The “Fourth Trimester”

by Donna Walls RN, BSN, ICCE, IBCLC

The initial transition to motherhood is unique for every mother/baby dyad. It is a time of exploration, nurturing, learning and falling in love. This transition time is celebrated and supported with very different traditions around the world.

An overriding philosophy in most western cultures has changed from what was viewed as the “lying in period” of rest for 3-4 weeks post birth to the present concept of encouraging self-care when the mother focuses on restoring her health to be able to care for herself, her newborn, and her family as quickly as possible.

In many other cultures, the emphasis is on a prescribed period of time focusing on rest and recovery while friends and family care for the mother and often her family and home. The mother’s only responsibility is caring for her infant. In China, the postpartum time literally means “sitting the month” when new mothers are served nourishing foods aimed at restoring health and supporting lactation. In Korea, the resting period post birth is commonly referred to as “the 100 days of birth” while in Japan the “ansei” means “peace and quiet with pampering” for the first three weeks.

In India, the “confinement” lasts from 40-60 days and includes herbal baths and massages. In Africa, new mothers remain quietly at home for 10-40 days, and in some African countries it can be up to three months with friends and family taking care of her home and other children

In Mexico, “la cuarentena,” translates to “quarantine” and continues for forty days which some studies have shown to encourage infant and mother bonding.

In Holland, a “kraamverzorgster,” a qualified healthcare professional, provides care at home to mother and baby during the first eight to 10 days post birth and is a mandatory part of maternity care. These women are generally in the home for 5-6 hours a day and provide physical, emotional, and breastfeeding support, much like the role of the postpartum doula in the United States.

In the United States, new mothers often face returning to work or school within 2-4 weeks after giving birth. This early transition time can be challenging with altered sleep patterns, uncertainties of the new maternal role acquisition, and changing relationships with spouse and other family members. Early return to previous job or school schedules can exaggerate anxieties or concerns common in this timeframe.

There are conflicting opinions on which care tradition seems to be the most advantageous. Is extended rest harmful, leading to complications? Or, is early return to physical activities resulting in increased risk of complications? Unfortunately, there is little research on this topic

The postpartum period associated with healing and physical return to the non-pregnant state is generally recognized as six weeks. This time period allows for uterine involution, establishment of lactation, and adjustment to the role of mother.

Women have always sought other women, both family and friends, for guidance and support. This tradition of passing along knowledge and wisdom regarding infant care, emotional changes, physical expectations, breastfeeding support, and sexuality can become difficult when women are geographically separated from female family members or close social support.

Resources
Postpartum Maternal Health Care in the United States: A Critical Review
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595301/
Factors Associated with Postpartum Maternal Functioning in Women with Positive Screens for Depression.Barkin JL, Wisner KL, Bromberger JT, Beach SR, Wisniewski SR. J Womens Health (Larchmt). 2016 Jul; 25(7):707-13. Epub 2015 Nov 24.
The inadequacies in postnatal health care – ScienceDirect
http://www.sciencedirect.com/science/article/pii/S2352081716301623 by N Fogel – ‎2017
Systematic review of the literature on postpartum care: effectiveness of postpartum support to improve maternal parenting, mental health, quality of life, and physical health.
Shaw E, Levitt C, Wong S, Kaczorowski J; McMaster University Postpartum Research Group.
Birth. 2006 Sep;33(3):210-20
Pregnancy as an ideal time for intervention to address the complex needs of black and minority ethnic women: views of British midwives.Aquino MR, Edge D, Smith DM.
Midwifery. 2015 Mar;31(3):373-9. doi: 10.1016/j.midw.2014.11.006. Epub 2014 Nov 13.
Understanding and meeting the needs of women in the postpartum period: the Perinatal Maternal Health Promotion Model. Fahey JO, Shenassa E. J Midwifery Womens Health. 2013 Nov-Dec;58(6):613-21. doi: 10.1111/jmwh.12139. Epub 2013 Dec 9. PMID:24320095
Social support during the postpartum period: mothers’ views on needs, expectations, and mobilization of support. Negron R, Martin A, Almog M, Balbierz A, Howell EA.
Matern Child Health J. 2013 May;17(4):616-23. doi: 10.1007/s10995-012-1037-4.PMID:22581378
The role of maternal self-care in new motherhood. Barkin JL, Wisner KL.Midwifery. 2013 Sep;29(9):1050-5. doi: 10.1016/j.midw.2012.10.001. Epub 2013 Feb 15. PMID:23415369

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