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CHAPTER 36: The Puerperium

Although the changes occurring during the puerperium are considered as physiological, they border very closely upon the pathological, in as much as under no other circumstances does such marked and rapid tissue metabolism occur without a departure from a condition of health.

—J. Whitridge Williams (1903)

INTRODUCTION

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 as stated above by Williams (1903), and some of these may be either bothersome or worrisome for the new mother. Kanotra and colleagues (2007) analyzed challenges that women faced from 2 to 9 months following delivery. The Pregnancy Risk Assessment Surveillance System—PRAMS—of the Centers for Disease Control and Prevention (2016) listed concerns of new mothers that are shown in Table 36-1. At least a third of these women felt the need for social support, and 25 percent had concerns with breastfeeding.

TABLE 36-1Pregnancy Risk Assessment Surveillance System—PRAMSa Concerns Raised by Women in the First 2–9 Months Postpartum
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TABLE 36-1 Pregnancy Risk Assessment Surveillance System—PRAMSa Concerns Raised by Women in the First 2–9 Months Postpartum
Concerns Percent
Need for social support 32
Breastfeeding issues 24
Inadequate education about newborn care 21
Help with postpartum depression 10
Perceived need for extended hospital stay  8
Need for maternal insurance coverage postpartum  6

aCenters for Disease Control and Prevention, 2016.

Data from Kanotra S, D’Angelo D, Phares TM, et al: Challenges faced by new mothers in the early postpartum period: an analysis of comment data from the 2000 Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Matern Child Health J 11(6):549, 2007.

REPRODUCTIVE TRACT INVOLUTION

Birth Canal

Return of the tissues in the birth canal 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. The vaginal epithelium reflects the hypoestrogenic state, and it does not begin to proliferate until 4 to 6 weeks. This timing is usually coincidental with resumed ovarian estrogen production. Lacerations or stretching of the perineum during delivery can lead to vaginal outlet relaxation. Some damage to the pelvic floor may be inevitable, and parturition predisposes to urinary incontinence and pelvic organ prolapse.

Uterus

The massively increased uterine blood flow necessary to maintain pregnancy is made possible by significant hypertrophy ...

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