The 4th Trimester
In Australia, and in many other Western societies, it’s not uncommon for women to overlook the importance of lying in, resting, slowing right down or taking it easy for the first 6 weeks postpartum. When new mums overlook their physical health or simply don’t understand the importance of giving themselves adequate time to recover from the extraordinary effort of giving birth, they are more likely to feel overwhelmed, stressed, anxious or depressed. However, even women who do understand the need to rest are likely to feel some shakiness, mood swings, anxiety, sadness and/or irritability in the week or so following the birth as their hormones undertake a dramatic shift. These symptoms, commonly referred to as the baby blues, usually resolve on their own within days and are generally easy to manage with a supportive partner and family, a nutritious diet and fresh air. If symptoms become more intense, last longer and generally interfere with daily life and the care of the baby and other children, the woman may be experiencing Postnatal Depression. According to Health Direct, an Australian government-funded service, providing quality, approved health information and advice, 1 in 7 Australian women are affected by Postnatal Depression each year. Some of the common symptoms of PND include:
feeling inadequate and a failure as a mother
feeling exhausted, empty, sad and teary and/or hopeless about the future
feeling guilty, ashamed or worthless
feeling anxious or panicky and/or worrying excessively about the baby
feeling scared of being alone or going out
thoughts about self harm or doing harm to the baby
If a woman is experiencing some of these symptoms, even if not all of them, it is recommended that she visit her GP. The GP may ask her to complete a set of 10 questions, known as the Edinburgh Postnatal Depression Scale (EPDS), to get a better sense of how she is feeling. If the woman’s care provider believes she is experiencing PND, she may be offered some support strategies to cope better, advised to attend therapy, or prescribed antidepressants. With the right approach and adequate support, the symptoms of PND will eventually resolve and the woman will usually be able to cease her treatment. It is helpful for doulas and support people to be aware of any factors that may increase a woman’s risk of experiencing PND in order to be proactive about the kind of support they can offer her, or the services they can refer her to, even prenatally. Some factors that may put women more at risk of experiencing PND include:
A personal or family history of depression or bipolar disorder
Inadequate support from family and friends
Current relationship or financial problems
Particularly low maternal age
Alcoholism and/or substance abuse
Having experienced a traumatic birth
Having a baby with special needs
Having difficulty breastfeeding
Having had an unplanned or unwanted pregnancy
Complications & Challenges in the Early Postpartum
The physical changes that occur in late pregnancy, birth and afterward also often present women with problems in the postnatal period that they may or may not have prepared for. Postpartum contractions of the uterus can be very painful, particularly during breastfeeding as the baby suckling at the nipple causes the uterus to contract. Sometimes women can manage these pains without analgesia but in some cases, they require pain medication. The pains usually subside within a week or so postpartum. After a vaginal delivery, however straightforward it was, the mother is also going to have a swollen, bruised and sore vagina and vulva. If she experienced tearing or an episiotomy, she will also have open wounds either internally and/or on the perineum which will add to her discomfort. Another complication that may arise at this time is haemorrhoids, which can give the woman anxiety about passing stools due to the pain she anticipates, which can also lead to constipation.
Although the region will heal on its own in time, there are some things she can do to provide short term relief and it would be good practice for a doula to make sure the woman is aware of these things head of the birth to ensure her client is prepared in advance. Other than using painkillers, she may find it helpful to sit on a sitzbath for 15 or 20 minutes a couple of times a day with warm water and salt (healing) or witch hazel (anti-inflammatory) to gently cleanse and sooth the area, particularly after a bowl movement. If she doesn’t have a sitz bath she can improvise by sitting in a shallow bath. A little peri bottle can be handy for her to keep in the bathroom to fill with warm water before she needs to go to the toilet so she can squirt it on herself whilst urinating to avoid stinging and help keep the area clean without irritating it with toilet paper. If desired, she can also prepare soothing cold compresses before birth by opening some maxi pads and wetting them with water or witch hazel and wrapping them up in clean plastic bags in the fridge or freezer.
