Duly Intro: Duly Noted, a health and care podcast, is the official podcast series of Duly Health and Care. Each podcast features physicians or team members discussing groundbreaking topics and innovations that help listeners re-imagine and better understand an extraordinary health and care experience.

Amanda Wilde (Host): Hello, everyone. I'm pleased to welcome you to another episode of Duly Noted, the official podcast of Duly Health and Care. I'm Amanda Wilde. We commonly think that pregnancy lasts three trimesters. But after birth, there is a fourth trimester that is just as important for mother's health. To talk specifically about the fourth trimester, my guest is obstetrician and gynecologist, Dr. Michelle Winter, Department of Obstetrics and Gynecology Vice Chair at Duly Health and Care. Great to have you here, Dr. Winter. Welcome.

Dr Michelle Winter: Thank you. It's really great to be here today.

Host: So obviously, most often emphasis of medical care is placed on women before, during, and then immediately following childbirth, but the fourth trimester is often swept aside. Can you talk us through the definition of the fourth trimester?

Dr Michelle Winter: Yes. So, this is so true. We've typically thought about pregnancy occurring in those first three trimesters, so different medical conditions, different needs for care that occur during each. But the fourth trimester actually refers to that first 12 weeks after birth. And that's a time of unique challenges and even some new medical conditions that can arise during that time. And yet for years and years, the vast majority of care that women are getting, it still focuses on those first three trimesters. So, we will typically see women once a month for the first trimester, once a month for the second trimester. And then in the third trimester, we accelerate that care. We're seeing them even sometimes weekly during that time. And then typically, they deliver the baby and then we don't see them again for two to six weeks. But there is actually more of a paradigm shift now, which is being supported by ACOG, the American College of Obstetricians and Gynecologists, and that is to have earlier contact in the fourth trimester and then an ongoing care model that sort of culminates in a postpartum visit, no later than 12 weeks at the end of that fourth trimester. But the ongoing care sort of correlates to what different challenges women are having during that time.

Host: Well, speaking of those challenges of all the changes that occur in all the stages of pregnancy, let us talk about hormones. In terms of hormones, can you talk about what are considered normal changes, physically and mentally, after birth and also when it might be time to seek professional help.

Dr Michelle Winter: Yeah, absolutely. So, almost immediately after childbirth, the main pregnancy hormones, progesterone and estrogen, they drop really rapidly, pretty close to pre-pregnancy levels. And then at the same time, we see an increase in hormones like oxytocin. People call this the love hormone. That's the hormone that kind of helps with contracting the uterus back into the pelvis, and it also helps with that maternal-child bonding that needs to happen in those first few days and weeks. And then, another hormone is called prolactin. That hormone starts to rise in our bodies to help stimulate our milk production in the breast. And so, all those changes can really cause both physical and mental health changes for the women. Physically, we mean like engorgement of breast tissue. So as your breast tissue is going to change to produce milk, you're going to notice some swelling and pain in the breast tissue. That contraction of the uterus generally doesn't happen right away after birth. Most women will tell you, "Yeah, I still looked pregnant for a couple weeks after birth," it takes several weeks for that uterus to kind of contract back down into the pelvis. Many women, because of that change in the progesterone and estrogen, they also get this rapid hair loss. It's called telogen effluvium. So if you have a lot of postpartum friends, they'll tell you like their hair just comes out, like, they run a comb through it and it's just coming out all over the place. And that generally can last a couple of months, but it's usually temporary. But, you know, it can be kind of distressing for a few months.

And then, in terms of mental health, that's where we see a lot of changes too. So, it's not necessarily the level of the hormone that's affecting us, it's actually that change. It's the rapid change in the hormone after the placenta is delivered. And so, baby blues is really common during that period. So, it affects about 80% of new moms. Baby blues generally means like you're feeling sad, maybe a little irritable, maybe anxious. And it usually resolves after about two weeks. If it's not resolving after two weeks, that could be moving into something more of like a postpartum depression and that's something that women should be seeking care from their provider for.

Host: And that's all hormonally related. Lots of body changes, anxiety. What are some of the other most common challenges women are faced with physically and mentally during the fourth trimester?

Dr Michelle Winter: Well, there's a lot. So, physical challenges, I mean, the most obvious would be just postpartum pain. So, it doesn't really matter if you have a vaginal or cesarean delivery. There's usually some pain associated postpartum. This could be from lacerations, from surgical pain, from swelling. So, there's just usually like a fair amount of pain. So, pain medicines obviously can be used for that.

Fatigue is probably the most common thing that I think most women, they're aware of it before they deliver, but they don't really know what that's going to feel like until they deliver. I mean, caring for a newborn is physically exhausting. It can lead to sleep deprivation, as you know, because the infant is waking up every two to three hours and needing to be fed, whether it's breastfed or bottle fed, somebody has to be with the baby. And then, a lot of women experience pretty significant blood loss from delivery that can lead to anemia and then they can have, increasing fatigue from that on top of their sleep deprivation.

Breastfeeding challenges are super common. Probably, the thing that women feel most unprepared for after birth is breastfeeding, especially for first babies. You can have problems with poor feeding from latch difficulties, sore nipples; mastitis, which is an infection of the breast tissue from breastfeeding. Some women have an oversupply of milk, some women have an undersupply of milk. Inevitably, everyone's going to have some kind of challenge with breastfeeding.

 You know, pelvic floor is another one, pelvic floor weakness. You can get urinary sometimes even stool incontinence in the first weeks birth. And a lot of that does resolve with time, but some people need a little extra help for that. Same thing with the women talk about diastasis recti, it's like a separation of the abdominal muscles and it leads to weakness in the abdominal muscles and that's our core. That's what's kind of holding us up and standing. So, all of those things are these major physical changes. Lots of women have changes in their body image during this time. So, there's a lot that gets packed into that first 12 weeks.

