The Fourth Trimester

BY  Kristy Wood

We were called upon recently to see a new mama who had just delivered her perfectly healthy, beautiful baby boy. We will call her “Jane.” Jane’s breastfeeding struggles are too familiar to all of us “lactivists” and lactation professionals. She had a history of breastfeeding difficulties with her older children, had been misinformed, and now she wanted to set the stage for an optimal breastfeeding experience with this new baby. Jane had sought out all of the pieces of the puzzle for an optimal birth and postpartum experience this time around. She knew what she wanted. She hired a supportive birth doula and had family on hand for after the birth, she had researched and chosen a Baby Friendly hospital based on their policies and normal birth outcomes. However, this mama traveled 4,000 miles to get to this hospital, because standards of maternity care in her country of origin were not to her liking.

After she had done so many things right, Jane was unable to rest on her laurels. She needed to nurse her baby. It was the weekend, so the hospital lactation staff brought a pump to her room, but because of their heavy caseload, were unable to do much more. She felt that she could get more personalized support by calling in private help. She had a number of family members from overseas staying in their beach home for the much anticipated arrival of this baby, so believing that there would be fewer interruptions and distractions, Jane wanted us to come to her bedside before leaving the hospital.

During our visit with her in the hospital that morning, where her goal was to work on latch pain and positioning difficulties, her effort to nurse her baby was interrupted at least 8 times in the course of 2 hours. Nurses came and went, her meal tray came and went, the hospital photographer came, photographed, and went. The baby, who had not eaten for many hours, was even removed from the room without Jane’s direct consent for 30 minutes. She was stressed out to say the least.
Those immediate hours and days after having a baby should be sacred–but it didn’t feel that way.

In that moment, our mothering instincts went into overdrive. We wanted to create a safe space for Jane and her baby who desperately needed the time to get to know each other. We were able to work with Jane here and there in spite of the interruptions at her hospital bedside, but ultimately decided that it would be best to come to her home the next day upon her release from the hospital.

We arrived at Jane’s home early the next afternoon with the agreed upon intention of focusing on breastfeeding in a calm and quiet environment. Much to our surprise, we were greeted at the door by a house full of extended family. Jane’s husband and older children were going to be flying home later that night, and she was surrounded by excited children, to-do lists, and carry-on bags. We retreated into the master bedroom where she had to lock the door several times as we proceeded through our appointment with her–working on the necessary skills of latching and explaining to her how vital frequent skin-to-skin time is to establishing breastfeeding, bonding, and attachment.

Jane just wanted to be successful at breastfeeding this time around. She listened to what we were saying about the sacredness of fourth trimester, but somehow, we worried that it would still go unheard. There was pressure on her to return to a sense of normalcy as the family matriarch. It was so intense that even we could feel it. As she put it: the older children needed attention, her husband needed her to see them off at the airport, the house was disheveled from her two days away while she was in the hospital, and she wanted to simply sleep one whole night. When she returned home, there would be the children’s activities back on her plate once more, too.

We did everything we could do as outside hired help to support and nurture Jane for the short period of time we worked with her. We encouraged her to do nothing but relax with her little son. No errands, no lunches, no shopping trips, sightseeing, or beach outings with the grannies and aunts and uncles who were visiting from home. Those activities are meant to be fun and relaxing family bonding time, and they would be ordinarily, but are not beneficial to a mother and baby who are trying to get to know each other. We hope that the pressure to get back to what she knew as “normalcy” didn’t take from her the ability to continue to nurse her baby. This pressure was felt in many aspects of her birth and postpartum journey, from her care at the hospital, to her expectations to return to her matriarchal post.

A baby’s desire and physiology to nurse are driven instinctively. And those instincts are triggered by the touch of mama’s skin, the warmth of her body when she holds him close to her, when he smells her colostrum, and by hearing the familiar sound of her beating heart. It is so important in those immediate moments, hours, and days after birth to keep mother and baby close and connected. This is basic human biology and the way mammals nurture and continue their species. In theory, it seems too simple: keep mama and baby close, and the rest will come. Even the best of hospitals know that “breast is best,” but why is it not happening?

