The Fourth Trimester Guidebook: Postpartum Nutrition

8 minute read

fourth trimester, postpartum, postpartum nutrition

Medically reviewed by Amy Fathman, DNP, FNP-BC

This is the first installment in our Postpartum Guidebook series.

If you’re pregnant or have had a baby recently, you might have heard the phrase “the fourth trimester.” Often, the phrase accompanies a plea for women to honor this time as one of rest, healing, and appreciation of their bodies. But that’s not easy in a culture that urges women to “get their pre-baby bodies back” as soon as possible, in a society that wants postpartum women to go back to work almost immediately, or in a healthcare system that frankly pays little attention to the unique health needs of a mother once her baby is no longer inside of her.

This article will be the first in a three-part series about the fourth trimester that will tackle what it is, what is happening within a woman’s body during this time, and the importance of protecting the fourth trimester as much as one possibly can despite the challenges. In this first installment of our “Fourth Trimester Guidebook,” we’ll be tackling the subject of postpartum nutrition.

First off, what is the fourth trimester?

The phrase “fourth trimester” first gained popularity thanks to pediatrician Dr. Harvey Karp in his book, The Happiest Baby on the Block. In the strictest definition, the “fourth trimester” refers to the first twelve weeks after the baby’s birth, a time of significant physical, hormonal, and emotional adjustment for a mom, plus major developmental changes for her baby. Some postpartum resources even go a step further, like Allison Auth’s Baby and Beyond: Overcoming Those Post-Childbirth Woes, and emphasize the importance of the whole first year after a baby’s birth for both mother and child.

The most important thing to remember about this time is that your nutritional, physical, and emotional needs don’t disappear just because you are no longer pregnant; they change, but they are just as important as they were when your baby was still inside of you. This is especially true of your nutritional needs.

Postpartum nutrition: Nourishing yourself well during this time is just as important as during your pregnancy

While there’s much ado about what mothers should (or shouldn’t) eat during pregnancy, very little attention is paid to the nutritional needs of new mothers after their babies are born. Fortunately, there are a few excellent resources you can seek out for yourself on this topic. Among those are: Marilyn Shannon’s book Fertility, Cycles, and Nutrition, registered dietitian Lily Nichols’ book Real Food for Pregnancy, women’s hormone expert Alisa Vitti’s book In the Flo, and the above-mentioned Baby and Beyond by Allison Auth.

Did you know that nutritional needs for breastfeeding moms are even higher during the postpartum period than they were during the pregnancy, translating to about 500 additional calories needed per day for the first six months? According to Nichols in Real Food for Pregnancy, this is because in addition to continuing to grow the baby (now outside the womb), the breastfeeding mom is also recovering from the energy and overall nutritional depletion of the labor and delivery process.

Good postpartum nutrition also aids in wound healing, which is important for every new mother; not just those who breastfeed. You may already know that after you deliver your baby, the wound left behind by the placenta’s detachment (regardless of which route your baby came out) can be up to the size of a dinner plate (that wound, by the way, is the reason for the postpartum discharge known as lochia)! Along with healing that area, you may need to recover from an episiotomy or stitches after a natural tear, a Cesarean section scar (in which case you are quite literally healing from a major abdominal surgery), and more.

Focus on “warming foods” for their healing benefits during the fourth trimester

Both Nichols and hormone expert Vitti encourage all postpartum women to consume what traditional cultures, especially South American and Asian cultures, consider “warming foods.”

Vitti writes, “Think bone broth, liver pate, red meat, warm oatmeal, avocados, whole eggs, and coconut oil. This is not the time for salads, smoothies, or raw fruit–nothing cold!” (Vitti, 294). This obviously refers to foods served hot, such as stews, broths, and curries, but could also, according to Nichols, mean warm drinks like herbal teas and spices that are considered warming like cinnamon and ginger. Warming foods are often made from and in animal products, which contain high amounts of protein and the amino acids that form the building blocks to make protein, and are essential for wound healing. Warm liquids like bone broth contain electrolytes and fluid that replace labor losses. Animal meats also restore iron levels depleted due to blood loss.

Nichols offers a logical rationale for this emphasis on warm foods, such as meat slow-cooked in bone broth or other liquid for hours, rather than cold fruits, raw veggies, etc. The warm, cooked foods are naturally easier to digest, and so provide ready energy. For her part, Nichols recommends “soups, hearty stews, and curries made with bone broth” as well as “high-iron foods, such as slow-cooked meat (think pot roast or pulled pork) and organ meats, such as liver, kidney and heart.” She also suggests “high-fat foods, like pork, butter/ghee, fatty fish, nuts/seeds, etc.” plus “foods rich in omega-3 fats, such as seafood, eggs, and grass-fed beef.” As mentioned above, she advocates for “soft-cooked vegetables (instead of raw veggies or salads)” and “well-cooked grains/starches such as oatmeal, rice, or sweet potatoes (eaten alongside plenty of fat and protein to provide enough energy and stabilize your blood sugar).” (Nichols, 225)

Similarly, Marilyn Shannon emphasizes in Fertility, Cycles, and Nutrition, that “high-quality protein and natural fat in the diet are the most important of the major nutrients for milk production,” in no small part because “50 percent of the calories that breast milk provides come from fats.” Shannon was a big proponent of fish oil or flax oil supplements specifically to ensure adequate maternal intake of the omega-3 fatty acid DHA, which is not only vital for baby’s brain development during pregnancy but also postpartum.

