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Introduction

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The word puerperium is derived from Latin—puer, child + parus, bringing forth. Currently, it defines the time following delivery during which pregnancy-induced maternal anatomical and physiological changes return to the nonpregnant state. Its duration is understandably inexact, but is considered to be between 4 and 6 weeks. Although much less complex compared with pregnancy, the puerperium has appreciable changes, some of which may be either bothersome or worrisome for the new mother. Importantly, several complications can develop, and some are serious.

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The puerperium may be a time of intense anxiety for many women. Some mothers have feelings of abandonment following delivery because of a newly aimed focus on the infant. Kanotra and colleagues (2007) analyzed challenges that women faced from 2 to 9 months following delivery. A third of these new mothers felt the need for social support, and 25 percent had concerns with breast feeding (Table 36-1).

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TABLE 36-1Pregnancy Risk Assessment Surveillance System—PRAMS.a Concerns Raised by Women in the First 2–9 Months Postpartum
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Involution of the Reproductive Tract

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Birth Canal
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Return to the nonpregnant state begins soon after delivery. The vagina and its outlet gradually diminish in size but rarely regain their nulliparous dimensions. Rugae begin to reappear by the third week but are less prominent than before. The hymen is represented by several small tags of tissue, which scar to form the myrtiform caruncles. Vaginal epithelium begins to proliferate by 4 to 6 weeks, usually coincidental with resumed ovarian estrogen production. Lacerations or stretching of the perineum during delivery may result in vaginal outlet relaxation. Some damage to the pelvic floor may be inevitable, and parturition predisposes to urinary incontinence and pelvic organ prolapse. This is discussed in detail in Chapter 27 (Route of Delivery).

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Uterus
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The massively increased uterine blood flow necessary to maintain pregnancy is made possible by significant hypertrophy and remodeling of pelvic vessels. After delivery, their caliber gradually diminishes to approximately that of of the prepregnant state. Within the puerperal uterus, larger blood vessels become obliterated by hyaline changes, are gradually resorbed, and are replaced by smaller ones. Minor vestiges of the larger vessels, however, may persist for years.

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During labor, the margin of the dilated cervix, which corresponds to the external os, may be lacerated. The cervical opening contracts slowly and ...

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