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The Journal of Perinatal Education logoLink to The Journal of Perinatal Education
. 2020 Apr 1;29(2):103–112. doi: 10.1891/J-PE-D-18-00034

A Fourth Trimester Action Plan for Wellness

Jane S Savage
PMCID: PMC7159799  PMID: 32308360

Abstract

Expectant mothers/couples often report planning for early parenting is overwhelming. Lack of anticipatory planning makes evident the need for providers, like childbirth educators, to assist expectant parents in minimizing or eliminating the problems associated with the transition to the fourth trimester, early parenthood. Planning for birth should extend beyond labor and birth to include the weeks following. The author's purpose is to explore the problems associated with the fourth trimester, to review the current health-related literature, and to propose an integrated behavioral action plan as an effective strategy. Self-efficacy constructs support a wellness plan approach to enable expectant mothers/couples to be proactive in preparing for their physical and emotional needs after the arrival of their newborn.

Keywords: fourth trimester, action plan, childbirth educators, transition, wellness

The fourth trimester, postpartum, including the adjustment to parenthood, is a significant life event. Parents often describe this time as difficult because planning for the unexpected is “impossible.” Concern about the well-being of the new family, especially the level of stress in the first postpartum year, is well documented (Barimani & Vikström, 2015; Entsieh & Hallstrom, 2016; Romm, 2013; Sampson, Villarreal, & Padilla, 2015). Studies, old and new, validate a genuine need to reduce threats to parent and newborn well-being. The fourth trimester is characterized by a myriad of change—emotional, physical, social, and spiritual (Cohen, 2014; Johnston-Ataata & Kokanovic, 2014) and the psychosocial health of new parents is at risk during this time (Fahey & Shenassa, 2013; Miller, Kroska, & Grekin, 2017; Sampson et al., 2015). Planning for stress-reduction measures may serve as a proactive intervention to lessen the incidence of maternal distress, postpartum stress syndrome, or postpartum mood disorders (Kuipers, 2016; Summerfeldt, 2018).

However, current research (Razurel, Kaiser, Sellenet & Epiney, 2013; Johnston-Ataata & Kokanovic, 2014) suggests that the process of preparing mothers and their partners for active coping in the fourth trimester is missing. Proactive preparation also needs to include adoptive parents and those who use surrogates (Cohen, 2014; Foli, South, Lim, & Jarnecke, 2016; Mott, Schiller, Richards, O'Hara, & Stuart, 2011). The purpose of this analysis is to review the current evidence related to the efficacy of preparing for the fourth trimester and the use of an action plan for wellness to support new mothers and their partners to mitigate the potential negative impact of the fourth trimester.

BECOMING A MOTHER

Because postpartum distress is a complex, multifaceted concern for a mother/couple, disruptions in daily living, relationships, and self-concept, not to mention the physical recovery from childbirth are common (Simkin, 2019). Positive adaptation to the maternal role involves active preparation to minimize stressors that may inhibit maternal identity and hinder newborn attachment. Other influencing factors include perception of the birth experience, social stress, social support, and health status. Mothers report challenges in role acquisition related to balancing multiple social roles that lead to feelings of incompetence (Mercer, 2004).

Current studies (Entsieh & Hallstrom, 2016; Gilmer et al., 2016; Hjälmhult & Lomborg, 2012) reveal a gap in assisting women as they adjust to the complexities of becoming a mother. This gap may contribute to the incidence of postpartum stress and postpartum mood disorders (Brenning & Soenens, 2017; Clout & Brown, 2015).

CHILDBIRTH EDUCATION

Naturally, expectant parents are focused on navigating childbirth. To meet those expectations, traditional birth education focuses more time on labor and birth topics, less time on becoming a mother, and even less time to being a father (Declercq, Sakala, Corry, Applebaum, & Herrlich, 2013). Postpartum may be addressed in only a few slides shown in a particular class. However, this phase should exceed the focus of most prenatal classes (Kitzinger, 1975). Kitzinger reminds us that childbirth preparation must be more than just a “drill for coping with contractions” (p. 118).

