Postpartum Healing: What to Expect in the Fourth Trimester

Pregnancy comes with 3 distinct trimesters, all of which have well-known symptoms associated with them. But the post-partum period, which comes with a lot of less commonly discussed changes, is just as common as the first trimester nausea. The postpartum period brings with it changes in your hormones, your body, and your emotions…all while caring for a new babe, and maybe for the first time! All this to say, navigating this time period can be challenging…made even more difficult by sleep deprivation! Growing a baby and giving birth is beyond incredible, but giving yourself the tools and time to restore nutrients, balance hormones and heal delicate tissues will have a huge impact on how you experience the early days of motherhood. Here is what you can expect.

POSTPARTUM HORMONES

ESTROGEN, PROGESTERONE, AND OXYTOCIN

During pregnancy, estrogen and progesterone are at an all-time high. Right after giving birth, these hormones drop dramatically, marking the single largest sudden drop in hormones, in the shortest amount of time, for any human being.

At the same time, a hormone called oxytocin floods the bloodstream. Oxytocin is responsible for strengthening the contractions during labour and promoting lactation. It is also important in human behaviours like recognition, trust, and mother-infant bonding (some refer to it as the “cuddle chemical”). But when oxytocin goes up, so can anxiety. Oxytocin puts you into “mother-mode” and one important part of that behaviour is being on high alert for danger in your child’s world.

As you can imagine, these drastic changes in hormone levels can have profound effects on the female body and brain. The low levels of estrogen and progesterone combined with the high oxytocin, contribute to mood changes seen in the post-partum period.

BABY BLUES AND POSTPARTUM DEPRESSION

The feeling of “baby blues” is completely natural after giving birth and extremely common. Most women experience baby blues to some extent following childbirth and are even more common in Western cultures due to less family support and bonding.

“Baby blues” symptoms include frequent crying episodes, irritability, confusion, and anxiety within the first 10 days post-partum, peaking around 3-5 days after childbirth.

Up to 85% of Western women experience baby blues – so it’s shocking that we don’t talk about this more. Baby blues will dissipate as hormones become more balanced, but if symptoms last for more than 2 weeks it can make a woman vulnerable to more severe mood disorders and it is important to talk to a healthcare provider.

If mood symptoms become more persistent and severe, a new mom may actually be dealing with postpartum depression (PPD). Up to 15% of women experience PPD postpartum, making it the most common psychiatric disorder seen after childbirth. PPD typically starts within the first 2-3 months after giving birth. It may be similar to baby blues, but the symptoms are more intense, last longer and interfere with daily activities, including caring for the new baby. PPD can have serious impacts on mother-infant interaction and attachment of the baby and so, it is really important to speak to your doctor if you think this could be you.

It can take time for hormone levels to return to normal after childbirth, especially if you’re breastfeeding. There are also many other variables impacting hormone balance such as stress and the amount of support a woman has, lack of sleep, anxiety, and concerns about a new baby and so this experience will be very different for every woman, but most women feel more balanced about 6-8 weeks after birth. Remember, feeling the baby blues is a natural experience after childbirth and you aren’t alone in this feeling.

Ways to support a healthy mood postpartum:
  • Getting support is critically important. This can be through your partner, friends, family or a counselor who specializes in the postpartum period.
  • Ask for help – you can’t do it all! Whether it’s making dinner, cleaning up the house or holding the babe while you shower, ask!
  • Get outside, especially when the sun is shining. In the winter months, light therapy can be greatly beneficial.
  • Omega-3 fatty acids and a B-complex supplement can help to nourish the nervous system and balance mood.
  • Stay well-fed and well-rested (when possible). Lack of sleep increases the feeling of anxiety and depression, and blood sugar dysregulation can enhance the feeling of anxiety.
THYROID HORMONES

The thyroid makes thyroid hormones that help regulate body temperature, metabolism and organ function, and giving birth may affect these hormones. The American Thyroid Association states that postpartum thyroiditis, or inflammation of the thyroid gland, affects up to 10% of women. The symptoms of postpartum thyroiditis change with the course of the condition.

