Maternal Mental Health in the Fourth Trimester: What Postpartum Moms Need to Know is Okay
By Eleanor McGlinchey, PhD
Life transitions are always hard. I think we can forget that even the most exciting life changes are often challenging. If you think back to key life transitions you were eagerly looking forward to, such as going off to college or starting your first full-time job, my guess is that within those first few weeks of adjustment, you found yourself experiencing some mixed feelings that included disappointment or even sadness - even if you overall enjoyed college or the new job. For some, the experience was clearly not what you hoped it would be. As a result, you may have felt anxious or confused about the discrepancy between what you hoped and what you experienced. Many of us also feel lonely, isolated, or guilty when we believe we “should” feel good about a big moment - but don’t always.
A guide to the fourth trimester and postpartum transition
In my professional (and personal) experience, the “fourth trimester” for mothers can be a brutal example of this internal discrepancy that occurs with major life transitions. The perinatal period is defined as the time between pregnancy through the first year post-delivery. The fourth trimester is what’s known as the 3-month transition period specifically after birth. It’s often the most challenging trimester physically and psychologically for postpartum mothers, but often receives less attention as so much is dedicated to the newborn baby. In addition to the extraordinary physical tasks of healing after birth or caregiving, part of what makes the fourth trimester so challenging for mothers is the powerful expectation that you “should” feel wonderful. When the truth is, most postpartum mothers also feel stressed, anxious, and sad.
For many of the pregnant and postpartum women I have worked with, they wanted to be pregnant and have a baby. I have found that for these women, it can sometimes feel hard to acknowledge that their personal experience of having a baby was or is not all positive. There is real external and internal pressure to feel joyful and grateful all the time about becoming a mother or having another child. Unfortunately, these pressures make any normative emotional distress unacceptable and causes mothers to question whether there is something seriously wrong with themselves.
This will be the first in a series of blog posts I write that aim to normalize the perfectly normal moments that a mother might feel in pregnancy and her postpartum year. This will not be an exhaustive list, nor will everything mentioned here be relevant for every mother. However, I do hope that this post helps mothers feel less alone, uncertain, or self-critical as they navigate their own pregnancy, fourth trimester, and beyond. The sad truth is that “No one ever told me…” is an all too common refrain among new mothers. My hope is to break the silence or lack of awareness among expecting and postpartum mothers so they can view their own experiences as normal, typical, and perfectly healthy - and even learn to share and support one another through one of the biggest life transitions there is.
Four common fourth trimester moments that postpartum mothers experience
Moment #1: Feeling like if things did not go the way you hoped or planned that this means you’re a bad mom.
You may notice having thoughts like, “My pregnancy or birth plan or X didn’t go as planned. I’m already failing at being a mom.” There is so much pressure to have a perfect pregnancy and birth story. There is also so much fear that a wrong decision along the way will lead to a terrible outcome. When a medical intervention or change in birth plans inevitably happens, many mothers report feeling guilt and shame that they weren’t able to deliver the way they wanted or felt they were “supposed to”. Mothers are expected to have an impossible level of control over their bodies or medical circumstances - and when they inevitably don’t have full control, they judge themselves or are judged for it. It’s important to recognize that this is a result of generational patriarchy, sexism, and traditional gender roles. Perhaps if this thought looms, a way to reframe it could be, “I delivered my child into the world, and that is to be celebrated, not picked apart.”
Moment #2: Feeling constantly anxious that you or your baby might be in imminent danger.
Common thoughts might be, “I might be in life-threatening danger if I do not attend to every physical change in my body.” or “My baby is in life-threatening danger if I do not watch out for red-flags 24/7.” Unfortunately our hospital systems are not set up to educate, normalize, and equip new mothers to respond to the host of new worries that arrive post-birth. Instead, the messages sent to women at the hospital tend to reinforce the feelings that you must be constantly vigilant in monitoring your body for any post-birth warning signs (e.g., change in your blood pressure, excess bleeding) and your baby’s (e.g., number of bowel movements, jaundiced skin). It can be hard to break the habit of vigilance once it starts and can often make a postpartum mother feel more anxious when returning home. Of course the hospital needs to educate new parents about physical warning signs in both mother and baby, and this is particularly important in the first few weeks. However, if these thoughts are persisting after those first two weeks, perhaps a way to reframe can be, “My baby/I am strong. We have made it here and will continue to get stronger.”
Moment #3: Feeling guilty for feeling anything other than joy and gratitude.
You might think “What is wrong with me? Shouldn’t I be enjoying every new moment with my baby?” There is nothing wrong with wanting to feel excited or happy about being a new mom. And there is also nothing wrong if you don’t feel that way all the time or even some of the time. You are allowed to feel sad, frustrated, disappointed, lonely, doubt, scared, grossed out, confused, bored - and the list goes on. You are adjusting on multiple levels, and it would make sense that comes with a lot of thoughts and emotions which will also include joy and gratitude. A reframe could be “it would be weird for me to feel one emotion towards anything or anyone in my life - so it’s okay for me to feel a range of emotions here too”. As a psychologist, I’m constantly reminding my patients that we are capable of feeling multiple, co-existing feelings about the same situation (or person!) without them canceling each other out or making ourselves explode.