Hjälmhult and Lomborg's study (2012) of mothers' experiences in the initial period after birth revealed a view among the participants of minimal support from healthcare providers. With short hospital stays and prenatal classes concentrated on labor and birth and newborn care, limited attention was devoted to coping with the stressors of continuous newborn care within the fourth trimester.

Australian mothers viewed postnatal care to be the weakest link in their maternity care experience (Zadoroznyj, Brodribb, Young, Kruske, & Miller, 2015). Zadoroznyi et al. concluded that mothers receiving care in private hospitals were more likely to report concerns about poor quality discharge care. Perhaps at the time of discharge, anxiety is high and learning receptivity is low.

On a positive note, Kantrowitz-Gordon, Abbott, and Hoehn (2018) interviewed a small cohort (12) of postpartum women at 2 and 16 months to determine the impact of mindfulness-based interventions. Mindfulness interventions, such as positive affirmations, learned in a formal, prenatal setting were found to assist in coping with emotional and physical challenges and enhancing positive relationships with partners and newborns during the postpartum phase.

Additionally, Marshall and Thompson (2014) interviewed seven mothers about the stress and difficulty of caring for a newborn. Coping with the stress of early motherhood involved using skillsets for practical problem-solving, problem management, engaging social support, modulating relationships, and enhancing self-esteem. Participants found their new role challenging yet positive. Concerns about adjustments to baby needs such as feeding, sleeping, and crying were at the forefront. Identified as crucial to dealing with those concerns was social support in the form of playgroups and mothers' groups.

Traditional hospital perinatal education attendance is declining. Declercq et al. (2013) reported in Listening to Mothers III only 34% of women, first-time (59%) and experienced (17%), reported taking childbirth classes for their current pregnancy. Classes most frequently attended were focused on (a) labor and birth, (b) expectations for giving birth specific to the hospital, and (c) benefits and risks for care options. Gilmer et al. (2016) recommend that the customary model of providing information to new parents with a lack of andragogy and the context of learner engagement, may explain the decline.

With recent emphasis on the safety and physical well-being of the mother in the fourth trimester (American College of Obstetricians and Gynecologists, 2018; Amnesty International, 2011; Tully, Stuebe, & Verbiest, 2017), midwives, Women's Health Nurse Practitioners, childbirth educators, perinatal nurses, and doulas are poised to encourage proactive planning for the postpartum period above the current curriculum for prenatal education. Reevaluation of the relevance of prenatal class content and teaching methodologies will more likely reach a greater variety of learners. The results from a meta-analysis and systematic review by Entsieh and Hallstrom (2016) indicated that using participatory and experiential adult learning strategies are effective and have improved outcomes.

Equal emphasis on the postnatal period as the prenatal in childbirth classes is more likely to enhance a positive transition to parenthood. Learning from other new parents may inform expectant parents of the need for positive coping and potential relationship changes.

POSTPARTUM SOCIAL SUPPORT: FAMILY FRIENDS, CARE PROVIDERS

Hamilton, Stevens, Lillis, and Adams (2018) identified the need for a robust network of support in the fourth trimester; a comprehensive network including but not limited to medicine, lactation, behavioral health specialists, family, and friends. As to who are the best resources for social support in the fourth trimester, the outcomes are mixed.

Barimani and Vikström (2015) examined ways Swedish parents experienced early postpartum support from care providers. The qualitative approach used focus group interviews with 18 women and 16 men. Fathers were often unsure of what was expected in their new role. Uncertainty in a new role as a father was also an outcome in a qualitative study of 15 first-time fathers (Pålsson, Persson, Ekelin, Hallström, & Kvist, 2017). Fathers also needed strategies, support, and expert guidance.

Using a survey of new mothers conducted at 3 and 6 months postpartum, Schwab-Reese, Schafer, and Ashida (2017) determined social support did not strongly moderate or mediate the relationships between stress and maternal mental health. Consequently, a continuous needs assessment of postpartum mothers is necessary to determine how their needs may change over time.

