The Fourth Trimester — Wellness Guide

As referenced in the New York Times via

Alexandra Sacks MD
7 min readMar 14, 2018


To feel well as a new mother and care for your baby, you need to take good care of yourself — physically, socially, intellectually, and emotionally. It’s important to stay in touch with how you normally experience rest and pleasure; all-giving with no-taking becomes no fun. Mothering requires you to nurture others with your body and energy, which is why you need time to recover from childbirth, and to nourish yourself.

Think about your life before baby. What were the most physically and emotionally essential parts of your day? Start off with the simple things: sleeping, eating, exercise (when you’re ready), grooming, going outside, and getting dressed. Then expand to more social or outward activities, like texting your best friend, taking a salsa dance class, tending your garden, or going to church. Make a list of your favorites and place it somewhere visible, like your fridge, so you have a constant reminder of the activities and routine you need to connect to your pre-motherhood identity and new motherhood wellness.

Postpartum wellness is also connected to physiology and neurobiology. The hormonal shifts (estrogen, progesterone, oxytocin) of pregnancy and the postpartum impact women in different ways depending on their unique biology and other factors. Up to 80% of mothers experience symptoms of “The Baby Blues” in the first 14 days after delivery; these are mild symptoms of worry, restlessness, irritability, loneliness, mood swings and sensitivity that cause only mild discomfort, go away on their own, and are thought to be a natural hormonal reaction and not part of an illness. If your symptoms are more severe, started before labor and delivery, or you have a history of depression, you may be one of the 15% of mothers who experience Postpartum Depression.


Breastfeeding is one of the most emotionally charged issues in new motherhood, making it one of the most fraught experiences for new mothers. While there are many physical and psychological benefits of breastfeeding for some women, others may experience discomfort in both body and mind. Furthermore, breastfeeding may also be associated with more sleep deprivation (if you’re the only one who can feed the baby in the middle of the night.) Sleep deprivation impacts the brain, and, from what I see in my office, is amongst the greatest psychological stressors on women in The Fourth Trimester. If you’re exclusively breastfeeding, consider pumping milk and asking for help with at least one of the nighttime feeds so that you can get at least four consecutive uninterrupted hours of sleep. Alternately, supplementing with or even switching entirely to formula allows someone else to take over one or two of the night feeds so you can get a longer stretch of sleep. Whether and how much you breastfeed is a personal decision: trust your instincts and your body, and pay attention to whether breastfeeding is a net positive or net negative for you. If you decide or need to switch to formula and are feeling disappointed, try not to judge yourself (or your baby) as “failing.” When asked if breastfeeding is best, my colleagues and I like to tell families that “fed is best.” And if you’re worried about bonding with your baby, you and your partner can experience the bonding hormone oxytocin from skin to skin contact if you’re not breastfeeding. Switching to or supplementing with formula doesn’t hurt babies — in fact, it is the healthier choice in certain situations.


You’re going through matrescence, your psychological birth as a mother, and like adolescence, this is a time of hormonal fluctuation, body morphing, and identity shifting. Know that you don’t have to always love the work of motherhood to love your baby. Know that the baby you’ve imagined (and perhaps emotionally bonded with) in your mind during pregnancy may feel different from the baby you’re meeting now. And know that dramatic body changes may also impact your identity and routine. It can be disorienting if you are not yet able to sleep, use the bathroom, have sex, exercise, or even walk with ease. It can also be very easy to feel critical of yourself and your body, so try to remind yourself that these physical changes were essential to growing a baby, and that is something to be proud of. Give yourself time (I recommend at least 12 months) to return to your prior shape if that is a goal, or enjoy your new shape as is. For some women, experimenting with maternity clothing can help with identity affirmation and self esteem.

Matresence can be a disorienting and isolating experience. To find support and solidarity, speak honestly with other moms (especially your friends!) about your experiences face to face and on social media to make motherhood unfiltered. Remember that the perfect is the enemy of the good-enough mother, and that the idealization of the goddess-myth will make you and other mothers feel like they can’t measure up.

