What I Wish I’d Known About the “Fourth Trimester”

Something was not right.

Seven weeks after the birth of my son, Sam—a 23-hour ordeal, including 3.5 hours of pushing, that ended in an emergency cesarean section—I ran two miles. An hour or two afterward, a disturbingly heavy pressure settled deep in my lower abdomen. It felt as if I’d just jostled all my internal organs out of place, like giving a box of puzzle pieces a good shake, and they were now jockeying for position on top of my pubic bone. Maybe that’s normal for the first time out, I told myself. But when the discomfort lasted for the next three days, I knew “normal” was not the right word.

In hindsight, running that soon was a terrible idea. And yeah, part of my decision to do it was hubris: Like plenty of other outdoorsy Colorado women I know, I’d cross-country skied and hiked while pregnant and—when I couldn’t do those activities anymore—swam laps up until the week before Sam’s birth. I figured that since I’d stayed in shape during pregnancy, of course I would bounce back quickly. I’d also specifically asked my obstetrician at the standard six-week postpartum checkup if I could resume my regular workouts, and he’d immediately given his blessing.

For several weeks after that run, I gingerly tried getting back into my pre-baby activities. I’d been strong and fit before getting pregnant and was eager to recapture that feeling. But hiking brought on some of the same pelvic discomfort, especially when I was hauling a heavy pack on my back. Certain weight-lifting moves, like lunges and squats, were equally unpleasant. And running…forget about it. Even the everyday task of schlepping Sam around in his bucket car seat was more challenging than I’d expected.

The lasting pain finally made me nervous that something was really wrong. I brought it up to my general practitioner, who felt my stomach and promptly diagnosed “diastasis recti,” or separated abdominal muscles (picture the six-pack muscles unzipping down the middle, vertically). Up to 60 percent of new moms have the same issue—caused by the massive belly-stretching that goes on during pregnancy and the hormonal changes that loosen connective tissues within the body—at six weeks postpartum. My OB hadn’t checked for it, and I hadn’t known to ask. It’s likely the separation, and resulting general core instability, was contributing to my workout woes.

Turns out, I was in good company. Chronic postpartum health issues like these are rampant among new moms. The huge hormonal shifts of pregnancy and breastfeeding, combined with the physical marathon of labor and delivery, can put significant stress on the body, resulting in weakened pelvic floor muscles (the ones that support the uterus, bladder, and rectum—and the ones a mom uses to push out a baby) and stretched-out abs. And all that can manifest as not only the exercise-induced pelvic pain I was having, but also in lower back pain, urinary or fecal incontinence, sexual dysfunction, and—in rarer cases—a prolapse in which the uterus or bladder starts to slip down into the vagina.

“The vast majority of women have no idea that A, these things are even possibilities, and B, they are something that’s not normal and can be managed,” says Amy Osborne, a physical therapist who specializes in pelvic floor rehab at Denver’s N2 Physical Therapy.

I didn’t go into baby-making blind; I’d read the books and checked the apps on pregnancy and childbirth, yet none of these issues was on my radar. We hear plenty of chatter about fitting back into our pre-pregnancy jeans but almost nothing about how giving birth can take a long-lasting toll on physical function. I thought I might look a little different—and truly, my belly button has never been the same—but I figured I’d be back to my old self in terms of what my body could do within a month or two, tops. As I was discovering, that was a bit ambitious. “I really encourage women not to expect this ‘bounce back’ thing—it’s BS,” says Cassandra Selby, a certified nurse midwife with the Women’s Clinic of Northern Colorado in Fort Collins. “You’re in a serious recovery time, and you need to be patient with your body.”

I wasn’t alone there either: “In Colorado in particular, women are really eager to get back to working out,” Osborne says. “They’re like, ‘I’ve got to get back on my bike, gotta get back to skiing.’ A Colorado woman is not going to want to hear me say, ‘I don’t want you going out for more than 30-minute walks for the first six weeks.’”

Postpartum physical complications take many women by surprise—but what’s worse, when they do crop up, many of us don’t realize we can do something about them. “You just accept that after you have a baby, your body is different,” says Jen Steir, a certified nurse midwife with Banner Health in Fort Collins. “ Women have problems with leaking urine or with their backs hurting. A majority of women dismiss these issues as the new norm, but they don’t have to be.” Embarrassment can also contribute to the problem, preventing a new mom from admitting that she pees when she sneezes or that sex hurts.

Luckily, my primary care doctor was plugged into a network of physical therapists who specialize in pelvic floor health. By 12 weeks postpartum, I was in a therapist’s office, learning how to isolate my transverse abdominal muscle to help pull the gap under my navel back together and practicing a suite of Kegels (so many Kegels). For the next few months, I squeezed in daily targeted exercises between full-time work and parenting.

For many women, this type of therapy, plus time and patience, is all it takes to get back into reasonable shape. And the sooner new moms get into physical therapy, the better the chances of healing quickly—making early postpartum intervention especially important. Untreated, diastasis recti can lead to or intensify pelvic floor problems such as incontinence and lower back pain and get worse in subsequent pregnancies. Plus, common core exercises like crunches actually make the gap wider; women who don’t know they have diastasis can make it worse while trying to firm up their abs.

So why didn’t my OB bring any of this up at my checkup? Turns out, many don’t. These issues tend to be glossed over for a variety of reasons: OBs need to cover everything from breastfeeding to postpartum depression to infant care to how well a C-section incision is healing in what’s often just a 30-minute appointment. Over the past few decades, OBs have been making an effort to view postpartum care more holistically, but many doctors tend to prioritize looking for more serious problems, such as blood clots. And: “I hate to say it like this, but to some degree, if it were thousands of years of men having babies, it might have been addressed better,” Steir says. Midwives tend to do better discussing these postpartum problems, she adds, in part because they typically spend more time with their patients than OBs do.

Change, however, could be coming. “The American College of Obstetricians and Gynecologists [ACOG] has begun to recognize that the postpartum course of evaluation after women give birth has been inadequate for most women,” says Dr. Julie Scott, a clinical associate professor of maternal fetal medicine at the University of Colorado School of Medicine. “We’ve thought of pregnancy as three trimesters and focused all our care on getting a mom safely through pregnancy with a healthy newborn. [Now] they’ve realized that a lot of problems occur during the postpartum period.” To wit: ACOG issued guidelines this past May recommending more thorough care during what is now called the “fourth trimester,” or the three months that follow the delivery of a baby. The new guidelines include at least one more doctor’s visit at three weeks postpartum and more discussion with moms about potential issues such as emotional well-being, sleep, and birth control.

After a few months of diligent rehab exercises, my pelvic floor muscles were regaining strength—and though high-impact activities such as running still made me sore, the pressure was less intense, and recovery came faster. Unfortunately, though, my diastasis recti has proved stubborn, and the gap remains. I switched therapists and started visceral manipulation, a specific type of abdominal massage that has shown promise in treating the issue. That therapy helped narrow the split a bit, but I’m still working on it. Lengthy recovery time is one last postpartum element I didn’t expect: Sam is now almost a year and a half, but my therapists tell me that a year-plus rehabilitation time is not uncommon. Would I have had better luck if I hadn’t leapt back into workouts so soon after childbirth, or if I’d known about the possibility of these issues sooner? Perhaps.

I haven’t given up hope, though. By early July of this past year, I’d worked up to a 5.5-mile hike through the Medicine Bow Mountains with my 20-plus-pound son on my back. I still didn’t feel like my old self; 5.5 miles used to be a warmup for me. But we were outside, we were both healthy, and I was on the road to recovery. Baby steps can still add up to big miles.