From a care provider perspective, Romm (2013) further addressed the complexities of the postpartum period for a new mother experiencing a significant lifestyle change including issues surrounding mood fluctuation, role change, weight loss, libido, time management, and relationship strain.

Midwifery-guided discussions regarding imparting wisdom to expectant mothers in preparation for mothering was a topic of concern in social media blogs. For example, Tritten's midwifery blog (2017) included the importance of sharing knowledge even when the expectant mother may be overwhelmed. The belief was that she would remember when the time comes. Brainstorming evidenced in the blog identified effective and ineffective strategies. “Nurse your baby, go to a support group, eat often and get plenty of rest” (p. 61). Positive coping in labor translated into positive coping in parenting. Other suggestions for positive coping included preparing meals ahead, staying in bed, skin-to-skin, asking others to help with housework, and limiting visitors to grandparents the first week.

Negron, Martin, Almog, Balbierz, and Howell (2013) explored women's experiences of social support after their babies were born. The quality and availability of family and spousal support was identified as a priority among the participants. Barriers to support were personal attitudes, cultural norms, support expectations, support availability, and impact on family relationships and partners. The need for active father involvement in the fourth trimester was also identified as a priority for new parents (Widarsson, Engstrom, Tyden, Lundberg, & Hammar, 2015).

Aligning with theories of becoming a mother, women may need reassurance about their mothering skills from healthcare professionals, family members, and friends with infants (Cabrera, 2018; Mercer, 2004). Although perhaps not the most reliable, friends and family are often identified as sources of support and information for new parents (Ateah, 2013). Mothers and fathers report their partners as being the best resource for help in the postpartum period (Sampson et al., 2015; Widarsson et al., 2015).

Are parenting distress and challenges linked to knowledge deficits? How do care providers redirect learning to include a robust postpartum emphasis? If teaching-learning strategies do not meet learner needs and preferences, what are the best practices for imparting knowledge to expectant parents? Alternative evidenced-based methods must be devised to meet the demands of a healthy postpartum adjustment. Knowledge alone may not reduce distress and promote a healthy attitude and behavior changes. A plan of action for wellness may be in order.

ACTION PLANS

The fourth trimester requires the new mother/couple to adapt emotionally, physically, spiritually to the needs of her baby, her partner, and herself. How are we helping our expectant mothers/couples to develop an action plan to cope effectively with fourth trimester challenges? Do you offer a plan outline to manage the challenges of the fourth trimester? A postpartum action plan may reduce the number of barriers and secure support for the new mother.

Although the evidence is sometimes conflicting as to the effectiveness of health management action plans; for chronic illnesses such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and asthma the evidence shows promise (Baig, Sbidi, & Sbidi, 2016; Lau, Arguel, Dennis, Liaw, & Coiera, 2015; Mehring et al., 2013; Zakrisson et al., 2019). At the very least an action plan intends to increase awareness to offset the inherent challenges of adjusting to life with a new baby. A best practice approach is to include the mother's support team, especially involving her partner. If the mother feels supported, she is less likely to be at risk for perinatal mood disorders such as anxiety and depression (Johnston-Ataata & Kokanovic, 2014; Summerfeldt, 2018). Positive coping with inevitable conflict and effective communication of needs that are likely to change over time may make the initial prenatal months easier (Bennett, 2008; Nolan, 2012).

POSTPARTUM ACTION PLAN FOR WELLNESS

Action plans for wellness may have a holistic impact on new mothers and families. However, postpartum action plan development, implementation, and outcomes are unknown. MacDonald and Flynn (2012) developed a comprehensive toolkit to support mothers' mental health. The comprehensive toolkit is an excellent resource for assessment and planning particularly for those women at risk for perinatal mood disorders. Typically, if the ideas outlined in planning for normal birth are followed, the fourth trimester action plan can be viewed as a foundation for partnership among care providers, family, and others in the identified support system, to assist in meeting the requirements of new parents based on their values and needs.

