9 Questions About the 'Fourth Trimester' with Alexandra Sacks

9 Questions About the 'Fourth Trimester'

May 3, 2019

9 Questions About the 'Fourth Trimester'

9 Questions About the 'Fourth Trimester'

Once your baby is born and comes home, you’re entering the phase known as “the Fourth Trimester.” It’s a time that can be emotionally and physically challenging for new moms. Reproductive psychiatrist and author Alexandra Sacks M.D. offers some advice on how to deal with this stage of parenthood.

Question: Why do we call this early phase of motherhood “the Fourth Trimester”? Isn’t pregnancy over after the baby is born?

Alexandra Sacks: So it’s funny—the language of “the Fourth Trimester” shows us that when we talk about women’s experience after pregnancy, we’re actually talking about the baby, not the mom. We’re talking about the baby’s development—their next trimester—after they’re born. They’re born needy and vulnerable. Basically, babies are still growing, and they’re mostly in a similar state to what they are in utero—sleepy and not active and alert.

Newborns are so dependent and physically fragile. It’s so hard to care for them during the fourth trimester. It’s demanding to care for a baby during that time, and moms are also going through a physical recovery and dealing with a lot emotionally.

So “the Fourth Trimester” is in terms of the baby’s growth and development, but the mother is in the first trimester of motherhood and perhaps we need a new language for what this time is for her.

Q: What does it feel like to come home from the hospital with your baby and be alone with them for the very first time?

A.S.: There’s a joke that the only criteria you need to be a parent is a car seat to take your baby home—and it’s kind of true! But this is a huge transition—you go from being at the hospital or birthing center, where there are tons of experts giving the baby all this TLC and then you go home to zero structure. And again, newborns are so fragile they can’t do anything themselves, and if you have never done this before, the palpable experience of how fragile they are can be a lot to deal with.

As a new parent, you set your guard up and your fight and flight system on to protect them, so it’s natural to feel high strung. Add to that sleep deprivation and physical recovery, it’s overwhelming. And you’re doing a job you’ve never done before.

There’s no one story for one coming home with a baby. For adoptive or non-physical-birth moms, the experience can be taxing in similar and different ways. They may feel exhausted from the travel of going to meet their baby or their own experience of being in the hospital where the baby was born and not having their own room or resting place, as well as the intense emotions from interactions with the birth family or surrogate. It’s a lot.

Another category is what it’s like to come home after the NICU. If you’ve developed hypervigilance of watching and worrying, you can have another layer of emotions where it’s really hard to relax and trust things are going to be OK when you bring your baby home.

Q: How can you tell if your level of worry about your newborn is “normal” or “overdoing it”? What’s the appropriate level of worry?

A.S.: Being on your guard is a natural response to new parenthood. We’re wired to be alert and attentive, and it’s natural to worry. You’re learning a new skill and a new experience.

Often we say that the difference between worry and anxiety is whether or not you can be reassured by logic or information. Say the first bath, you do it and it goes well. But if you cannot be reassured that it was OK and your baby is doing well, then you may have clinical anxiety. It’s the feelings that are driving your mind and coloring your thinking at that point.

We usually consider an experience a symptom is if it’s interfering with your quality of life and basic functioning—sleep, digestion or your ability to eat, or it causes other physical tension or is preventing enjoyment of the things in life that usually bring you pleasure. If this is the case, it’s important to talk with your doctor or call the hotline for Postpartum Support International (call (800) 944-4773, #1 En Espanol or #2 English, or text: (503) 894-9453).

I would just say that when in doubt ask for help. There’s never a downside to asking questions for you or your baby about your physical and emotional health.

Q: How is our culture in the US different from other parts of the world in the way that new moms are supported in the fourth trimester?

A.S.: There are all sorts of ways of supporting moms in different cultures. For example, in China there’s a tradition of “sitting the month,” where some women are nurturing and caring for the mother while others are caring for the baby.

Even if we just look at policies, other countries have mandated leave and usually for much longer, where you know you have longer to recover and you’re getting paid. In England, they send a nurse to come and check on you to discuss both physical and mental recovery in the postpartum.

In America, there’s both an issue with American healthcare coverage and practices and also the trend over time in upward mobility where people are moving away from their homes to urban centers and live farther away from own parents and families, so a lot of people don’t have that intergenerational support system.

