The puerperium is the period of time encompassing the first few weeks following birth. The duration of this “period” is understandably inexact, and it is considered by most to be between 4 and 6 weeks. Although a relatively uncomplex time compared with pregnancy, the puerperium is characterized by many physiological changes. Some of these changes may be simply bothersome for the new mother, although serious complications can also arise.
Some mothers have feelings of abandonment following delivery because of a newly aimed focus upon the infant. Thus, the puerperium may be a time of intense anxiety for many women. To illustrate this, data gathered by the Pregnancy Risk Assessment Monitoring System—PRAMS—is informative. This on-going population based surveillance system was initiated in 1987 by the Centers for Disease Control and Prevention (2007a) to better understand why infant mortality rates had plateaued. The system collects data concerning maternal attitudes and experiences before, during, and shortly after pregnancy. Kanotra and colleagues (2007) analyzed data in a 10-state area in 2000 to assess challenges that women faced from 2 to 9 months following delivery. Their main findings are listed in Table 30-1.
Table 30-1. Pregnancy Risk Assessment Surveillance System—PRAMSa. Concerns Raised by Women in the First 2–9 Months Postpartum |Favorite Table|Download (.pdf)
Table 30-1. Pregnancy Risk Assessment Surveillance System—PRAMSa. Concerns Raised by Women in the First 2–9 Months Postpartum
1. Need for social support
2. Breast feeding issues
3. Inadequate education about newborn care
4. Help with postpartum depression
5. Perceived need for extended hospital stay
6. Need for maternal insurance coverage postpartum
Vagina and Vaginal Outlet
Early in the puerperium, the vagina and its outlet form a capacious, smooth-walled passage that gradually diminishes in size but rarely returns to nulliparous dimensions. Rugae begin to reappear by the third week but are not as prominent as 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 relaxation of the vaginal outlet. Some damage to the pelvic floor may be inevitable, and parturition predisposes to uterine prolapse as well as urinary and anal incontinence. This is a matter of great contemporaneous concern and is discussed in detail in Chapter 17, Laceration Risks and Morbidity.
The massively increased uterine blood flow necessary to maintain pregnancy is made possible by significant hypertrophy and remodeling of all pelvic vessels. After delivery, their caliber diminishes to approximately the ...