You and Your Partner

This is the moment when your family goes from a pair to a trio and you will have to renegotiate your roles to include the baby, both physically and psychologically within your home and your lives. You and your partner may find that caring for your baby leaves less energy to put into your relationship with each other. Again, it sounds obvious, but not when you’re both exhausted and longing for more support and attention. It’s easy to start feeling of rejected and resentful, so even when your needs — or the baby’s needs — are obvious to you, your partner may not see what you see. Ask for help directly.

It can certainly be challenging for a primary caretaker to share control around parenting decisions, especially when they are the one who is spending more time on childcare and making more personal and professional sacrifices. Remember you’re a team. If your partner is doing well, you’re doing well. Even when you’re parenting as a team, disagreements will arise. You may need to spend more time educating each other about how you were raised (family roles, financial choices, disciplinary style, educational values, culture around eating and food, how affection was expressed and arguments negotiated — or not). You may be surprised by your differences of perspective and learn new things about your partner’s history and childhood warm memories and wounds.

Let’s not forget about sex. It may feel like a competition between you, your partner, and the baby for a limited resource: you. Even the most empathic partner may feel rejected if you are newly uninterested sexually. If you’re not ready for sex, expand your idea of intimacy — maybe it’s cuddling or kissing, or a few minutes of talking about something other than the baby, that will reinforce and strengthen your relationship during this challenging time. You may not realize how important your sexual connection is for communication in your relationship until it goes away.

Family and Friends

Parenthood is intergenerational. This means that becoming a parent provides a beautiful opportunity for a do-over — to repeat what your parents did well, and improve on what they did not. But this intensity may lead you to feel extra-emotional or revisit complex childhood memories. Your parents may also experience their own psychological transitioning to grandparenthood and that too may affect your relationship. For some, it’s challenging to defer to your authority as a new parent. In other cases, seeing how your parents lavish love on their grandchild can leave you feeling neglected. Some patterns are hard-set, but others will shift in surprising ways. Sibling rivalries, experiences of loss, and setting boundaries with in-laws may also intensify and require emotional attention. If you no longer live near your parents/extended family but would like their help, discuss the pros and cons with your partner and consider asking for them to stay for a prolonged visit. Whether the visit is long or short, be prepared that family may give solicited or unsolicited advice with the intention of being helpful, but may come across as judgmental or critical. Your parenting instincts may be different from (or a reaction to) theirs — follow your own gut.

When it comes to friends, you may be too tired to stay out late, unable to drink, or unable to get childcare — or you just might not want to. You may have to cancel plans at the last minute, or cut short a visit or phone call. But if you stop socializing with other adults entirely, you may narrow your circle of support and feel disconnected to the person you were before motherhood. Most new parents are nervous about their own choices (especially because there’s no one “right” way) and some are competitive when defending their approach because they’re just trying to make themselves feel more secure. It may help to share aspects of parenting that make you feel vulnerable to create a more authentic context and welcome your friends who are parents to also reveal their own struggles and concerns. My hope is that new parents can continue speaking openly about the natural transitions of matrescence and other postpartum adjustments, so please pass along this guide and offer support to anyone else who might benefit.

This advice is oriented towards women who have been physically pregnant. However, it is not meant to exclude any family structures including single and divorced, married and unmarried, and LGBTQ mother/fathers/parents and those who have gone through surrogacy/reproductive technology, adoption, and many other paths. For more writing on the many topics that aren’t included in this piece, such as single motherhood, work/family balance, childcare, and the financial and sociocultural demands of parenthood today, please sign up for my newsletter.

Finally, this guide is not a substitute for proper professional/medical advice or care. For resources, call your doctor/provider or consult Postpartum Support International.

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Alexandra Sacks MD

Reproductive Psychiatrist / Parenting Contributor @NYTimes / Book Author “What No One Tells You” | Podcast Host @GimletMedia’s “Motherhood Sessions”