The Fourth Trimester

Jeannie C. Kelly

George A. Macones

Introduction

The term, “the fourth trimester,” was originally coined by pediatrician Dr Harvey Karp in his popular parenting books to describe the first 3 months of a newborn’s life. This time was framed as a period of transition for the infant and focused on soothing techniques to ease and aid in adaption to an extrauterine environment.¹ Recently, the fourth trimester has also been underscored as a critical transition for the woman as she physiologically recovers from childbirth and additionally adjusts to the physical, psychologic, emotional, and social demands of caring for a newborn.² During this time, she also transitions out of obstetrical care to well-woman primary care for her own medical needs, which can require challenging navigation through a complex medical system, especially if she has preexisting or newly developed health conditions. Yet, more than 40% of women have no postpartum visit with their obstetrical clinician.²

In the United States, birth rates have been increasing steadily for women older than 35 years, with high rates of preterm birth, cesarean delivery, and medical comorbidities compared to other developed countries. Concurrently, postpartum hospital readmission rates have risen sharply, and maternal mortality is increasing, with most cases (>40%) occurring postpartum.²^,³^,⁴ Thus, the postpartum period represents a critical and medically vulnerable time, underscored by increasing obstetrical complexity and morbidity. In order to improve clinical outcomes, the postpartum period must be considered as equally crucial as prenatal care in a woman’s obstetrical course with ongoing medical care.

Redefining the Fourth Trimester

In a review of cultures around the world, the postpartum period is typically defined as the time between 6 and 8 weeks after delivery, due to the resolution of postpartum lochia and other physiologic changes of pregnancy. Common postpartum rituals include organized maternal support from family members and a rest period that includes restricted activities and diets.⁵ However, postpartum rituals and support groups are less defined for women in the United States outside of immigrant and ethnic/cultural group communities, leaving patients devoid of any specialized or structured care. Postpartum support thus sometimes only comprises the medical follow-up encounters between the patients and their pediatric and obstetrical clinicians.²

The American Academy of Pediatrics (AAP) recommends eight standard follow-up well-baby visits during the first year of an infant’s life, during which screening for maternal depression is recommended at the 1-, 2-, 4-, and 6-week visits to evaluate caregiver health.⁶ In contrast, traditional obstetrical medical care culminates in a single 15-minute visit at 6 weeks after delivery and must address all postpartum health concerns, including psychosocial stressors and future pregnancy planning in addition to formulating primary care and specialist follow-up plans for any medical conditions.² Recognizing the impractical and unfeasible challenge of this expectation, the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) revised their postpartum care recommendations in 2018 to include, at minimum, an initial postpartum encounter within the first 3 weeks of delivery to address immediate delivery recovery and concerns, and a comprehensive visit no later than 12 weeks postpartum to transition out of obstetrical care (Figure 53.1).² These changes reframe the postpartum process as a sustained and active component of a woman’s obstetrical care that should link seamlessly into ongoing preventative healthcare. After all, the postpartum time can also be considered the
interval “between pregnancies,” and the ability to optimize medical comorbidities during pregnancy intervals is crucial to decrease future obstetrical disease.

Figure 53.1 Proposed paradigm shift for postpartum visits. The American College of Obstetricians and Gynecologists’ Presidential Task Force on Redefining the Postpartum Visit and the Committee on Obstetric Practice propose shifting the paradigm for postpartum care from a single 6-week visit (bottom) to a postpartum process (top). BP, blood pressure; f/u, follow-up.

Postpartum Care Planning

Formulating the birth plan, which is a document that details a woman’s preferences and expectations regarding labor, delivery, and newborn care, has become a popular and routine component of prenatal counseling with maternal care clinicians.⁷ This anticipatory discussion regarding the birth process is seen as an important piece of advocacy for patient autonomy in medical decision-making and presents an opportunity for the patient to openly disclose her fears and concerns. Notably, the postpartum component of most birth plans is centered around newborn care and feeding, and the plans typically conclude with discharge from the hospital. Postpartum maternal care, support, and medical follow-up visits are frequently lacking from detailed planning or discussion in current routine practices, resulting in an underutilized opportunity to maximize comprehensive maternal medical care and ensure a smooth transition to appropriate long-term care for chronic medical conditions. Increasing the proportion of women attending a postpartum visit is an objective of the Centers for Disease Control and Prevention’s Healthy People 2020 initiative, and proactive postpartum guidance and planning should be started during pregnancy.² The positive association between preparatory counseling and maternal outcomes has been shown in randomized controlled trials to decrease rates of depression and increase rates of breastfeeding.² Thus, similar to the now-ubiquitous birth plan, a Postpartum Care Plan should be discussed in detail with patients prior to delivery.

