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Kirtly: Welcome to the "7 Domains of Women's Health." We are about to embark on a "7 Domains" journey of the fourth trimester, those three months after the birth of a child that are critical to the development of a newborn and the recovery and development of a new mother.

I'm Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah, and as a specialist in reproductive hormones, I know this transition from pregnant to not pregnant has a profound effect on the new mom. And we'll talk about these months as we focus on all of the seven domains, physical, emotional, social, intellectual, financial, environmental, and spiritual.

Now, you may never have heard the term "fourth trimester" used when you were pregnant or were involved in the pregnancy of someone close to you. And the term "fourth trimester" was first used by a pediatrician, Harvey Karp, in 2022 to describe early post-delivery needs of the neonate, the newborn.

He argued that human beings were born three months too soon. Nine months is not enough for the total development of the newborn. Our babies are very dependent compared to those great apes with whom we share 95% of our DNA. They certainly aren't like some species of mammals, like caribou and wildebeests, who can stand up and see and run on their first day. So there you go.

The term was first used to describe the three months after birth of the infant. In OB/GYN, we've recognized this critical period in the discovery and recovery of the mother. The word "puerperium" has been used, and that's what we use in our medical language, some of us use, for the first six to eight weeks after childbirth. And the term comes from the Latin puerpera, meaning woman who has given birth.

So the time of six to eight weeks is when the uterus has returned to its normal non-pregnant size, and women who are not breastfeeding may have returned to their first period.

For many women, the return to pre-pregnancy state may take longer, more like three months, or never. So the fourth trimester has important milestones for the new mom as well as the new baby.

So we'll start today with the physical domain, but first I want to introduce my co-host, Katie Ward. Katie has a doctorate in nursing practice and is a women's health nurse practitioner and an anthropology student to be a PhD and thinks a lot about hormones and stuff.

Hi, Katie. So any thoughts about evolutionarily why our babies are so immature and what we have to do to get these babies' heads out?

Katie: It seems awfully hard, doesn't it? When I was training, we talked about something that we called the childbearing year. So the idea that it was a whole year of not just being pregnant, but returning to normal. So I wanted to throw that out there as an alternative title for the period of time.

But yeah, the anthropologist in me, we've talked for a long time about something that we've called the obstetric dilemma. And that was this concept that in order to be an animal that walks on two legs and walks around a lot, our hips got more narrow. And as a result, it was difficult to get our babies out.

And your pediatrician's idea that they were being born three months too early, that was a thought for a while, but it's really been something that's been proven not to be the case.

The traditional story was that our hips got narrowed, and it was this trade-off. But when people have analyzed it, it turns out that really, we give birth to a baby at just about the right size.

And it probably is metabolic cues that are the trigger for when babies need to come out, that moms just sort of reach the maximum amount of time that they can fuel their baby's brain and keep themselves healthy. And that's actually the reason babies are born when they are. It's not that they don't fit through our pelvises.

And so I think that's actually an important message that I hope we can share with everybody. It's not that we're sacrificing giving birth to babies at a grossly premature age because they don't fit out of our pelvises. They do fit. Pelvises come in lots of sizes and shapes, and we used to name them and say one was better than another. And again, researchers have kind of said, "No, they all work." Really, what that tells us is that there's a lot of fantastic variation in the human form, but all of it is effective and works.

Our babies are not being born at a premature state at nine months. They shouldn't stay in there for 12 months. Our metabolisms, we need to get babies out. They actually accelerate their growth. The brain grows faster after birth. And so, yeah, it's just time for them to be born, and our bodies are exquisitely designed to do that.

Kirtly: I like that. Katie, you teach me something new every podcast. I was stuck on that "had to come out too early because our brains were too big" probably because my kid's brain was way too big and he got stuck. But it is nice to know that we've had a million years to try to get this sort of right, and maybe we're still working on it. Of course, we're still working on it in evolutionary terms.

But anyway, let's talk about how our bodies return, if they ever really do return, to the pre-pregnancy state. We're often deluged by images and claims in social media of that movie star or influencer who had her body back in two weeks or four weeks, a flat stomach, all toned, and God, whatever. Well, that might happen, but it usually doesn't. I'm almost back to my pre-pregnancy state 40 years later. Not quite. But anyway, it takes time, and I think a mommy body is a badge of courage. So we're going to talk about the different kinds of domains in the physical realm.

For my whole career, and maybe even today, the letters EDC were used by obstetricians in medical records for the due date. And that was on the piece of paper, "What was the EDC?" or "When is your EDC?" It means estimated date of confinement, EDC.

The confinement part is the time when a woman would be confined to bed after delivery. Of course, this was only women with no other small children and no help from neighbors and friends and family. The women who had an EDC were women who went to doctors, and originally, up to 100 years ago, women didn't.

