Here’s what you need to know about the so-called “fourth trimester.”

By Amanda Gardner
Updated May 07, 2018

Kate Middleton may have appeared before the cameras looking immaculate, groomed, and composed just hours after giving birth to Prince Louis Arthur Charles, but don’t think this has to be you.

Fully recovering from pregnancy and childbirth can take months–or longer–and many women are blindsided by the changes that take place. Case in point: Who knew hot flashes could be part of the picture?

How well and how quickly you recover after having a baby depends on many things, including your health before you got pregnant, what kind of pregnancy you had, as well as what kind of delivery. Regardless, it helps to be prepared. Here’s what you need to know about the “fourth trimester” and beyond.

You’re going to feel really tired

You probably expect at least a little bit of fatigue, but many women aren’t prepared for how tired they feel after pregnancy.

That exhaustion comes from being on your baby’s timetable–but also from how difficult it can be to sleep through the discomfort while your body heals.

“[The fatigue] can last for days, weeks,” says certified nurse-midwife Elizabeth Hill-Karbowski, PhD, director of midwifery practice, education, and global outreach at the American College of Nurse-Midwives.

Instead of feeling like you have to clean the house or attack a to-do list when there’s a moment of quiet, rest when you can. Nap when your baby naps, if at all possible, she advises.

Your abdomen is going to hurt

This may be the least surprising aftereffect given what you’ve just been through, but there’s a name for abdominal discomfort after pregnancy: afterpains. They’re from uterine contractions, which help return the uterus to its pre-pregnancy size. Breastfeeding can trigger these contractions, so you might notice more pain when you’re nursing your baby.

There can also be some pain from the abdominal wall healing. “The muscles undergo separation, and they have to go back to normal,” says Hector O. Chapa, MD, clinical assistant professor of obstetrics and gynecology at the Texas A&M College of Medicine in College Station.

How long this lasts and how long it impedes getting back to normal function is highly variable, but it’s going to take longer if you had a C-section, he says. Applying a heating pad or hot water bottle may help ease some discomfort.

You’ll feel sore down there

Even if the delivery goes perfectly, you’re likely to feel sore for a while in the area between your vagina and your anus, called the perineum. It’ll hurt even more if your vagina tore during delivery or if you had an episiotomy, a small cut your doctor makes in the opening of the vagina to help delivery.

Sitting on a pillow can help. So can a sitz bath, sitting in cool or warm water covering just your buttocks and hips. Some women try local anesthetic sprays and ice packs.

Your periods won’t resume right away

Although some women start menstruating six to eight weeks after delivery, the timing of getting your period back really depends on the individual. If you’re breastfeeding, it may be several months, says Hill-Karbowski.

Once your period does start, you may notice it’s different than it used to be. Your periods may be more irregular or heavier, and your cramps may be either more or less intense than before you got pregnant.

Even if you haven’t restarted your period, you may still be able to get pregnant. “This should not be considered a form of birth control or contraception or family planning,” says Hill-Karbowski.

You may need birth control

Speaking of getting pregnant again, doctors usually recommend waiting 12 to 18 months after childbirth. “Delivery that is less than that is linked to growth restriction [to the fetus], preterm labor, gestational diabetes, and hypertension in pregnancy,” says Dr. Chapa.

Despite what you may have heard, breastfeeding is not birth control. It’s not that common, but you can definitely get pregnant while you’re breastfeeding–and even before you resume your period after childbirth.

If you’re not ready for another pregnancy, you’re going to need some kind of birth control, whether that’s condoms or hormonal pills, patches, implants, or shots.

In Canada and Latin America, many women are fitted with IUDs in the delivery room or before they leave the hospital, says Dr. Chapa. This is less common in the U.S., where IUDs are more often inserted during an office visit, but if long-acting contraception is your preferred method of birth control, it can’t hurt to ask.

You’ll have other bleeding and discharge

This is called lochia, and it’s common regardless of whether you’ve had a vaginal delivery or a C-section.

“It’s a natural shedding of the lining of the uterus,” says Dr. Chapa, “and it goes through different characteristics, going from reddish initially to whitish-pale to transparent.”

Lochia is normal unless it turns yellowish or green or starts smelling, which could mean you have a bacterial infection.

Use pads to deal with the flow, not tampons, which can increase the risk of infection.

Lochia usually goes away on its own after a few weeks, but if you find that you’re going through more than one pad an hour or you notice any clots bigger than a quarter, get in touch with your health care provider. You could be having postpartum hemorrhaging.

You may feel sad or depressed

It’s normal to feel sad or blue for a week or two after giving birth, says Dr. Chapa. At least half of women, probably more, feel weepy, irritable, sad, or overwhelmed after having a baby. This is from a combination of hormonal changes, stress, and fatigue, and it’s sometimes called the “baby blues.”

If you’re still feeling down after about four weeks, though, you may be experiencing more serious postpartum depression, which affects about one in 10 women after having a baby. Contact your health care provider right away; he or she can suggest ways to feel better and monitor your condition for other changes. A few women also develop postpartum psychosis, which can bring hallucinations and a desire to hurt yourself or others.

“This is real and very dangerous, and it needs to be addressed,” says Dr. Chapa.

You might get constipated

Constipation is another all-too-common aftereffect of pregnancy, especially if you took any painkillers or had anesthesia in the hospital. For some women, the blockage comes from fear that a bowel movement will hurt or cause any stitches (say, from an episiotomy) to rupture.

Simple strategies can help ease the constipation, including drinking lots of water and eating fruits, veggies, and other fiber-filled foods. Exercise can also help, but get your doctor's approval before starting anything strenuous.