  • For the first 4 months after childbirth symptoms include anxiety, insomnia, fast heart rate, fatigue, weight loss, and irritability. But, since life with a new baby is linked to these symptoms, post-partum thyroiditis is often overlooked.
  • After 4-8 months postpartum, these symptoms become fatigue, weight gain, constipation, dry skin, and depression.

Most women will regain normal thyroid function within 12-18 months after the onset of symptoms, but most new moms don’t love the idea of living with these symptoms for a year or more! This is why It is so important for your healthcare provider to monitor your thyroid levels with blood tests so that you get the support you need to function optimally as a new mom.

NUTRIENT STATUS

A growing baby puts a high nutrient demand on your body throughout pregnancy, but add that with blood loss during childbirth and breastmilk production, and postpartum nutrient depletions become highly likely. There are some key nutrients that have been found to be depleted after pregnancy and childbirth, including folate (folic acid), iron, zinc, vitamin A, vitamin B6, and B12. The symptoms of many of these nutrient deficiencies may look a lot like being an exhausted new mother, so they may be overlooked.

During this critical time, optimal nutrient status is imperative to be able to show up to motherhood full-force. To ensure you are getting nutrient support, it is key to continue to take your prenatal vitamin until you are finished breastfeeding, or if you aren’t breastfeeding, until your post-delivery bleeding stops. For more tailored support, it is important to have your nutrient levels tested after giving birth to ensure you are getting the supplementation you need.

I encourage you to also have your vitamin D levels tested as there have been a handful of studies that suggest a link between low vitamin D levels and high incidence of PPD.

OTHER POSTPARTUM SYMPTOMS

UTERUS, VAGINA, AND PERINEUM

Although after labour and delivery you may feel like the uterus has done its job, it isn’t quite finished yet! It takes time to heal and return back to normal size after what it has been through! It is normal (and expected) to experience pain, bleeding, bruising and swelling after childbirth. The uterus takes about 6 weeks to return to pre-pregnancy size.

AFTERPAINS

Afterpains are the contractions that take place to help your uterus shrink back to its regular size. These feel similar to period cramps, but with subsequent births, the afterpains can become quite painful, especially during nursing. These typically begin after delivery and can last for several weeks.

BLEEDING

After delivery, you will also have bloody discharge that is called “lochia”. This happens as the placenta site heals and can last up to 6 weeks.

PAIN, BRUISING, AND SWELLING

Perineal pain will vary depending on your birth experience. If you had a tear, an episiotomy, or if you had to push for a prolonged time period you will likely experience more local pain. There is usually swelling and bruising of the vaginal tissues as well.

To ease pain & promote healing of these tissues:

  • Apply an ice pack during the first 24 hours to prevent excessive swelling. After 24 hours may inhibit tissue healing. Instead, increase circulation by alternating hot and cold compresses on hands and feet.
  • Use baby wipes when you go to the washroom or a squirt bottle with warm water.
  • Soak cotton pads or maxi-pads in witch hazel and stick them in the freezer. A couple of times a day, take one of the pads and tuck it inside the vagina. This helps the tissue heal and provide pain relief.
  • Sitz bath: submerge your entire perineum into warm water with Epsom salts or iodine solution to help heal and reduce the risk of infection. Do this for 15 minutes several times a day for the first few weeks postpartum. You can also add fresh herbs like rosemary or thyme for their anti-microbial activity.
  • I highly recommend you start seeing a pelvic floor physiotherapist 6 weeks postpartum. This ensures proper healing and to promote the health of the perineal tissue.

A note on intercourse: it is recommended to wait 4-6 weeks postpartum to allow the tissues to heal and reduce the risk of infection.

  • Once you resume having intercourse, it may be painful due to lower estrogen levels and recent trauma. Lubricants, Kegel exercises and vitamin E suppositories can be helpful.
CONSTIPATION AND HEMORRHOIDS

Constipation is very common in the first couple weeks of the postpartum period. This can be because of dehydration, medications, and fear of pushing when things are already feeling tender down there. Hemorrhoids can also add to this fear, as they can be very painful after childbirth. The hemorrhoids formed from intense pushing during labour should disappear within a few weeks, but some may last longer.