But the postpartum period was marked by so many women who died and so many babies who died in the days to months after delivery. Perhaps the delivery was too soon, and the baby died of prematurity. Maybe the delivery was extremely difficult, and the mom and the baby died of sepsis or hemorrhage.

If the mom and the baby didn't die, they were often very weak, and the mom may have had difficulty breastfeeding, and there was not formula in those days.

With the vulnerability of the new mom and baby in mind, it was thought that the mom and the baby should be confined to bed, lay around a bit for a couple of days or a couple of weeks, to be confined to the house for a month.

About 100 years ago, my grandmother was confined. She was a well-to-do woman who had a doctor deliver her. So she was confined after a difficult delivery and she developed what was called milk leg. In medical terms, medical literature, it was termed phlegmasia alba dolens, means a painful white leg. And this was due to a clot in the leg, which gets us to the blood system and the pregnancy and postpartum period.

Women bleed a lot in pregnancy. It's an impressive and sometimes terrifying amount. Nature's way to try to help us out is for the hormone of pregnancy to cause an increase in clotting factors so women clot more easily. It's a good thing until it isn't.

Blood clots in the legs during pregnancy or postpartum are pretty common. And those blood clots can travel to the lungs and cause pulmonary embolism, which can be fatal.

If women are immobile in bed after the delivery in the weeks postpartum, then the risk of blood clots increases.

During World War II, they kicked women out of the hospital because they needed the hospital beds and there weren't that many doctors. They were all doing other things. And lo and behold, the risk of milk leg went down.

So we like women to move around. We don't like to start hormonal birth controls with estrogen in them right after birth because of this increased risk of clots. So for women who want hormonal birth control that will not affect milk supply or increase the risk of clots, we offer progestin-only methods, such as the mini pill, or the implant, or an IUD.

It's important to get up and walk around after a baby is born by vaginal birth or by cesarean. But you don't have to run a marathon, and you don't have to get your 10,000 steps. Just get up and move around the room or around the house in the hours and weeks and months after birthing a baby.

Some women can be quite anemic after childbirth and pretty exhausted and pretty beat up, and care should be taken that walking around is with some help in those first days.

Katie: Again, the anthropologist in me, I think women would have gotten up. Lying around in bed is sort of a modern luxury that our ancestors probably didn't have. So you would get up.

The other thing that gets you up, and it's related a little bit to what you were just saying about blood supply, is your blood supply increases by 50% or more. And after you deliver, a lot of that fluid comes back out. And so one of the things that happens in that postpartum period is people have to pee.

Kirtly: A lot.

Katie: And starting a couple of days after delivery, there's this big flood of blood products and fluid that needs to leave your body. And so I think nature's telling you, "Get up and go. You've got to get rid of some of the fluid. You've got to get up and pee." So this idea of keeping people confined to a bed seems just a little crazy.

Kirtly: Well, I hope the EDC concept has kind of moved along, but you still see that. "What's their EDC?" You still see that in . . .

Katie: You do. Although it's funny now, I feel like we've gotten so good at counting pregnancy days that people, even patients, don't talk about how many months they are anymore. They tell me to the day. "I'm 28 weeks and 6 days."

Kirtly: Right. So an estimated, but they know.

Katie: Nothing is estimated anymore.

Kirtly: Let's talk about hormones. And we're going to talk much more about the change in hormones after the birth of a child in a future podcast in the 7 Domains of the Fourth Trimester, but a little bit right now.

The body and the brain . . . well, the brain is in the body . . . are flooded with hormones during pregnancy. Hormones meaning estrogen and progesterone and a whole bunch of other hormones made by the placenta that we don't talk about much, but the placenta is like a second brain hanging.

Katie: It's a whole factory.

Kirtly: Yeah, it's a whole factory of hormones. These hormones drop dramatically during the postpartum period, and this is an important trigger for lactation. And they stay down for months if a woman is breastfeeding. These hormones actually keep your joints lax, make the pelvis a little more wobbly and a little bit bigger so the baby can get through a little bit better, and they keep your muscles a little bit more relaxed.

And so in the postpartum period, not only do your female estrogen and progesterone hormones fall, but other ones do too. Actually, women who are breastfeeding can have very low levels of hormones for six, nine months, a year, or whenever until they start ovulating again.

Sometimes women just start to feel a little stiff. And there are some tissues that would like to have some hormones, like the vagina, that get a little dry. Anyway, there you go.

So they stay down for months if a woman is breastfeeding, and if she isn't breastfeeding, they may return to ovulation within a month and be fertile in the next month or two. So planning contraception, if a woman is having intercourse with a fertile male partner, means you don't really want to have another baby right away.

