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The Spokesman-Review Newspaper
Spokane, Washington  Est. May 19, 1883

Fourth trimester: Earlier postpartum care for new moms

While pregnancy has been long divided into three trimesters, increasingly there’s an emphasis on the “fourth trimester.”

The idea is make sure both mother and baby are getting the right care in that three-month period after birth. It’s also about helping women know what to expect with their changing body and to seek support earlier.

A year ago, the American College of Obstetricians and Gynecologists set new guidelines refocusing postpartum care. And the conversation gained momentum after Meghan Markle gave birth to her son, Archie, in May.

“Postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs,” the group says.

Now, the group urges women to see an OB-GYN or similar provider within three weeks postpartum, rather than six, and to seek ongoing care as needed. The guidelines also include a comprehensive postpartum visit at no later than 12 weeks.

Spokane-area providers say fourth-trimester care is more often discussed, but they cite barriers remaining for many women.

“We’ve always been aware that our system isn’t set up very well to integrate maternal and newborn care together in the postpartum time frame, and that’s a barrier that’s becoming more often discussed,” said Dr. Mark Schemmel at Spokane OBGYN.

He sees moms within three weeks after deliveries, but he’s long told his patients about how most of everyone’s focus shifts to the newborn.

Some women are at risk if they don’t get post-delivery care, including under difficult pregnancies or deliveries, hypertensive disorders that can persist or worsen postpartum and gestational diabetes.

“Within obstetrics, there is growing recognition of the need for health management for many women in the postpartum period, and the risks to their long-term health that lack of management in that period can present,” he said.

MultiCare Rockwood OB-GYN Midwifery Clinic has long set postpartum visits at two to three weeks, and at six weeks. Alyssa Martsching, a nurse midwife, said many changes happen to a woman’s body after a birth.

“You have a lot of hormonal shifts, emotions, physical changes, nursing for the baby.”

The visits cover “B” checkpoints: Bleeding, breastfeeding, blues, bottom for where delivery occurs, birth control and bowel issues.

“We also get into sleep,” Martsching said. “Are you trading baby care with a partner so you can sleep?”

Nurse and lactation specialist Angie Tollefson talks to new moms weekly for classes and support groups at MultiCare Valley Hospital. She said more needs to be done to teach women and their families about those first weeks.

“It’s putting a huge emphasis on a lot of skin-to-skin time, limited visitation from guests, and mom needs support from dad and as many women as she can get her hands on,” she said.

Kayla Balholm, a postpartum doula, said she often hears new moms aren’t getting fourth-trimester support. She said many women are seen by providers at six weeks, unless they have complications.

“Even though it’s a recommendation that women should be seen earlier, they’re not typically,” Balholm said.

“So there are a lot of questions, and moms aren’t sure who to ask, how to get help, what to do. They wonder, should I be able to tough it out and do it myself?”


Tollefson said she sees many women in groups who are young and often don’t advocate about their health issues. Others are low income. Overall, lack of support remains a central issue.

“So many of our moms don’t have that support network of female family members like they used to in the day when your mother-in-law, mom, grandmother and aunties would all come and clean your house and make dinners.

“A lot of these moms have to go back to work less than six weeks postpartum. It’s hard to encourage a realistic fourth trimester.”

She thinks social media gives an illusion of newborn ease. In reality, she said women struggle with depression and anxiety. They don’t feel comfortable seeking help or know who to ask.

“It’s teaching new moms if they get to prenatal classes about realistic expectations of what these first three months are going to be like with very little sleep, no time for yourself, that the relationship between you and your partner changes dramatically.

“It’s knowing ahead of time it’s going to be pretty tough for most moms.”

Juggling medical appointments for both baby and the mother herself can be difficult, when adjusting to a newborn is challenging, Schemmel said. Some family doctors can care for both in one visit, he added, but fewer of them can do so.

“We’re trying to coordinate appointments on days when they can also have their newborns seen by the pediatrician, but that’s a lot of juggling,” he said.

He thinks other barriers to women attending early postpartum visits include lack of family support, transportation issues and perceptions about insurance coverage.

“We see a lot of people who literally take the bus to see us, then you add a newborn, a baby carrier, a bag of supplies, and the logistics become pretty daunting,” he said.

“There are many women who live in complex social-economic environments, and they might not have the support they need to come in and see us.”

Distance can be a barrier, too. Martsching said some patients in outlying areas schedule postpartum check-ups as online video conferences.


Balholm said postpartum doula services such as hers are available at hourly rates.

After a delivery, she lists important mom questions: Is there an ability to rest? Are they physically comfortable? Are they eating well and drinking enough fluids? Do they need help with breast feeding, around the house and with infant care?

Women typically ask her if their pain is normal after giving birth.

“They wonder how long it is going to last,” she said. “Am I ever going to have my body back?”

Other questions surround emotional recovery. She suggests recruiting a support system, calling it “finding your tribe” among other new moms, family, women in prenatal classes or neighbors.

“For a lot of us, we haven’t seen other moms do motherhood before. We haven’t seen newborns, nursing and moms being tired. There are a lot of questions about is this normal? That I feel alone.”

“When we can answer all those questions and love on the mom, then baby does just fine.”

The American College of Obstetricians and Gynecologists says the 12-week maternal visit should cover: Mood and emotional well-being; infant care and feeding, sexuality, contraception and birth spacing; sleep and fatigue; physical recovery from birth; chronic disease management and health maintenance.

Under the six-week postpartum visit guidelines, as many as 40% of women didn’t go, the group said.

Contact the writer:

(509) 459-5439