A new way of delivering care in the fourth trimester

Key messages for my fellow health professionals

  • We should take a proactive rather than reactive approach to the postnatal period
  • Postnatal care should begin antenatally and be a continuous process, rather than a series of isolated consultations
  • A two-week check, with a focus on the A-B-C-D will lead to early intervention and change the course of the postnatal period
  • The current six-week check should be comprehensive and individualised to the patient’s needs

First things first … what is the ‘fourth trimester’?

The ‘fourth trimester’ is a term used to describe the first three months post-delivery. It is a period in which the focus has traditionally been on the neonate. Today, the focus is shifting slowly to the dyad – both the mother and the neonate.

Challenges mothers typically face during the fourth trimester

This is a time of massive transition. Not only are women adjusting to motherhood, they are often doing it in a sleep deprived, fatigued state. It is a very vulnerable time during which they tend to focus all their attention on their newborn, to the detriment of their own health and wellbeing.

While the initiation rates for breastfeeding are very high, with over 90% setting out with an intention to breastfeed, by three months only 50% have continued breastfeeding.

One in seven women are diagnosed with postnatal depression which seems high but is actually a significant underrepresentation of the true incidence as many women never seek help. Unrecognised depression can negatively impact on the health of the mother, neonate and other family members. It also impacts the initial bonding of the mother and neonate as well as the cognitive and emotional development of the neonate.

Many women experience issues related to their pelvic floor, with both urinary and faecal incontinence being very common in the immediate postnatal period. Women often assume that these issues are ‘normal’ post childbirth and are reluctant to disclose or seek help about these issues. The incidence of anal incontinence is 2-6%, with the rate being higher in those who have experienced an anal sphincter injury during childbirth.

What fourth-trimester care currently looks like

The current model of postnatal care is based on a single encounter (usually at six-weeks postpartum) and a reactive approach to the management of postnatal issues. This model of care persists despite evidence showing:

  • Over 50% of those that develop postnatal depression had evidence of symptoms antenatally.
  • Many of the problems with breastfeeding occur in the immediate postnatal period and lead to early cessation. A longer duration of breastfeeding is linked to the provision of antenatal education, presence of support systems (both professional and personal) in the immediate postpartum period, breastfeeding support groups and early intervention in the event of breastfeeding difficulties in the postpartum period.
  • Urinary and anal incontinence can be prevented or minimised by education and exercise during the antenatal period.

Changing our approach to fourth trimester care

The first thing we can do to improve patient outcomes is to work with expectant mothers to ensure their expectations of what motherhood will look like are appropriate. Many expectant mothers believe that motherhood will be a time of fulfilment, contentment and excitement. When these expectations are not met, there are often feelings of guilt and a sense of failure, leading many to cover up the difficulties that they are experiencing, rather than seeking assistance.

Secondly, we need to recognise that the postpartum period starts antenatally. Appropriate screening can help us identify those at risk of developing problems postnatally and ensure those patients receive education and support appropriate to their individual needs.

Thirdly, we need to move from a solitary visit at six weeks after birth to a continuous conversation, with an emphasis on support and early intervention. This begins in hospital and continues to a brief check at two weeks postpartum where the A-B-C-D approach allows for early intervention and can change the postnatal course for the women we care for.

The A-B-C-D approach is as follows:

A: Adjustment

B: Breastfeeding

C: Coping (check for postnatal depression and anxiety)

D: Down there (constipation, bleeding, incontinence, pain and prolapse)

The final step in comprehensive postnatal care is to expand the scope of the ‘six-week check’ (which is traditionally done somewhere between the six-week and eight-week mark). It is essential for this check to comprise a full assessment of the physical, social and psychological well-being of women.

In addition to looking at:

  • mood and emotional wellbeing,
  • infant care and feeding, and
  • the physical recovery after child birth,

it is important that we also discuss:

  • sexuality,
  • contraception and birth spacing,
  • sleep and fatigue and
  • health maintenance- with pregnancy often being the first sign of chronic disease’s such as diabetes and hypertensive disease.

‘I wish someone had told me how hard it was going to be.’

My goal is that this term is something we’ll eventually be able to relegate to the history books. We need to set realistic expectations for our expectant mothers, identify those risk of having issues in the postnatal period and intervene early.

By adopting a proactive approach to the fourth trimester, we can significantly improve the outcome for our patients and create a ripple effect that ensures new mothers feel appropriately supported and cared for during a vulnerable period in their lives.

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