Of course, some men get a vasectomy in the early months after the delivery of their child, if that's what the couple had planned. And some women don't have a male partner, but if they do, contraception is important.

Now, in a teaching hospital, medical students and residents go in to check on the new mom in the first 12 to 24 hours after delivery. Women used to stay in the hospital, if they didn't deliver at home, for several days. So now, though, the exhausted new mom is about to go home, and some chipper or not-so-chipper medical person pops in their room to check out their legs and make sure they don't have a clot, and the size of their uterus, and ask about what they're planning for contraception. I guess a reasonable answer could be, "I'm never going to have sex again."

Katie: They certainly don't feel like it.

Kirtly: "I don't feel like it." But women don't have an answer to that, and I don't blame them.

We also check on the blood count to make sure they aren't too anemic and check on whether they have immunities to rubella, which was part of their first OB visit blood work. If a woman isn't immune to rubella, we can get them a vaccine before they go home because rubella is a bad thing to get when you're pregnant.

So there are good reasons to avoid another pregnancy during the first three months after the birth of a child, even the first year. Moms and babies are healthier if pregnancies are spaced a minimum of 18 months apart. Not everybody does that. Not everybody can do that. But that's kind of what's good for moms and babies.

And naturally, when women breastfed for months to years, we spaced our babies two to three to four years apart naturally.

So anyway, next topic. Why do I still look pregnant when I just had a baby?

Katie: I'm so grateful that people are starting to post that. I see it a little bit on social media. You were saying earlier that people feel like they need to have their pre-pregnancy body back in just a couple of weeks. And that's been a little bit of a trend on social media lately, where people actually are posting what they look like immediately postpartum. I think that that's helpful to see other women and recognize that it's normal that you look almost just as pregnant when you go home as you did when you walked in. There's not a lot of change.

Kirtly: Well, I've got nine pounds of baby and blood and uterus or whatever, I got it out. Why all that space? Why don't I have a flat tummy? Well, number one, the abdominal wall is very relaxed. It's been stretched out. Number two, once the baby's out and the uterus is shrinking, actually the bowel tends to fill up space, and it gets a little extra gas. So there are lots of reasons why you look so poochy, even without a baby in there.

It can take a long time. It may be three months and some work before your abdominal wall muscles are tight again. So give it time. You can get back to your crunches in a month or so. Let the uterus get back to its small pre-pregnancy state, and just give yourself a break and wear loose clothes for as long as you need to. If it's three months, great. If it's six months, great.

Katie: But I want to give a shout-out to the uterus, because here's this little organ that's the size of your fist most of the time. You just were saying this. You've got a seven- or eight-pound baby, you've got a couple pounds of placenta, you've got more pounds of amniotic fluid, not to mention the blood vessels and everything else that the uterus requires for itself.

So here's this organ that's holding up 13, 15 pounds of content, and pushes it out, and then shrinks itself back down to its pre-pregnant size in just a few weeks. And the placenta doesn't even leave a scar on it. It's honestly a pretty remarkable organ.

Kirtly: Well, that's the business about being a mammal. We've had at least 20, 30, 40, 50 million years to practice that. But the uterus is incredibly dynamic, pretty outstanding, not so little, but little thing.

Katie: Yeah. I mean, it's just amazing when you think about what it does. Anyway, yeah, give it a minute to get back in shape. Don't expect everything to go back in an instant when you consider how much work it just did.

Kirtly: Yeah. Let's talk about skin and hair. Our skin and hair were so beautiful when we were pregnant, but now that I'm postpartum, my skin is dry and my hair is falling out.

So pregnancy synchronizes the growth and falling-out cycle of our hair. While we're pregnant, we don't lose as many hairs as we would have in a natural cycling menstrual cycle, whatever. And so they all get in the growing phase, and then the hair doesn't enter the falling out cycle until we deliver. And so in the months postpartum, we move into the falling-out cycle, and then we lose a lot of hair.

For some women, it's quite impressive. It's called telogen effluvium. I love that word. Telogen effluvium. It gets better, and new hairs will come in. But until you're eating well, you may want to continue your prenatal vitamins for a couple of months postpartum. Keep your iron up because you lost a lot of blood and you gave lots of minerals to your body. Give your skin and hair some time and some nourishment, and it'll come back.

A new mom and a mom with a new baby and little kids at home is overwhelmed with all that's going on in those first three months, and the next 20 years. So let people feed you. If you're listening and you have a new mom in your life, put good food in their freezer.

Katie: It's frightening when you lose hair. At the same time, I think this creates, again, a sort of a myth out there. So I have patients that won't give up their prenatal vitamins because they're convinced that that's what's making them grow hair.

Kirtly: Oh, no. It'll grow anyway.

