'4th Trimester' Problems Can Have Long-Term Effects On A Mom's Health

Melody Lynch-Kimery had a fairly routine pregnancy. But when she got to the hospital for delivery, she says, things quickly turned frightening.

After an emergency cesarean section, Lynch-Kimery hemorrhaged; she heard later she'd lost about half the blood in her body.

"I just kept thinking 'I'm not going to die. I'm not going to die. I'm not going to let you let me die,' " she says.

After that traumatic experience, Lynch-Kimery spent a week in the hospital. She went home with her newborn daughter, Sawyer, thinking her delivery complications were resolved.

Then, about three months later, she started to feel pain in her lower abdomen.

"Just randomly, one day I started to have a lot of burning," she remembers. "Just a lot of cramping — a lot of pain around my scar area."

She spent months seeing doctors and researching her symptoms online. The pain, she eventually learned, was likely caused by abdominal adhesions — scar tissue beneath and around her C-section incision.

About a third of all U.S. deliveries are by C-section, according to the Centers for Disease Control and Prevention.

"Anywhere from 6 to 18 percent of those [women] will end up with chronic pain in their scar," says Jennifer Wasserman, a physical therapist who studies chronic pain after C-sections.

Chronic pain is just one health concern women can struggle with after giving birth. Some, like Lynch-Kimery, who have complicated pregnancies or deliveries, can also see long-lasting effects to their physical and mental health.

Risks during pregnancy

Among developed countries, the United States has the highest rate of death among pregnant women and new mothers. And for every woman who dies, dozens more come close. Lynch-Kimery is biracial, and that's another risk factor, research suggests; among Americans of color, rates of maternal mortality in the U.S. are particularly high.

Many women who become pregnant already have chronic conditions like high blood pressure and obesity that can negatively impact their pregnancy and future health. Others develop health problems during pregnancy.

The two major pregnancy and delivery complications women face are pre-eclampsia (a condition marked by high blood pressure, swelling and signs of damage to the kidney or liver), and gestational diabetes — a form of the illness that develops during pregnancy.

"Both of these conditions are associated with basically a doubling in their lifelong risk for cardiovascular disease," says Dr. Lisa Hollier, president of the American College of Obstetricians and Gynecologists. "What we're seeing is that pregnancy can act as sort of a natural stress test."

Hollier says most complications of pregnancy ease after delivery. But some women see a long-lasting impact.

A 2017 review of studies found that women with gestational diabetes, pre-eclampsia and preterm delivery had higher risks of heart disease, diabetes and stroke.

"The fact that [a woman] has these complications during pregnancy ... can be used as a warning sign to her and to her physician that she is at future risk for long-term problems," Hollier says.

Mental health problems after a tough birth can be seen as a complication, too, she says.

"Some situations, like having a preterm birth of a baby that goes to the neonatal intensive care unit, are also associated with a mom developing postpartum depression," Hollier says.

"It's really important to be sure that a woman is receiving integrated care — so that her mental health is not seen as completely separate from her physical health."

Many moms neglect their own health after a baby's birth

One problem is that many women don't seek medical care in the busy months after delivery. Doctors generally advise new mothers to come back for a checkup between six and 12 weeks after giving birth. But 20 to 40 percent of women don't get to that appointment, studies suggest. And those rates of follow-up are even lower for mothers on Medicaid, who account for more than half of all births.

Other research suggests that 15 percent of women don't have a primary care doctor after delivery.

"Women who are young don't go to the doctor every year unless they've got a problem, so they're not being monitored," says Susan Groth, a nurse practitioner and associate professor in the school of nursing at the University of Rochester, in Rochester, N.Y.

With a grant from the National Institutes of Health, Groth and several colleagues have a longitudinal study in the works to examine how pregnancy affects a mother's health in the three years following delivery.

They hope to fill gaps in research that has, in the past, largely focused on just the first few post-birth months.

"The studies have not looked at women long enough to see what really changes over time," Groth says. "Does pregnancy make a difference in their health, or is that really just this incident that happens, and then everybody goes back to normal?"

Mind the "fourth trimester"

ACOG now recommends that women see their doctor three weeks after delivery — or sooner, if there have been complications.

"Women with high blood pressure, for example, are often seen within the first five to seven days after the delivery," Hollier says. "We really believe that to best optimize the health of women, the postpartum care should really be process — not a visit."

She and her colleagues say such care should continue throughout what they call the "fourth trimester."

During this period, doctors help women transition into more routine care and connect them to follow-up services, like physical therapy.

Lynch-Kimery now travels an hour from her home in Bloomington to Indianapolis every few weeks to see physical therapist Camille Fenwick.

"So, tell me how you been feeling since I've seen you last," Fenwick asks at the start of a recent appointment.

Lynch-Kimery tells the physical therapist the pain has been "on and off," recently. It's better, she says, after the stretching exercises Fenwick showed her. But the pain is worse when she exercises too long.

Fenwick lightly massages the 6-inch C-section scar on Lynch-Kimery's lower abdomen.

"I'm kind of going across that scar and getting those little muscles around it to help it to loosen up a little bit," Fenwick explains. She's checking for any little places that seem "kind of stuck," she says, and monitoring to see when and where Lynch-Kimery feels the pain.

After the exam, Lynch-Kimery stretches on an exercise ball and with a Pilates machine, working to strengthen her core abdominal muscles and pelvic floor.

She says she isn't sure how long she'll need physical therapy for the scar tissue pain, and the costs of the sessions add up. Those bills have kept her from seeking other needed postpartum care, she says — such as counseling to address the traumatic aspects of the delivery.

"I'd love to be free of it," she says. "I'd love to not have to worry about it." For now, she's focusing on her daughter and making the best of a health problem she never anticipated.

This story was produced by WFYI and Side Effects Public Media, a news collaborative covering public health.

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