A new approach to delivering care in the fourth trimester

The ‘fourth trimester’ is a term used to describe the first three months post-delivery. It is a period during which the focus has traditionally been on the baby.

In recent times, the focus had slowly started to shift to both the mother and the baby. But at One For Women, we feel that shift in approach needs to speed up.

We call the fourth trimester the ‘silent’ trimester because it is so under-represented and poorly understood. Many women require specialist care during that time, but seldom receive it.

Shining a light on the challenges mothers 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 significant under representation of the true incidence as many women never seek help.

Unrecognised depression can negatively impact on the health of the mother, baby and other family members. It also impacts the initial bonding of the mother and baby as well as the cognitive and emotional development of the infant. 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 prior to their baby being born.
  • 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 pregnancy.

Changing our approach to fourth trimester care

At One For Women, one of our stated goals is to become world leaders in fourth trimester care. How do we propose to do this?

The first thing we do is 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 fulfillment, 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 believe excellence in post-birth (postnatal) care starts during the pre-birth (antenatal) period. 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’re replacing the industry’s current model standard of a solitary visit at six weeks with a continuous conversation that emphasises support and early intervention. That conversation begins in hospital and progresses to a check at two weeks postpartum where the A-B-C-D approach allows for early intervention:

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 wellbeing of the new mother.

In addition to looking at:

  • mood and emotional wellbeing
  • infant care and feeding
  • the physical recovery after childbirth It is important that we also discuss:
  • sexuality
  • contraception and birth spacing
  • sleep and fatigue
  • health maintenance

It’s our dream to relegate the sentence, ‘I wish someone had told me how hard it was going to be’, to the history books.

We need to set realistic expectations for our expectant mothers, identify those risk of having issues in the post-birth period and intervene early.

By adopting a proactive approach to the fourth trimester, we know we’ll be able to significantly improve the outcome for our patients, while also creating a ripple effect that ensures new mothers feel appropriately supported and cared for during a vulnerable period in their lives.

June 2020 note: We have already received fantastic feedback on our approach and patients saying they feel like one of the family. This is especially important to those who may not have an immediate family support network. Our rapid growth is testament to the effect that this model is already having, with many sharing their stories.


By Dr Stuart Prosser, Co-Founder and Clinical Director, GP Obstetrician/GP Anaesthetist

First published: February 2019

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