Katie: And I have to explain it was the pregnancy that made your hair not fall out, nothing special about the prenatal vitamins.

Likewise, the other time when people lose their hormones at menopause, they think taking hormones is going to make them grow hair because it happened when they were pregnant.

So a lot of myths about where the hair comes from, but hair does just go through cycles. And one of those cycles is postpartum. For all the reasons you mentioned, it falls out, and sometimes it's frightening, but it does grow back.

Kirtly: I lost a bucket of hair. I mean, I knew why, but it wasn't fun. I wasn't really happy about it. My hair is my crowning glory, but I lost a bunch.

Katie: I tell my patients who are not planning to get pregnant that this is the time to take a prenatal vitamin. Build up your iron stores, build up your folic acid stores. It seems like sort of a rite of passage when you get pregnant to get your prenatal vitamin prescription. But really, you needed them a little bit before to build up those stores.

It's just the hair thing that drives me crazy, when people think there's something special in their vitamin that's making them grow luxurious hair. And the vitamin people are happy to sell their vitamins on that.

Kirtly: Yes. Another little myth is that babies with a lot of hair gave their mom's heartburn.

Katie: Or took a tooth or . . .

Kirtly: I never heard that one.

Anyway, next. "My bladder isn't strong, and I leak urine often," or "I can't control my bowels as well as I used to." It takes months for the pelvic floor to heal and tighten up.

Now, we have a podcast that recently posted that will be in the links below, or you can put "7 Questions for a Perinatal Health Specialist" into your search engine and check out "Healing After Birth: What Every New Mother Should Know." Put that into your search engine, and you'll get a podcast specifically on what you can expect and what kinds of things happen in the fourth trimester and those three months after birth.

If your bladder and bowels don't get back to normal by six to eight weeks, you should talk to your clinician. They can check things out and help you get back in pelvic floor shape or see if a bigger fix is indicated.

"I have brain fog. What's that about?" Well, there's a lot that goes on in the brain of pregnant women and postpartum with a new baby and sleeplessness and hormones. Your brain will never be the same, but it will be better in the domains of things that make you a mom. Now, we'll be getting to this in detail in the upcoming podcast on the intellectual domain. So stay tuned.

The postpartum visit is the most ignored, mistimed, and canceled appointment in the long line of pregnancy visits. I think after the first prenatal visit it's probably the most important visit, but only about 40% of women go to their postpartum visits, and it varies widely with respect to economic and racial and geographic variables.

Women are not guaranteed paid maternity leave in this country, and women may be back to work at the time when they should be trying to get this visit in. And it may be one or two or three jobs, with taking care of the baby possibly being job number one.

They may live far away from the place where they delivered. They may be too sick and tired and depressed to make the visit. And it doesn't often really get to the concern of the woman who has delivered, the puerperium.

Often, medical issues are uncovered during pregnancy, things that show up in the prenatal labs such as anemia, or problems such as hypertension or diabetes in pregnancy show up later in the pregnancy, and these issues must be addressed during the pregnancy and assessed after birth. Some women continue to be anemic or hypertensive or diabetic, and careful evaluation and treatment is part of what the postpartum visit is all about.

Keep your postpartum visit. If you skipped it, make another one. If you're the helper or employer for the new mom, help her get to that visit.

Ideally, we would have a visiting nurse come and see us at two weeks, and we would have another one to come and see us at six weeks, and then somewhere around two to three months, we'd go see our clinician. But that doesn't happen. We've got this one opportunity to make sure we're getting seen, so it's important. 

Katie: And it's included in the cost of your prenatal visit if you have Medicaid or insurance. Remember that, too. It's actually part of the package, and you're not going to get an extra charge for that.

Kirtly: And here, we need to acknowledge the women who are not with their newborn, women who by disaster, misfortune, or circumstances do not have a baby. This includes gestational surrogates, women who've carried a baby for another woman, women who've given up their baby for adoption, women whose babies have died in the early postpartum period either from prematurity or from congenital malformations, and women who have suffered one of the greatest of losses, a stillbirth. In their need to recover from their loss, they may be the least likely to keep their postpartum visit, but their needs may be the greatest.

So the long and short of it is that the three months postpartum are critical to the health of the new baby and the recovery of the mother. It's unrealistic to think you can bounce back in any of the seven domains. It takes time, and it takes a village.

We want to be part of your village at the 7 Domains of the Fourth Trimester and help you learn and think about this new part of your life. Every pregnancy and postpartum period is different, but for everyone listening this evening, take your time, if you can, as a new mom, and give yourself a break. If you care about a new mom, pitch in a little or a lot.

You can get the rest of our 7 Domains of the Fourth Trimester or all of our "" wherever you get your podcasts, or at womens7.com. Thanks for listening, and stay tuned.