To reduce pain, heal hemorrhoids and make bowel movements more comfortable:

  • Magnesium oxide or citrate can be used to help soften the stool. If this isn’t enough, other stool softeners can be used.
  • Ensure adequate fluid intake – about 3L/day especially if breastfeeding.
  • Increase fiber by adding psyllium husks, chia seeds and flax to yogurt, oatmeal, smoothies, etc.
  • Use a “donut” or hemorrhoid pillow to ease the discomfort while seated. This can also help for perineal pain too!
  • Sitz baths with witch hazel (see above) can be useful for hemorrhoid healing
  • Over the counter hemorrhoid preparations can be used
BREASTS AND NIPPLES

After delivery, the hormone prolactin is released to promote blood flow and milk production in the breasts. This leads to intense engorgement of the tissue that peaks 2-3 days after birth. Your breast will be pretty hard and sore, and this can be quite painful, but with breastfeeding, this will ease up within a few days. If you aren’t breastfeeding it can take a few days longer. Nipple pain is also very common. Although it is said that nipple tenderness should subside after 1 week of breastfeeding, 38% of breastfeeding women interviewed at 1 month postpartum were experiencing persistent sore nipples.

Nipple pain is one of the main reasons women stop breastfeeding before they had planned and is the most common reason for women to abandon the idea of breastfeeding before even leaving the hospital. Pain during breastfeeding is linked to PPD, stress, sleep disturbances and mastitis, so this something women should know about, be prepared for and have the tools to help.

To relieve breast and nipple pain:

  • See a lactation consultant as soon as possible.
  • Apply warm packs to the breasts before feeding and cold packs afterward. Heat can also be used during the day to help with the pain associated with engorgement.
  • Self-breast massage will help increase blood flow
  • Take hot showers; you can express some milk in the shower if needed
  • Lightly crush a clean cabbage leaf until the juices are visible and place it over the breast to relieve inflammation and pain
  • Nipple cream can be applied to help relieve nipple pain

OTHER WAYS TO SUPPORT YOUR BODY DURING THE POSTPARTUM PERIOD

  1. Sleep banking: It is well-known that if you lose sleep it is very challenging to catch up on the loss and bring your body back to a happy place. Sleep banking basically means you are pre-sleeping in preparation for deprivation or storing sleep for later use. Research shows that sleep banking makes you more resilient to future sleep deprivation. Make it a commitment to yourself to sleep when the baby is sleeping, even when it is tempting to do other things. The extra sleep can have a huge impact on your mood, hormones, and healing.
  2. Diet: Including good protein and fats into every meal is key to help with hormone balance, returning to a healthy body weight and keeping your mood steady. Also, by keeping blood sugar stable, your moods will be more stable. Remember, if you are breastfeeding ensure you are getting enough calories to support breast milk!
  • Good fats: olive oil, coconut oil, avocado, nuts, and seeds, butter or ghee
  • Good proteins: grass-fed meat, organic poultry, eggs, fish, organ meats, lentils, and legumes
  1. Movement: When you feel comfortable, get outside and walk with the baby. Movement will calm and relax you, as well as promote circulation. Wait to start exercising again until all bleeding has stopped and you feel ready, but start gently!
  • Try joining a postpartum yoga class or something similar. This can be a great way to get support from women experiencing all the same things!
  1. Get extra support: You may start to experience new aches and pains based on the way you hold the baby, feed the baby and how you are sleeping. See a chiropractor, acupuncturist or a massage therapist from the beginning to promote proper body positioning and avoid tension and discomfort. Also, if you see a practitioner regularly this means you are getting an hour or so to yourself and have another form of support.

Although it may only take 6 weeks for your uterus to go back to pre-pregnancy size, this does not mean you will be “back to normal” after 6 weeks. There are many normal and expected changes that happen throughout the postpartum period. Your body has been through a wild ride and you created life – so be gentle on yourself. And remember to ask for help when you need it; nobody can do it all, even moms.

To a healthy fourth trimester,

Dr. Bronwyn

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WRITTEN BY:

Dr. Bronwyn is a naturopathic doctor in Toronto, Ontario with a clinical focus in Women's Health. She works with women transitioning off the oral contraceptive pill and those with specific fertility concerns, to reach a state of hormonal balance or in preparation for a healthy pregnancy. Dr. Bronwyn is passionate about empowering women to reclaim their hormonal health, to enable a full and vibrant life.

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