If planning for birth is good practice, then planning for the fourth trimester is also a good practice. Wellness action plans are characteristically concrete with specific tasks to meet goals generated by the expectant mother. For example, “I will walk outside every morning with my baby.” Specific goals are more likely to be achieved than vague or no goals. Specific short-term goals (weekly goals) are more likely to be met than long-term goals (Bodenheimer, Davis, & Holman, 2007). Barriers will occur so an optimal plan will be to establish alternative goals to ensure success and minimize frustration.

Wilkinson (2011) describes involving everyone identified in the support system to implement the plan to ensure success. Planning for the fourth trimester helps to set direction and priorities; planning helps to get all involved on the same page; and planning communicates the message. Effective communication among the support system is a must to serve as a preventative measure to avoid conflicts (DeBaets, 2017).

When addressing the idea of an active approach for a postpartum wellness plan each woman will be unique in identifying her priorities and plan. A recommended starting point is to ask the expectant mother to identify a few things she can do to stay healthy after her baby arrives (Kuipers, 2016). Best practice elicits from the mother what her priority is and her concerns about the reality of postpartum and barriers to achieving her prioritized goal. Barriers might relate to family dynamics, environmental constraints like poor weather conditions limiting outdoor activity, financial issues, or transportation (Agency for Healthcare Research and Quality, 2018; Stratis Health & KHA REACH, 2015).

INTEGRATED HEALTH PROMOTION MODEL

Models of health behavior provide a framework of understanding of new parents' use of coping strategies and health promotion theories are well documented in supporting behavior change (Baig et al., 2016; Barley & Lawson, 2016; Bistricky et al., 2018).

With variation in current study outcomes related to a wide range of selected behaviors and subjects, integrating constructs from several theories to create a health behavior model may be sound practice (Bistricky et al., 2018). No one theory is likely to fit every circumstance (Barley & Lawson, 2016; Jones, Smith, & Llewellyn, 2014). Research findings from studies concerning behavior change and health promotion support integrating health promotion constructs into a model supporting an action plan to improve coping strategies in the fourth trimester for the new mother and her family. Action plans have been useful in managing a variety of health promotion issues (Lenzen, Daniëls, van Bokhoven, van der Weijden, & Beurskens, 2017; Waldecker, Malpass, King, & Ridd, 2017).

Fishbein and Ajzen's theory of planned behavior (1991) describes influences on the planning process regarding successful outcomes. Applied to the emerging family, if the expectant mother plans an action, she is more likely to achieve it. Several factors, like intention, drive planning behavior. Intention is also shaped by attitudes, subjective norms, volitional control, and behavioral control. Attitude and beliefs shape values associated with behavioral outcomes. For example, if an expectant mother considers breastfeeding a healthy choice for her baby, she is more likely to breastfeed. Subjective norms also influence intention. If a respected role model, like her mother, expects the new mother to manage to care for her baby alone, she is less likely to ask for help from others. A strong sense of self also influences her willpower, or volitional control and perceived behavioral control, relating to believing she is capable of improving her wellness behavior and effectively caring for her baby.

Models of health promotion that support components of an action plan for wellness like decision-making, goal setting, and action planning can be developed from constructs like self-efficacy, confidence (Bandura, 2004), self-management, overcoming barriers to change (Lorig et al., 2012) intention (Ajzen, 1991), and values and relationships (Deci & Ryan, 2008). A health promotion model also translates to the weeks and months after childbirth. The following are guidelines for an action plan to be tailored to the needs of the emerging family to minimize the stress associated with the postpartum period. The expectant mother would ideally start formalizing her plan no later than the 3rd trimester. The plan should be meaningful, realistic, achievable, action-specific, anticipate barriers, and include reinforcement. McCulloch (2014) recommends weekly action plans for the successful management of health issues. The more specific or detailed the plan is, the more likely the success. For example, stating that a goal is “to eat healthy” is more likely to be met if each meal is broken down and how the meal will come together is determined. Will a partner or family prepare? Will food be delivered by friends, support groups, or birth service? Details are important. However, Hagger and Luszczynska (2014) warn when providing specific examples of goals also ask the expectant mother for ways to reach her goals to ensure her unique needs are met.