Talk to your doctor if you haven’t had a bowel movement for four days after your baby arrives. He or she may recommend a laxative.

You could develop hemorrhoids

These swollen blood vessels in the rectum can occur after the physical exertion of childbirth. Not only do they hurt, they may also itch and bleed, but they do go away in time.

In the meantime, try putting witch hazel on the hemorrhoids. Cold packs, warm sitz baths, and sitting on a cushion can help ease the pain.

As with constipation, follow a diet rich in fiber, drink lots of water, and, when your doctor says it’s okay, start exercising.

You may experience some leaks

Urinary incontinence is common after a vaginal delivery, but it can also happen after a C-section. Your bladder may leak if you laugh or cough, and you may notice it’s harder to control your bowel movements too.

Like constipation and hemorrhoids, the problem should subside with time. “It doesn’t mean a lifelong curse,” says Dr. Chapa.

Kegel exercises to strengthen your pelvic muscles can help. These simple movements involve tightening your muscles as if you want to stop peeing, then loosening up.

Fitness comes back gradually

You might be feeling eager to get back to your regular exercise routine, especially because it can help with some of the very aftereffects that may be plaguing you. Not only can exercise help with hemorrhoids, constipation, and incontinence, it can also stave off depression, improve sleep, and give you more energy.

But don’t rush back into your pre-pregnancy regimen, especially if you’ve had a C-section. How quickly you can get back at it is highly individual. “Your body has done something amazing,” says Hill-Karbowski. “Don’t overdo it right away.”

Walking and swimming are gentle ways to ease back into exercise. Your health care provider can offer you more individualized exercise advice.

You could have hot flashes

You thought this wouldn’t happen until your baby days were over, right? Turns out, post-pregnancy hormones can cause menopause-like hot flashes as well. This is, after all, another major life transition.

One study found that just over a third of women said they had hot flashes while they were pregnant, and 29% continued to sweat it out afterward. The flashes tended to get better after the second week following delivery. Women who had depressive symptoms and who had a higher BMI before their pregnancies were at higher risk for hot flashes.

If hot flashes or night sweats seem more like a fever, talk to your doctor. It’s possible you could have an infection.

Your boobs and nipples can hurt

Breastfeeding is good for you and your baby­­–but it isn’t always easy.

“Breastfeeding can be very complicated. It’s not as easy as one would think,” says Hill-Karbowski. “Rare is the child that just attaches and doesn’t need additional encouraging, coaxing, and training.”

It can also be painful, resulting in sore breasts and chapped nipples. A lactation specialist or your doctor can give you helpful tips to make things more comfortable, like changing the position of your baby when she’s feeding.

But don’t ignore the discomfort. “It can be something as simple as chafing, but it can also be something as serious as a breast infection,” says Hill-Karbowski.

You won’t lose your pregnancy pounds all at once

The average weight gain during pregnancy is 25 to 35 pounds, but you can expect to lose only six to 12 pounds in the delivery room, according to the American Academy of Family Physicians.

“You lose the weight immediately associated with the weight of the baby, the weight of the amniotic fluid, and the weight of the placenta,” Hill-Karbowski explains.

You’ll probably also lose some water weight in the week after delivery; you’ll see swelling in your hands, legs, and feet go down.

The rest takes time–probably months–and it’s best to let it. Your body needs calories and energy to heal, take care of your new baby, and breastfeed, if you choose to do so. (For some women, breastfeeding may actually speed weight loss.)

You might not be in the mood

Doctors usually recommend waiting for four to six weeks after childbirth before having sex again, both to help the natural healing process and to prevent infection, especially if the vaginal tissue has been cut or torn.

After that, resuming sex is highly individual, and you might find you’re not as eager to do the deed as you once were. “Changes in estrogen levels and breastfeeding can cause a slower return of libido,” says Dr. Chapa.

You may need to experiment with positions to see which is most comfortable. You might also need a water-based lubricant for a while.

“It’s very important that couples understand that just because the pregnancy is done, intimacy may take time,” says Dr. Chapman. “What is right for the patient is right for the couple.”

This doesn’t always happen, though. Some women report that their libido is through the roof after childbirth.

It’ll take longer to recover from a C-section

A C-section is major surgery. You’ll probably have two sets of stitches: one in your skin and one in your muscle. You can anticipate it taking about 12 weeks to heal from the innermost stitches.

Once you’ve had a C-section, you may or may not be able to have a vaginal delivery in the future. “Vaginal birth after a C-section is fantastic, but it’s highly dependent on what the indication was and what type of C-section they had,” Hill-Karbowski says. If you have a classic or T-shaped incision, it’s probably not a good idea to have a vaginal delivery in the future. Other incisions are better suited to delivering vaginally later on, she says.

You may still be at risk for complications

Just because you’re not pregnant anymore doesn’t mean you’re out of the woods when it comes to pregnancy complications.

“Everything that happens [during] pregnancy can affect the postpartum period,” says Dr. Chapa. “High blood pressure and gestational diabetes can have long-term and lifelong implications,” he says, as can extra weight gain.

Preeclampsia–a potentially dangerous pregnancy complication involving high blood pressure–puts you at a higher risk of cardiovascular disease later. Gestational diabetes ups your risk of developing regular diabetes.

“Pregnancy is a stress test for future complications,” Dr. Chapa says.

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When to get help

In the midst of all the excitement surrounding your new baby, don’t neglect your own health.

Contact your health care provider right away if you have fever or chills; severe headaches or vision changes, which could indicate soaring blood pressure; vomiting; signs of infection; or pain in your legs, a possible sign of a blood clot.

“This is a time to really be kind to yourself,” says Hill-Karbowski. And that includes looking after your own needs.