Don’t let yourself reach “nutritional rock-bottom,” for your health and your baby’s

If you don’t take care of yourself during the fourth trimester and the rest of the postpartum time period, you may not notice it right away, especially if you are young and otherwise healthy. But sooner or later, it will probably catch up to you. In Baby and Beyond, Auth notes that in her experience following the births of each of her first four children, she experienced “nutritional rock-bottom” when each child was closer to their first birthday. Her body’s nutritional stores were gradually depleted by breastfeeding. Thankfully, she noticed substantial positive changes when she modified her diet and added supplements specifically intended to boost her levels of the B vitamins, Vitamin D, Magnesium, Zinc, DHEA, and the essential omega-3 fatty acids EPA and DHA.

Nichols notes that maternal nutritional intake matters for breastfeeding moms because while breast milk will always contain enough “calories, protein, folate, and most trace minerals,” even if the mom is undernourished, breast milk concentrations of “Vitamins B1, B2, B3, B6 and B12, vitamins A,D and K, choline, fatty acids (such as DHA) and trace minerals (such as selenium and iodine)” are proportionate to what the mom actually takes in. (Nichols, 230) So, good nutrition postpartum isn’t just for your benefit–but your baby’s, too!

A note about birth control and nutrient depletion

Most women will not hear any of this important information about their health and nutritional needs at their single standard postpartum follow-up visit. However, most (if not all) women are pressed about what birth control they plan to use, either to space pregnancies or permanently avoid pregnancies.

Natural Womanhood recently addressed some of the issues postpartum women using long-acting reversible contraceptives (LARCs) like an IUD or an implant have experienced, such as decreased milk supply and increased incidence of mood disorders (during a time when women are already at increased risk for developing a mood disorder or experiencing worsening symptoms of an existing mood disorder!). On the nutritional front, birth control can also do more harm than good: studies show that birth control use is significantly linked to important nutritional deficiencies.

In fact:

Since at least the 1970s, researchers have known that use of the Pill is associated with depleted levels of such essential nutrients as vitamins C, B2, B6, and folate [1]. More recently, hormonal birth control use has also been shown to have an association with depleted levels of vitamin E and the minerals magnesium, selenium, and zinc [2]. Studies have also indicated a link between birth control use and inflammatory bowel diseases and poor gut health [3].
(Source: “Hormonal Birth Control Depletes Your Body of Key Nutrients,” by Grace Emily Stark at Natural Womanhood)

Clearly, the fourth trimester can be an especially problematic time to begin birth control!

The good news is that contraceptives are not your only option for spacing pregnancies or postponing pregnancy, because as Natural Womanhood has previously covered, “ just as before you were pregnant, your body is producing observable signs that can be interpreted to indicate what’s going on with your fertility and your overall health.” (More specifics on finding the best postpartum fertility awareness method for you are here.)

It’s no secret: Many mothers in America are woefully underserved while postpartum

A 2018 committee opinion put out by the American College of Obstetricians and Gynecologists (ACOG) noted some of the issues specific to the fourth trimester, and the ways that our modern medical paradigm does not address those issues. With the one-size-fits-all approach of a single follow-up visit after labor and delivery at 6 weeks postpartum, many women can feel left by the wayside.

The ACOG paper reads: “In addition to being a time of joy and excitement, this ‘fourth trimester’ can present considerable challenges for women, including lack of sleep, fatigue, pain, breastfeeding difficulties, stress, new onset or exacerbation of mental health disorders, lack of sexual desire, and urinary incontinence.” Unfortunately, the authors note, “for many women in the United States, the 6-week postpartum visit punctuates a period devoid of formal or informal maternal support.“

The most important thing to remember about this time is that your nutritional, physical, and emotional needs don’t disappear just because you are no longer pregnant; they change, but they are just as important as they were when your baby was still inside of you.

But while the committee opinion advocated for postpartum care becoming “an ongoing process, rather than a single encounter,” not much has changed in postpartum care. Despite the noted “intense focus on women’s health prenatally,” care during the fourth trimester in 2022 remains as the ACOG paper stated in 2018: “infrequent and late.”

But it doesn’t have to be this way, Moms. We can, and should, demand better care. Our health and wellbeing does not become inconsequential just because our babies are no longer inside of us. With this postpartum guide on nutrition, and with our forthcoming guides on postpartum exercise, and mental health and emotional wellbeing, we hope we can be part of bridging the gap in care for new moms after their babies are born.

Here are Part 2 and Part 3 of our Postpartum Guidebook series.