Some hospitals are finally catching on to the benefits of “the magical hour” and family-focused recovery (which has been connected to better breastfeeding outcomes) by even implementing a protocol or adopting similar policy to the **Baby Friendly Hospital Initiative: “Ten Steps To Successful Breastfeeding”.

Even in the best of circumstances, the best birth possible, and in the most “breastfeeding-friendly” of hospitals, the fast-paced setting and number of different staff members with different roles can make it difficult for the facility to fully adhere to their own policies! For example, even when nursing on cue is encouraged, if there are rules that say the mother and baby must each have their vital signs checked every x number of hours, then the vital signs will be checked and breastfeeding will be put off “for a few minutes.” The issue starts to become problematic when every cue is being put off because there is another test, another check of the hospital bracelet, another hospital photographer, another person popping in to bring a tray, take a tray away, and so on until hours have passed and the swaddled baby, like Jane’s, has fallen asleep without a chance to just be at his mother’s breast undisturbed. And almost immediately upon arrival at home, mothers are expected to not only nurse and care for their newborn, but somehow transition a new person seamlessly into the routine of caring for an entire household.

So, how can you protect your Fourth Trimester experience?

As you gather your birth team, think about what postpartum support you will need and start a discussion about the importance of breastfeeding and the Fourth Trimester to you. Feeling as if you are “on the defensive” goes against the natural oxytocin saturation that new mothers should be basking in. Allow your postpartum support people to be gatekeepers and advocates, keeping this time sacred for you and your newborn.

Set limits and expectations in the hospital by:

Having your assigned postpartum support person privately explain to every nurse and lab tech whose shift rotates through your hospital room that you want your newborn to stay bed-side. Staff should never assume you are comfortable with them taking the baby away for bathing or tests. In almost all circumstances, routine tests and procedures can be delayed.

Asking that people come back later. Your support person can place a note, or door knob hanger, on your door whenever you are breastfeeding your baby. This is not because there is anything wrong with nursing in public (we are huge advocates of that cause!), only that we have seen again and again that, in the early postpartum period, mothers and babies who are behind closed doors are more focused on each other. Newborns that are undisturbed and skin to skin with their mothers are calmer, cry less, regulate their body temperature more efficiently, and of course have an easier time breastfeeding.

Letting everyone know that your priority is to be skin to skin, to nurse, and get to know your baby. Your healthcare team should support this. You can kindly ask for a new nurse assignment that is a better fit for you if you are not feeling supported.

Reminding your healthcare team that everything should be done in your presence. Remember, you are always entitled to ask “why” when someone asks you to hand over YOUR new baby. Even the simplest request to postpone or decline your newborn’s bath can have an enormously positive impact on breastfeeding.

How to give honor to this sacred time and re-define your babymoon:

Before giving birth, envision yourself simply resting in your favorite places in your home with your baby. Prepare your home for baby’s arrival by reducing clutter in your bedroom (where you plan to be during your baby moon) and arranging things to be visually appealing to you.

Mobilize a team of close friends and family who are on board with your “vision” of a babymoon. It is not your time to be entertaining house guests. This is your time to be cared for. If there will be visitors in town for the baby’s birth, be sure to provide them with a list of recommended hotels and restaurants, and maybe assign a trusted friend to play tour guide while you are “resting with the baby.”

Prepare freezer meals yourself during the last months of pregnancy, or have a friend organize others to provide food for you. Let your partner know what tasks can be delegated, in case someone drops by to help out. Your job is to rest with the baby, but helpers can walk dogs, pick up groceries, or vacuum!

Wear (cute) pajamas! You won’t likely feel like resting all of the time, so this can be a good reminder to not launch back into your old routines just yet. In fact, we find that some of the moms who struggle with this the most are ones who have had great natural births. They feel so good after giving birth that it can be hard to remember to slow down and be present for the huge paradigm shift they are actually in the middle of.

Be clear with your friends, family, and your partner that you plan to be out of your normal routine for quite a while. The fourth trimester is the time you need to get to know your baby, bond, and establish a solid breastfeeding foundation. Our culture often glorifies being busy, especially for moms, but we’d like to challenge you to redefine success for yourself during this once-in-a-lifetime experience.


1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in the skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within one hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
6. Give infants no food or drink other than breastmilk, unless medically indicated.
7. Practice rooming in. Allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no pacifiers or artificial nipples to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.