Moment #4: Feeling like you are doomed to feel bad, and things are never going to get better.
Typical thoughts may sound like, “It’s always going to feel like this” or “I am doomed in this new role.” The fourth trimester and postpartum period is a very difficult and vulnerable time for most mothers. It can feel endless and like you suddenly aren’t looking forward to anything, especially as all the days blur together. Hold on! It will not always be this way. Postpartum hormones play a big role in increasing feelings of sadness and anxiety. It’s so important to remember that the regulation of postpartum hormones often takes the full 3 months post-birth to fully stabilize and the first few weeks can feel particularly intense. (This is often known as the “baby blues” - and it can be very helpful to contextualize and plan for additional support.) Perhaps a way to reframe these types of thoughts can be, “I am still adjusting to this new role and that takes time” or to notice what’s been even slightly better since the first weeks of postpartum.
Knowing that these experiences are normal and often temporary can help to change your pregnancy and postpartum narrative. If you’re struggling with unexpected or overwhelming emotions, you’re not alone. Below are some practical suggestions.
Four practical tips to support postpartum maternal mental health
1. Choose self-compassion.
Can you be gentler on yourself for what you are experiencing today? You are indeed getting stronger each day and so is your baby. Maybe that is all that needs to be true for the moment. Becoming a parent can trigger perfectionism - because you want the absolute best for your child, and therefore want to be the best for them. However, practicing self-compassion is actually key to being the best for your child. It may also be helpful to think through the specific ways that you are doing the best that you can for yourself and for your baby today. It might not be exactly where you thought you would be or wanted to be, but you are growing in your new role more and more everyday.
2. Try mindfulness for a few minutes.
There is good evidence that beginning to practice mindfulness in the postpartum period can reduce the likelihood of developing postpartum depression. If you’ve never tried mindfulness exercises before, there are some great apps that are easy to start with that offer exercises as little as 1-3 minutes at a time. There are also some good online support groups that incorporate mindfulness into their content (e.g., Expectful).
3. Ask for help - and as best you can, be specific.
As mentioned before, there is pressure on new mothers to have everything under control, but as best you can, try to let go of that. For example, ask others to come over and hold the baby while you take a shower. Tell your mother/aunt/friend/neighbor, who came to see the baby, to also clean your refrigerator. Ask your friends to set up a meal train and start sending you meals a few times per week. Ask your partner to take the morning or night shift with the baby (depending on when you sleep better). There might also be some moms groups in your local area that you could join online or in person that will have helpful resources to support you as well.
4. Don’t hesitate to inquire about professional support.
If you think you might be experiencing postpartum depression or another postpartum mental health condition like anxiety or psychosis, consider reaching out for professional help. Symptoms of postpartum depression to look out for are sadness that persists for most of the day, everyday for over two weeks, difficulty enjoying things you used to enjoy even when you have the opportunity and ability to do them and difficulty sleeping even when given the opportunity to sleep. If the suggestions above do not help and you are noticing some of the symptoms mentioned, reach out to a therapist for additional support. Up to 1 in 5 mothers experiences postpartum depression and over 800,000 mothers in the United States are untreated. Postpartum Support International is a wonderful organization with resources for mothers, including immediate support via phone or text (PSI Helpline), support groups, and a therapist directory for clinicians specializing in perinatal mental health.
It is also important to tell someone if you are having thoughts about suicide or wanting to fall asleep and not wake up. If you are experiencing these thoughts or feelings strongly, go to your local emergency room or dial 988 for the National Suicide Prevention Hotline. Your safety and wellbeing are deeply important and there is help so you can feel better and enjoy parenthood in the ways you hope to.
Maternal mental health in the fourth trimester
Again, this is not an exhaustive list of things a new mother can do to help when she is feeling the wide range of joyful and challenging emotions of pregnancy and the postpartum period. However, I hope new mothers will more and more feel empowered and hopeful about this major life transition. Maternal mental health is always important - however, it can seem to take a backseat in the fourth trimester as there are such rapid fire changes, expectations, decisions, and moments that blur together. It may seem as though these three months may be the worst time to consider therapy for postpartum; however, it may actually be the best time (especially with the flexibility that teletherapy offers). Receiving practical and emotional support through this key period may significantly change the way you take care of yourself, your baby, and your family - and allow you to be present for all the wild and beautiful moments of motherhood in the ways you want to.
About the Author: Dr. McGlinchey is a licensed psychologist and a tenured professor at Fairleigh Dickinson University. She loves working with and supporting the mental health of pregnant and postpartum parents. She is a mother to three children ranging from toddler to 12 years of age and has experienced how different each pregnancy, birth and postpartum period is. With much gratitude, she is here on the other side of these experiences and passionate about maternal mental health.