The ACOG suggests nine components to the Postpartum Care Plan and recommends reviewing each element during routine prenatal visits (Table 53.1).² Given the scope of these topics, obstetrical practices should consider utilizing routine visits with peer counselors, nurses, support staff (such as lactation consultants), and discharge planners both prior to delivery and during the delivery admission as strategies to be as comprehensive as possible. Postpartum visits should be scheduled prior to discharge from the delivery, and technology (email, text, or other apps via smart phones) should be used when possible for reminders and communication.

Common Postpartum Symptomatology

Multiple changes in maternal physiology occur after delivery, resulting in a range of symptoms that are considered normal. However, less than 50% of women reported receiving enough information regarding postpartum expectations to feel prepared.² These common postpartum experiences should be briefly reviewed prior to delivery with each patient so they can be anticipated, with precautions for further evaluation if they fall outside of expected parameters.

Shivering

Shivering is a common occurrence in up to 50% of women after delivery. Onset is typically within 30 minutes of delivery, lasting up to an hour in duration.⁸ Many theories regarding the etiology have
been proposed, including normal physiologic consequences of childbirth and medical interventions. However, the mechanism is unclear, the process is self-limited, and no treatment is required.

Table 53.1 Suggested Components of the Postpartum Care Plan^a

Element	Components
Care team	Name, phone number, and office or clinic address for each member of care team
Postpartum visits	Time, date, and location for postpartum visit(s); phone number to call to schedule or reschedule appointments
Infant feeding plan	Intended method of infant feeding, resources for community support (eg, WIC, Lactation Warm lines, mothers’ groups), return-to-work resources
Reproductive life plan and commensurate contraception	Desired number of children and timing of next pregnancy Method of contraception, instructions for when to initiate, effectiveness, potential adverse effects, and care team member to contact with questions
Pregnancy complications	Pregnancy complications and recommended follow-up or test results (eg, glucose screening for gestational diabetes, blood pressure check for gestational hypertension), as well as risk reduction recommendations for any future pregnancies
Adverse pregnancy outcomes associated with ASCVD	Adverse pregnancy outcomes associated with ASCVD will need baseline ASCVD risk assessment, as well as discussion of need for ongoing annual assessment and need for ASCVD prevention over lifetime
Mental health	Anticipatory guidance regarding signs and symptoms of perinatal depression or anxiety; management recommendations for women with anxiety, depression, or other psychiatric issues identified during pregnancy or in the postpartum period
Postpartum problems	Recommendations for management of postpartum problems (ie, pelvic floor exercises for stress urinary incontinence, water-based lubricant for dispareunia)
Chronic health conditions	Treatment plan for ongoing physical and mental health conditions and the care team member responsible for follow-up
ASCVD, atherosclerotic cardiovascular disease; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.
^aA Postpartum Care Plan Template is available as part of the ACOG Pregnancy Record.

Lochia

Lochia refers to the normal vaginal discharge after delivery that consists of blood, endometrial decidua, serous exudates, and physiologic cells. Lochia typically progresses through three stages⁹:

Lochia rubra: typically lasts for the first week after delivery and is red in color due to a large component of blood
Lochia serosa: typically lasts for a few weeks after lochia rubra and is thinner in consistency and lighter in color
Lochia alba: light yellow and consists of serous exudate and maternal cells

Although the total volume of lochia is about 500 mL, the normal duration is, on average, 1 month and can last up to 8 weeks postpartum in 15% of women.

Hormonal Changes

Extensive hormonal changes occur, starting with uterine separation of the placenta. Progesterone and estrogen are at their maximum levels at the end of a term pregnancy and precipitously drop with delivery, remaining low for a month afterward.¹⁰ Some patients report hot flashes and night sweats in the first few weeks following delivery, believed to be associated with the same mechanism driven by estrogen withdrawal at the hypothalamus as in postmenopausal women.¹¹ Prolactin levels remain high immediately following delivery and, in the absence of progesterone, initiate milk secretion typically within 3 to 5 days. A substantial drop in human chorionic gonadotropin occurs within the first week followed by a slower rate of decline over the next month and typically disappears by 4 weeks postpartum.¹⁰^,¹²

