Postpartum - The Fourth Trimester

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In pregnancy, there are three trimesters, spanning over nine months. Postpartum is sometimes referred to as the “fourth trimester” and can be divided into three distinct phases. Let’s break down the fourth trimester (postpartum). The first phase is defined as the first six to twelve hours postdelivery.^[1] This is typically spent in the hospital, a birthing center, or even in your own home, if you’ve had a home birth. The amount of time spent in these settings will depend on how the baby was delivered and if there were any complications (mom and/or baby) during or after that process. The second phase is typically defined as the first six weeks postpartum—some sources say this ends at twelve weeks. This phase is also termed “puerperium.”

Typically, a woman’s hormones have returned to a “nonpregnant” state by the six-week mark. As in the 2018 recommendations, the American College of Obstetricians and Gynecologists (ACOG) recommends that all postpartum women have contact with their primary-care provider within the first three weeks postpartum.^[2] This comprehensive visit for mom and baby should definitively occur before twelve weeks postpartum, but ideally should occur before three weeks; it most commonly occurs around six weeks. This first postpartum visit is often poorly attended.

What are some emotional changes in the puerperium stage of postpartum?

Your estrogen and progesterone tend to decline by days three to five postpartum (essentially, when mature milk flow comes in), and this can be associated with postpartum “blues.” Postpartum blues (mood swings, forgetfulness, low mood, fatigue) are quite common, but most often resolve within two weeks. Postpartum depression is different and is defined as depression within the first year after delivery. The primary-care provider should screen for postpartum depression with objective measures, such as the Edinburgh Postnatal Depression Scale (EPDS). Unsurprisingly, one of the most common emotional symptoms in the puerperium period is anxiety. Another factor to consider is melatonin. Changes in melatonin secretion patterns can directly influence sleep quality, and postpartum women may be exposed to more nighttime light exposure while taking care of their newborn.

 So, in addition to significant hormonal changes, this postpartum period can also include sleep disruption and deprivation, navigation of feeding practices, and understanding how to care for the newborn (and other children). There may also be dynamic changes in relationships within the family, with friends, and in professional settings.

The third phase (starting at six or twelve weeks postpartum, depending on the source) is considered the delayed postpartum period. The research around the delayed postpartum phase primarily focuses on the physical changes within the female body. Naturopathic doctors tend to see a number of women who are in this phase. In addition to addressing care of the infant, we are working with women to support a number of maternal concerns, including:

• Mood;
• Energy;
• Milk flow and supply;
• Regulating the menstrual cycle; and
• Weight management.

So, what are some naturopathic approaches to care, when naturopathic doctors are working to support patients who are in this third phase of postpartum? For example, the TSH (a marker of thyroid health) range is quite vast, and usually ranges from 0.35 to 5.00 mlU/L. An individual may fall into this “normal” range but still deal with symptoms that warrant further investigation of the thyroid. For the most part, we consider a TSH range of 1–2.5 mlU/L as optimal, taking into consideration that the other thyroid markers are also at appropriate levels. Naturopathic doctors work to optimize lab values—this means that a patient’s history, signs and symptoms are always taken into consideration when looking at lab values. These lab values are taken into an individualized context. We can work to regulate the menstrual cycle and address sexual health. Ovulation can occur as early as 27 days after delivery (that’s not even a month)! The average amount of time it takes to have ovulation occur in a postpartum woman who is not lactating is 70–75 days. For breast-feeding women, the average length of time it takes to ovulate is approximately six months.^[4]

Most women who are breast-feeding tend to be amenorrheic (do not have a period) for an extended period of time during the postpartum period. That being said, some women get their period back within the first few months, while consistently breast-feeding. If the period has already returned, there is potential that ovulation has also already occurred. Therefore, breast-feeding is not an effective form of birth control. It’s important for postpartum women (breast-feeding or not) to discuss their birth-control options early on in the postpartum period.

Flaxseeds may be a viable option to help regulate estrogen in postpartum women. As a phytoestrogen (flaxseeds contains lignans) and source of omega-3, flaxseeds can help moderate estrogen in the body. Additionally, flaxseeds are a helpful source of fibre, helping regulate bowel movements.