And then, the mental and emotional side. I briefly touched on the baby blues, that's super common. But maybe about like 10-20% of cases will actually turn into a true postpartum depression or a postpartum anxiety. It's not always feelings of sadness. Sometimes it can be feelings of extreme anxiety. And even if you don't have postpartum depression, you can get just feelings of isolation or even just changes in your relationship with your partner. You know, bringing a baby into a family is a big change and not all women and their partners kind of see that in the same way. So even if you're not experiencing those postpartum depression or suicidal thoughts, there is a lot of emotional changes that kind of happen in this time period anyway.

Host: Major. So, with all these challenges that are likely to come up, what can we do to address them? Are there remedies or strategies to help prevent these challenges from persisting?

Dr Michelle Winter: Yes, there are. So, I mean, I think the number one thing that I talk to my patients about is seeking support. So, identifying who's your support network. This could be friends. This might be family. It might be a partner or it might be like a formal support group. There's lots of new moms groups. There's even like new moms groups surrounding breastfeeding, new moms groups surrounding fitness, new moms groups surrounding feeding, like how people feed the baby. So, it can be just really helpful to have other parents to connect with who are kind of going through similar experiences.

And then in addition to seeking support, it's also important to remember to accept help, I think a lot of us are feeling like, "This is my baby. I'm supposed to be able to do this all myself," and that's just not true. So, a lot of people will have family members that will offer to prepare meals. And I think I tell my patients, "Just accept the help while it's there, because you need it and it's okay to accept it." If you have out-of-town relatives that are coming in and expecting to be entertained, those are not the people to be inviting over in the immediate postpartum period. But if you've got friends and family that are like, "Hey, let me bring over a casserole" or "Why don't I clean up some bottles while you rest?" Those are the people that you want to surround yourself with. And so, that's more of your informal support system.

I also talk to women a lot about the sleep deprivation component because the partners, a lot of times they're not sure how they can help. And I feel like one way they can help is give you four hours of consecutive sleep. In the first two weeks postpartum, the baby will typically not sleep for four hours total. If they do, that's great. You got a good baby, but a lot of them it's two to three tops. And for sleep deprivation, you really need to get four hours of consecutive sleep. So, I tell patients plan ahead, come up with a schedule with your partner, what hours is he or she going to give you so that you can get your sleep. And if you don't have a partner, that could be a family member, that could be a friend, somebody that can just kind of relieve you for four hours.

Other formal things like physical therapy. So, Julie actually has a really wonderful network of pelvic floor specialists who are trained in postpartum recovery. So, they can deal with the diastasis recti, that separation of the abdominal muscles, incontinence, and then just general deconditioning from pregnancy, helping women get back to a state where they can be exercising. Exercising builds endorphins, it builds strength, it builds energy. All of those things are really important throughout that fourth trimester. So, our therapists are really great with helping women kind of get back on track.

Lactation support. So, many hospitals have lactation consultants in the hospital, which is really wonderful for that first 24 to 48 hours postpartum, but there are actually lactation specialists outside the hospital. Some of them will do home visits. Some of them you can do outpatient visits with. And so, I encourage my patients to identify a lactation support person that's going to be able to help them because they're really great for initial feeding and latching and all that stuff. But even as you go throughout the fourth trimester, your milk supply is going to change. The baby's food needs are going to change. The mouth gets bigger, so the latch might change a little bit. And then especially for moms who are going to be going back to work, they need to learn how to use a breast pump and understand when to pump, how to pump, what's the best method. And then, our lactation specialists are really helpful with that kind of thing.

And then, mental health, I touched on it earlier, but for those that are suffering with postpartum anxiety, depression, talk to your provider, your obstetrician or midwife, that person can prescribe medications. They often can give you therapy referrals. Group therapy is really great in the fourth trimester, because again, it's like that support network of other moms, but there's also individual therapy for women that might need a little bit more.

Host: Well, as you've described, being a new mom comes with so many highs and so many lows. And you've talked a bit about what kind of support systems moms can build to get through this time. Is there anything else we can do to prepare for that fourth trimester in advance before giving birth?

Dr Michelle Winter: Yeah, I mean, I think anticipatory guidance with your doctor is really key. So as, physicians, we should be bringing this up in that third trimester talking about what are the support things that you're going to need after delivery, what types of appointments should women be setting up, you know, women with chronic medical conditions, high blood pressure, diabetes, those women might need a follow up with their primary care doctor or a specialist postpartum. So, talking about that and preparing, having those visits kind of set up ahead of time. I think women, just like they discuss a birth plan, they need to discuss a postpartum plan with their providers and it's our job to make sure that women are aware of the services that are available to them. They need to know when to reach out if there's a problem, how high of a blood pressure is too high, how much swelling is too much, how much bleeding is too much. And then just to kind of help them anticipate a little bit what problems might arise. And then especially for those with the chronic medical issues, setting up their follow up appointments ahead of time can be really helpful.

Host: Great way to set yourself up for success. Dr. Winter, thank you for explaining what we can expect and what we can do when issues arise, and just great advice for navigating the fourth trimester.

Dr Michelle Winter: Yeah, no problem.

Host: That was obstetrician and gynecologist, Dr. Michelle Winter, Department of Obstetrics and Gynecology, Vice Chair at Duly Health and Care.

For more information, please visit dulyhealthandcare.com. If you found this podcast helpful, please share it on your social media. And thanks again for listening to Duly Noted, a health and care podcast.