In nonlactating women, ovulation will resume, on average, within 3 months but can occur as early as 3 weeks postpartum. Most nonlactating women will resume menstruation within 12 weeks postpartum, but importantly, a large proportion
(up to 71%) will ovulate prior to their first menses and thus may have a fertile period prior to onset of any symptoms indicating return of fertility. In lactating women, ovulation is delayed, with a broad variation in duration of amenorrhea that depends on maternal age, parity, duration, and frequency of breastfeeding, and is also associated with a prolonged hypoestrogenemic state.¹⁰^,¹¹^,¹²

Hair, Skin, and Muscle Changes

Hair, skin, and muscle changes occur due to hormonal fluctuations and rapid uterine involution that occurs postpartum. Hair loss is commonly seen starting within 6 months postpartum, but this is due to the increased anagen “growing” phase present in pregnancy returning back to the normal prepregnancy telogen “resting” phase, and concludes by 1 year postpartum in the majority of patients.¹³ Pregnancy striae are typically purple or red lesions that develop in up to 90% of women, commonly on the abdomen, breasts, and thighs, resulting from rapid stretching and tearing of the dermis.¹⁴ Although the color will fade after delivery, the skin may remain lax. Additionally, the abdominal wall will improve in muscle tone but rectus diastasis can persist and may result in discomfort, postural changes, and cosmetic dissatisfaction.¹⁵

Pain and Discomfort

Pain and discomfort are the most common complaints postpartum, after both vaginal and cesarean deliveries.¹⁶ Uncontrolled pain can interfere with activities of daily living, including infant care, and is associated with greater opioid use, depression, and development of chronic pain.¹⁷ Thus, pain control with both pharmacologic and nonpharmacologic strategies in a stepwise, multimodal approach is an important consideration in the postpartum period. Uterine contractions occur with oxytocin release after delivery and in association with nursing and may be worse in multiparous women.¹⁷ Oral nonsteroidal anti-inflammatory drugs (NSAIDs) have better evidence supporting their use for effective pain management than opioids, and the course is usually self-limited to a week.¹⁶^,¹⁷ After vaginal delivery, perineal hygiene and care, with elevation of the foot of the bed, may help with pain and discomfort. Use of perineal ice packs has been shown in meta-analysis to improve pain in the first 72 hours after delivery but does not appear to change wound inflammation/edema or healing.¹⁷^,¹⁸ Scheduled pharmacologic treatment using NSAIDs alternating with acetaminophen appear to effective in decreasing perineal pain for the majority of women but can be supplemented in a stepwise fashion with opioids if insufficient, especially for women with significant lacerations.¹⁷ To decrease the risk of acetaminophen toxicity, opioids should be given individually and not in a combination formulation with acetaminophen. After cesarean delivery, opioids given via neuraxial regional anesthesia provide the most effective pain control but must also be augmented with other forms of analgesia as the effects wear off over time. A similar stepwise approach should be taken with scheduled alternating NSAIDs and acetaminophen, reserving opioids for breakthrough pain as needed. A local anesthetic block injected between the internal oblique and transversus muscles may also benefit postcesarean pain.¹⁷

There is wide variation in opioid prescribing patterns for discharge after delivery, and usually the amount does not correspond to level of pain reported or opioid requirements in the hospital.¹⁹ The majority of women report being prescribed twice the number of opioids needed after delivery, and a minority dispose of leftover opioids appropriately.¹⁹ Additionally, recent studies demonstrate that 1 in 300 opioid-naïve women will become persistent opioid users after postcesarean exposure (Chapter 8).¹⁷^,¹⁹ As opioid-related overdose deaths have drastically increased and the incidence of opioid use disorder continues to rise in this country, prudent prescribing of opioids is imperative to decrease rates of misuse and diversion, while at the same time appropriately treating postpartum pain.¹⁷ Shared decision-making with the patient to determine the amount of prescribed discharge opioids, which includes discussing average pain scores and average opioid requirements after cesarean delivery, appears to improve patient satisfaction with pain control and decrease leftover opioids.¹⁹

Notably, about 4% to 5% of the population in the United States is “ultrafast metabolizers” of codeine and tramadol, resulting in high serum and breast milk levels of active metabolites.¹⁷^,²⁰ Cases of breastfed infants exposed to maternal intake of codeine have been reported with oversedation, respiratory depression, and even death.¹⁷^,²⁰ Thus, in 2017, the United States Food and Drug Administration issued a warning against codeine and tramadol in breastfeeding women.²⁰ However, oxycodone and hydrocodone are also metabolized by the same
enzyme, and cases of infant sedation in breastfeeding mothers have also been reported.¹⁷ Due to the wide variation in metabolism of opioids, all women prescribed opioids should have counseling regarding the risk of maternal and infant oversedation and/or toxicity, and opioids should be used for the shortest necessary time.

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