Vaginal health is often a concern for postpartum women, especially if healing from a vaginal birth. Some postpartum women experience vaginal concerns, most commonly, bacterial vaginosis (BV) and Candida (yeast) infections. Naturopathic doctors can monitor and support proper vaginal health by addressing risk factors and causes, and use strategies (such as probiotics) to target the vaginal microbiome. Pelvic-floor dysfunction is also common and is well-supported by referral to a pelvic floor physiotherapist.

We can improve and optimize nutrition in the postpartum period.

• Incorporate iron-rich foods, and supplement, when necessary.
  
  • Iron-rich foods:
    
    • Nonheme (plant sources of iron): Blackstrap molasses, pumpkin seeds, cooked beans (chickpeas, white, kidney, navy, pinto, black, adzuki), cooked peas (split, black-eyed), cooked lentils, cooked spinach, cooked oatmeal, cooked tofu, and cooked soybeans
      Note: Always consume soy products (tofu, tempeh, soy beans) as GMO-free, organic products.
    • Heme (animal sources of iron): Meat, fish, and poultry, including cooked oysters, and cooked liver (chicken, turkey).
  • Encourage patients to consume iron sources with vitamin C sources, in order to increase absorption: Strawberries, tomatoes, bell peppers, broccoli, and citrus fruits.
• Ensure proper hydration, especially when breast-feeding.
  
  • Patients can work to increase their daily water intake by incorporating herbal teas and low-sodium broths.
• Assess protein requirements and provide resources for patients to get enough protein, especially when breast-feeding. It is very common that postpartum women do not consume enough protein, and this can cause issues with hair loss/growth, energy, and mood.
  
  • Plant-based sources of protein: Tofu, tempeh, soy beans (cooked or roasted), beans (always cooked), nuts (walnuts, almonds), seeds (raw hemp seeds, chia seeds, flaxseeds, pumpkin seeds, sesame seeds, sunflower seeds), and green peas
  • Again, always consume soy products (tofu, tempeh, soy beans) as GMO-free, organic products.
  • Animal product sources: Cottage cheese, Greek yogurt, eggs, turkey, chicken, and properly sourced fish.
• Naturally, weight will be lost during the postpartum period. Some of this weight loss is attributed to the actual delivery of the infant (including weight of the infant, the placenta, amniotic fluid, and blood). Afterwards, most weight is lost between six weeks and six months, with most of the weight loss occurring in the first three months. For the majority of women, postpartum weight loss does not usually cause weight loss to the extent that women will return to their prepregnancy weight.^[5]
  
  • A Cochrane review (a high-quality source of evidence) determined that diet and diet plus exercises were the most effective strategies for postpartum weight loss. This is another area where naturopathic doctors can provide significant support, while still navigating other aspects of maternal postpartum health.^[6]

Naturopathic doctors can also safely and effectively use botanical medicine and natural health products to support milk supply, mood, energy, sleep, vaginal health, and hormonal regulation. Important to note: The following botanicals and supplements are only a few considerations that might be indicated and utilized, and should only be taken under the guidance of a naturopathic doctor. Naturopathic doctors are equipped to evaluate any potential interactions with other medications/supplements and ensure appropriate, safe use while breast-feeding.

• B-complex (a significant amount of B vitamins are found in a number of highquality prenatal vitamins) to support energy and mood.
• Magnesium to support sleep, reduce muscle tension, regulate bowel movements, and support appropriate estrogen metabolism. There are different forms of magnesium, and a naturopathic doctor is well-equipped to determine which one is suitable for you.
• Fenugreek, blessed thistle, or goat’s rue to support milk supply.
• Probiotics to support the vaginal microbiome.
• Vitamin D to support optimal functioning of the immune system.
• Fish oils (with DHA) to support mood and brain health.
• Adaptogens to improve mental and physical fatigue, allowing postpartum women to deal with stress more effectively.
• Monitor and correct any existing anemia, as there are higher iron demands during pregnancy and blood loss during delivery.
• Acupuncture is a helpful adjunctive therapy that can work to support mood, energy and sleep. Most naturopathic doctors are licensed to use acupuncture in their practice.