm. The medication caused hyper stimulation and my contractions were very close together. At 5pm I was 3cm dilated and at 7:25pm I had my bundle of love. At about 7 pm his heart rate started to drop and I was told water birth was out of the question. That is when I had to begin pushing due to his deceleration. A vacuum had to be used to get him out quickly and safely. Because of this, I had a grade 3 episiotomy. (For those of you that are not familiar with this term it means that my perineum was cut close to my anus to allow for baby Oliver to exit.) I have no clue how many stitches were needed but I know they were working “down there” for close to an hour.

That night I could not sit on my bottom. I thought to myself, “hmm…this is super painful, hopefully tomorrow will be better.” After labor, I thought the hard part was over. The next day, my bottom was worse. My internal questions: How am I supposed to feed my baby sitting up? How am I going to walk up my stairs to the nursery? How am I going to pee…or even worse, poop? When will I work out again? How do I function without sleep? Should I have had a baby? I didn’t expect this, did I? All very valid questions, right? How many women have similar experience with the same questions? The answer: all of them!

The idea of the “4th trimester” helps women understand that the moment they have their baby is not the end, and that there is help. So what is the “4th trimester”? It is the first 12 weeks of your baby’s life, and your new life as a mother. It is the period in which your baby is not only adjusting to life outside of the womb, but also the period of time you begin to recover from nine months of pregnancy, physical trauma from labor and delivery, and the shock that life is not going to be the same. The 4th trimester is not just focused on the physical aspects but also the mental and emotional aspects. This is such a crucial time period for both you and your baby.

Remembering there is a 4th trimester reminds us that in the first three months anything goes…truly. This helped me so much. There was no right and no wrong. Some days Oliver did great, I showered, and slept and other days the complete opposite happened. So what can you do to help you thrive during this time? FEEL IT, don’t cover it up! Lower your expectations and accept that you will have good days and bad days. Allow yourself to go to mom groups and talk about anything you want to. Seek out a mental health professional, pelvic physical therapist, discuss everything with your provider at postpartum visits (don’t hold back), and remind yourself “you just had a baby.”

“This too shall pass. Will you?” This was written out on a clock in my high school calculus class. I used it during my 4th trimester. I reminded myself that nothing lasts forever.

I cannot speak on mental and emotional help so I can only refer you to my amazing team of healthcare professionals in my area. However, physical help…that I can help with.

When should you seek out a physical therapist? When you are peeing on yourself 15 weeks postpartum? When you try to have sex and it hurts? When your neck is in spasm from feedings? When you are passing gas loudly in your first yoga class? NO! You should seek out a physical therapist prior….to help prevent all of these things. I saw my pelvic therapist 3 weeks postpartum. I wanted to make sure I was doing everything possible to help myself prior to returning to work, exercise, and daily functional tasks. (Yes, I saw someone even though I am a pelvic health physical therapist. I have had that question a lot.)

What will a pelvic heath physical therapist go over early on?

-body mechanics


-self care

-the “what not to do’s”

-breathing techniques


-intrinsic muscle activation

In conclusion, remember the plane analogy. Put your oxygen mask on before you put your child’s on. This is how we have to think of our bodies and returning to normal day to day tasks during this time postpartum. We have to help ourselves to be able to be strong and stable to help care for our new little ones.

Below are some resources that ACOG has now listed for the “4th trimester”

The American College of Obstetricians and Gynecologists (ACOG) now lists recommendations:

The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions:

1. To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs.

2. Anticipatory guidance should begin during pregnancy with development of a postpartum care plan that addresses the transition to parenthood and well-woman care.

3. Prenatal discussions should include the woman’s reproductive life plans, including desire for and timing of any future pregnancies. A woman’s future pregnancy intentions provide a context for shared decision-making regarding contraceptive options.

4. All women should ideally have contact with a maternal care provider within the first 3 weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth.

5. The timing of the comprehensive postpartum visit should be individualized and woman centered.

6. The comprehensive postpartum visit should include a full assessment of physical, social, and psychological well-being.

7. Women with pregnancies complicated by preterm birth, gestational diabetes, or hypertensive disorders of pregnancy should be counseled that these disorders are associated with a higher lifetime risk of maternal cardiometabolic disease.

8. Women with chronic medical conditions, such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, mood disorders, and substance use disorders, should be counseled regarding the importance of timely follow-up with their obstetrician–gynecologists or primary care providers for ongoing coordination of care.

9. For a woman who has experienced a miscarriage, stillbirth, or neonatal death, it is essential to ensure follow-up with an obstetrician–gynecologist or other obstetric care provider.

10. Optimizing care and support for postpartum families will require policy changes. Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit.

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