In these cases where there is limited family support, if you’re partnered, the first thing you may want to do, even in pregnancy, is talk with your partner about a new division of labor. If you’re breastfeeding, for example, you’ll be doing more of the hands-on care. So whoever is primarily caring for the baby, the other person needs to do the other things—cleaning, cooking and dealing with visitors.

Another thing: getting one solid four-hour block of sleep a night is essential. Have someone else feed the baby for one or more feeds, either with a pumped bottle or formula, so that you can sleep in one uninterrupted chunk.

Sleep is medicine. If you’re unpartnered or if you need additional resources, ask friends or other moms, “How can you help support me.” Or, if it’s not prohibitively expensive, hire someone to help care for the baby when the sleep deprivation starts to build up.

Babies really don’t need that many objects, so think about what you really need to spend your money on. And really, what you need is time and rest. In terms of gifts from family and friends, ask, “Can you offer food delivery or a night nurse or a babysitting voucher?” That can be the best indulgence and practical necessity during the early days and weeks.

Q: How do you suggest handling the pressures of social media to have everything look “perfect” in those first few months?

A.S.: At the very beginning everything feels high stakes—things like struggling with breastfeeding or not enjoying your time with your baby can feel like a failure.

Here are some things to consider if you’re feeling like you’re failing:

With your first baby, you may think this is how it’s going to be forever, but the fourth trimester may be the hardest stretch—it’s going to get better.

  • During those first two weeks, 80 percent of women experience baby blues, which brings emotional sensitivity and may make everything feel worse than it really is.
  • Sleep deprivation makes everything feel more dramatic.
  • Any sort of disappointment during those first few weeks can feel like a failure. But know you have a lifetime with your baby. So if, say, breastfeeding isn’t working out, know that you have a whole lifetime of feeding opportunities—this is not the only chance you’ll have to nourish and nurture in the ways you’d hoped.

With regards to perfectionism, you may want to get the baby started on the right track or schedule. But you can’t control babies, and their bodies and brains are rapidly developing and changing day to day. So you’re going to have to learn how to be flexible with your system and schedule at times.

Q: What are the common struggles people share with you about the early days of breastfeeding?

A.S.: This is another area where you may feeling like you’re failing if you’re struggling. But while there are benefits to breastfeeding, it’s not the case that formula is a dangerous or a lesser way to take care of your baby. The most important thing is that if your baby is getting well fed, through breast milk or formula, there’s nothing to beat yourself up about. We like to say that “fed is best” to remind people that there are no “lesser” ways to feed your baby well.

Q: What does it mean if you’re feeling bored around your newborn?

A.S.: It’s normal to experience boredom at times in the fourth trimester. It takes a while for babies to become active, become curious and to smile. It’s hard to engage with a creature that gives you no feedback! And in the fourth trimester, you’re not getting that interaction that will come later.

One benefit of your baby at this stage is you can allow yourself to relax and stimulate yourself in other ways—watch TV, read, give yourself permission to focus on yourself while you’re holding your new baby or feeding them. They won’t care the way they will later.

Q: Any advice for new moms who feel like they’re failing at everything—taking care of the baby, maintaining their homes, seeing their friends, keeping their relationship strong, losing the baby weight…

A.S.: Respect that this is on the most demanding transitions you’ll go through in your life. It’s healthy to take it one step at a time. There are all sorts of parts of you, but a newborn baby will locate themselves at the center of your life in all ways. Whether you like it or not, everything gets pushed aside to make room. This is a process that takes time. But the totality of that won’t last forever. Trust that you will reorient to your partner, your work, your interests, your other relationships, and your new identity, but it will take some time.

Q: Any advice on how to deal with family and friends who have come over to visit the baby?

A.S.: Try to remind yourself that it’s not your job to host. Give people the opportunity to support you. Know your needs and communicate them clearly. Ask people to bring food, or say you only have 10 minutes or if you trust them, ask them to hold the baby while you nap or shower.

It takes work but try to articulate your needs. And remember, leaning on others is a strength, not a weakness, and will serve you for years to come in parenthood.

You’re building your village—you’re not going to be able to do this all by yourself. So try to learn what you need and ask for help. Most people want to help.


Alexandra Sacks M.D. is a Reproductive Psychiatrist, co-author of What No One Tells You: A Guide to Your Emotions From Pregnancy to Motherhood and the host of Motherhood Sessions, a podcast from Gimlet Media. You can follow her on Instagram (@alexandrasacksmd) and Facebook (@AlexandraSacksMD).

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