In addition to My Postpartum Wellness Plan (Figure 1), several online resources for a postpartum wellness plan are available (Beaumont Hospitals, 2011; Perinatal Support, 2016; National Child and Maternal Health Education Program, 2016; Speier, 2017). The concepts in common are: planning for short periods of uninterrupted nighttime sleep; healthy eating; support for breastfeeding and baby care; prioritizing activities of daily living including fresh air and exercise; resources for childcare and babysitting; me and couple time; and support group and healthcare contacts.

Figure 1.

My postpartum action plan for wellness. (Examples of a goal are in parentheses)

BABY TIME
My plan for help after our baby comes is (after my partner returns to work, my mother will manage the house for the first 2 weeks; MIL second 2 weeks)
My plan for assistance also includes support from my partner, doula, family (bringing our baby to me for feeding; making sure I have fresh water to drink; giving me a break)
MOMMY TIME
My plan to listen to music is (while I am walking the baby for 15 minutes)
My plan for healthy eating is (I will drink 6–8 glasses of water daily; Eating green leafy vegetables at lunch)
My plan for nighttime sleep is (I will sleep uninterrupted for 4–5 hours every night while ______ cares for the baby)
My plan for napping when the baby is napping is to (silence my phone, etc.)
My plan for regular exercise and fresh air is (I will walk with my baby every day at 10:30 a.m. to the park)
My plan for friend time is (I will see/stay in touch with friends ________ times a week by [phone, text, meeting])
COUPLE TIME
My plan for couple time with our baby is (we will take a walk with our baby every evening)
My plan for spending time together alone is (schedule a babysitter and eat dinner at X)
INTENSE FEELINGS
For feelings of intense anxiety, fear, guilt, hopelessness. I will reach out to
my-care provider (insert number) ____________________________
Postpartum Support International 1-800-944-4PPD (4773)
family member (insert number) __________________________

  1. How confident are you in meeting your goals? What would make you more confident?

  2. What barriers may stop you from meeting your plan goals? Alternative plan/goals?

  3. Check your plan daily to see what went well and what needs improving.

  4. Congratulate yourself on meeting your goals!

SOCIAL MEDIA RESOURCES
Facebook:

  • New Orleans Moms Blog

  • Kelly Moms Breastfeed (Kellymom.com)

  • La Leche League of New Orleans

  • NOMB New & Expecting moms

  • Postpartum Support Louisiana

  • FIT4Mom NOLA

  • NAS JRB New Orleans Cloth Diapering, Baby Wearing, and Breast Feeding

IMMEDIATE SUPPORT
Websites/tool free numbers:

  • National SUICIDE PREVENTION Lifeline, 1-800-273-TALK(8255)

  • Postpartum Support International: http://www.postpartum.net/1-800-944-4PPD(4773) to speak to a volunteer


Nonurgent Support
GENERAL RESOURCES

  • Parenting Center at Children's Hospital NOLA-http://www.chnola.org/parentingcenter

  • Metairie and Uptown Locations, 504-896-9591-support and education for raising children

  • We PLAY, mytraininggrounds.org-free indoor play space for children 0–3 accompanied by parent or caregiver, 9–11 am, Tues, Wed, Thurs

  • TBears.org-parent program concerning fussy babies

  • Fit4mom.com-multiple park locations-meet other moms and stroller stride/work out together
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Wellness plans may also include information related to national social and community media resources for support groups, local resources for exercise, new mom groups, breastfeeding, childcare, and finding community resources for connecting with other new families. Including local, state, and national contact information and resources enhance plan effectiveness; mothers report they wish they had a “go-to” list of community resources (Giarratano & Savage, 2018).