While the wounds and swelling will resolve relatively quickly, the woman may experience painful scar tissue and sensitivity in the region for a long time thereafter and a visit to a women’s physio to support the recovery of her pelvic floor health would be a good investment. Women’s health physios are also specialised in assisting women to regain normal bladder control, as many women experience leaks after a vaginal delivery, particularly when coughing, sneezing, laughing and straining. They can work together to ensure the woman knows how to properly do Kegels, possibly get her to keep a bladder diary, learn how to massage scar tissue and generally support her recovery. In any case, women should avoid lifting anything heavier than their new baby for the first 6 weeks postpartum. Naturally, a woman whose baby is delivered via a caesarean section will have experienced major abdominal surgery and her recovery will be different, and often take longer. She may have a puffy belly and a painful incision and will have to be careful to avoid any lifting. She would also be advised not to drive at all until she has been given the all clear by her GP at her six week postpartum check-up.
Regardless of the kind of birth a woman has, and whether or not she plans to breastfeed, she will also experience a dramatic change in her breasts after the baby arrives. When a woman’s milk comes in about four days postpartum, her breasts are likely to increase significantly in size and they may become very painful or even engorged. The new baby has a tiny stomach at this point and only needs a little bit of milk to feel satisfied so often it cannot empty the breasts at each feed. Further, since newborn babies are so sleepy they often fall asleep at the breast, sometimes before they have even had enough to eat. A woman that doesn’t plan to breastfeed will still have her breasts fill up with milk unless she takes medication soon after birth to inhibit this natural process. She may experience some engorgement for a few days before her body understands that the baby is not suckling and it need not continue to produce milk. Applying warm packs before breastfeeding and cold packs afterwards, as well as taking a mild anti-inflammatory (such as ibuprofen, which is safe during breastfeeding), expressing a bit of milk in the shower, sitting in a warm bath with the breasts submerged, or tucking a clean, slightly crushed cabbage leaf against the breasts can all help with engorgement. It can take the whole six weeks postpartum for the mother and the baby to establish the ideal demand and supply for them and for the breasts to regulate their milk production accordingly.
Unfortunately, in the first week after birth some women find that they don’t experience a notable filling of their breasts when their milk comes in or they may report that they don’t get any milk at all and they feel that they cannot nourish their baby by themselves. This can be difficult to manage for women and they may be given conflicting advice by their GP, their midwife, lactation consultant, doula and/or family members regarding the best way to proceed. Some may suggest persevering without doing anything, some may suggest regular pumping to stimulate further production, some may suggest introducing some formula to top up after feeds, some may suggest switching exclusively to formula and some may suggest using donated breast milk to supplement her own milk until feeding is properly established. Not surprisingly, a woman in this situation is likely to experience some anxiety and confusion about the best thing to do in order to nourish her baby. She may also feel guilty and sad and may find that she is comparing herself to other women for whom breastfeeding seems to happen easily. There is no easy answer to her dilemma but as a doula I would encourage her to trust her instincts, try to trust her preferred support person rather than seeking advice from many different people, speak to the volunteers on the Australian Breastfeeding Support hotline and possibly join her local ABA Support group. Most importantly I would ensure she knows that it is a temporary challenge that will eventually be overcome and that as long as her baby is growing, however slowly, he or she will be fine. If the baby isn’t growing or is losing weight, I would encourage her similarly to trust her caregivers and her own instincts and proceed with the approach she feels most comfortable with.
the Early Postpartum Across cultures
Although just about any woman with a new baby is going to face physical, emotional and mental challenges as she, her baby and her family adjust to such a big change, there are some further steps she can take to try and make the transition as smooth as possible. I believe that we in Australia and in other Western societies can learn a lot from the traditional postpartum care practises of women in other societies around the world. While the practises vary, the period is often considered a sacred time and rest and even a hibernation of sorts is often ‘compulsory’ for the woman for the first 40-60 days. Family members may gather round to help out around the home, cook meals, clean and help with baby while the new mother takes necessary breaks in order to encourage and support her to heal from birth and ease into new motherhood. In some cultures the woman isn’t allowed to bathe or get her hair wet and must be kept very warm at all times during this period, in others the baby is never left alone and is always in someone’s arms, in others the mother is pampered with daily massages and other rituals and in others the mother and the baby are ‘quarantined’ so they can concentrate on rest and feeding in peace and develop their bond with minimal interactions.
Some women in Australia will adhere to the traditional puerperal practises of their cultures of origin, even though they are in a different context so it would be useful for a doula to enquire about such practises when working with women from CALD (culturally and linguistically diverse) backgrounds. In any case, having a baby is a big deal, physically, emotionally and psychologically and it should be treated as such. I believe that all women would benefit from making a concerted effort to slow down during this period, limit visitors to a minimum, remove distractions and ensure they are well nourished and cared for as they concentrate on caring for their new baby.
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