In preparation for the fourth trimester, an expectant mother/couple may need assistance with strategies for tailoring self-management goal setting and action planning (Finn, 2015). Childbirth educators often refer to a full range of normal in childbirth (Simkin, 2018), as a frame of reference, likewise, consideration should be given to a wide range of normal for the fourth trimester. Understanding there is more than one right way to achieve goals, we must then encourage the expectant mother to be resourceful and creative in developing alternative ways to meet those goals. An approach to discussing the role of a postpartum wellness plan coincides when postpartum home care is addressed.

With an overall learning outcome to increase the confidence of childbearing families in their ability to make informed decisions throughout pregnancy, birth, and early parenting, childbirth educators can utilize the Six Healthy Birth Practices (Lamaze International, 2018) as an essential educational foundation for expectant mothers and their partners. Healthy Birth Practice # 6 addresses a health transition from birth to baby by speaking to the importance of keeping mother and baby together. Further identified are normal physical and emotional changes, healthy lifestyles, post-birth warning signs, perinatal mood disorders, connecting with the healthcare provider, and community and family resources.

Based on the premise that one's perception to control their health drives their action to find and use knowledge related to health and well-being (Moshki, Beydokhti, & Cheravi, 2013), a postpartum action plan is a possible fit to ensure positive coping as an interactive tool for discussion. After the Healthy Birth Practice content is presented, expectant parents can brainstorm needs, barriers and solutions, knowing the next step would be to personalize a plan specific to their needs. The needs of the expectant mother/couple, personal preferences, and goals should inform a wellness action plan (Barrecheguren & Bourbeau, 2018). The plan outlined in Figure 1 is based on addressing postpartum stressors (Park et al., 2015) like sleep deprivation, breastfeeding, and mothering, and calls for the expectant mother/couple to identify and utilize reliable sources of social support like family, friends, coworkers or classmates, and care providers to lessen the impact of such stressors over the fourth trimester (Support Inventory).

Often, having a couple who has recently given birth share face-to-face what it is like to live with a newborn is a reality check for expectant parents. Sharing learned lessons from what worked well and what did not may serve as a motivation to prepare actively for the postpartum period. Rather than waiting to address a constellation of fourth trimester issues, consider progressively developing a wellness plan each week of childbirth preparation classes or consider offering a separate class devoted to postpartum survival using an action plan approach

Wellness plans are becoming more prevalent as a self-care strategy in managing chronic illnesses more effectively and helping individuals and families to move toward health. Using an integrated model of health behavior and promotion will assist in determining the validity, reliability, and effectiveness of the plan. Investigating the use of action planning for postpartum wellness is a necessary step to establish the validity and reliability of an action plan by designing studies to determine if the wellness plan mitigates the stress of the fourth trimester. Care providers—childbirth educators, in particular—may want to consider using and evaluating a wellness plan to assist expectant mothers/couples in transitioning to parenthood. Sharing ideas, strategies, and suggestions through online blogs like Lamaze International: Science and Sensibility (Lamaze International, 2019) or Connecting the Dots are excellent ways for childbirth educators to dialogue and improve this quality outcome for expectant mothers and their partners.

Childbirth educators and providers (Verbiest, Tully, & Stuebe, 2017) are challenged to link health promotion constructs to measurable outcomes of success (Jones et al., 2014) in the fourth trimester. However, this association can improve our understanding of the complexities and needs of the emerging family, beyond labor and birth, ultimately mitigating the stress associated with the postpartum period.

Biography

JANE S. SAVAGE is a registered nurse with extensive experience in labor and birth and postpartum. Jane has been independently teaching Lamaze preparation since 1978, is certified by Lamaze International and teaches Lamaze Childbirth Preparation at Ochsner-Baptist Hosptial, New Orleans, LA and graduate nursing for Simmons University, Boston, MA. Her program of research involves perinatal mood disorders and disaster; she also served as a clinical nurse researcher for an ANCC Magnet recognized hospital.

DISCLOSURE

The author has no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

FUNDING

The author received no specific grant or financial support for the research, authorship, and/or publication of this article.

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