Although the changes occurring during the puerperium are considered as physiological, they border vey closey upon the pathological, in as much as under no other circumstances does such marked and rapid tissue metabolism occur without a departure rom a condition of health.
-J. Whitridge Williams (1903)
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.
Return of the tissues in the birth canal to the nonpregnant state begins soon ater delivery. he 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. he hymen is represented by several small tags of tissue, which scar to form the mytom caunces. 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 loor may be inevitable, and parturition predisposes to urinary incontinence and pelvic organ prolapse.
The massively increased uterine blood flow necessary to maintain pregnancy is made possible by signiicant hypertrophy and remodeling of pelvic vessels. After delivery, their caliber gradually diminishes to approximately that of the prep regnant state. Within the puerperal uterus, larger blood vessels become obliterated by hyaline changes. They are gradually resorbed and replaced by smaller ones. Minor vestiges of the larger vessels, however, may persist for years.
During labor, the margin of the dilated cervix, which corresponds to the external os, may be lacerated. The cervical opening contracts slowly, and for a few days immediately after
The Puerperium 653
TABLE 36-1 . Pregnancy Risk Assessment Surveillance System-PRAMSa Concerns Raised by Women in the First 2-9 Months Postpartum
Help with postpartum depression 10 aCenters for Disease Control and Prevention, 201n6. Data from Kanotra 5, D'Angelo 0, 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,n2007.
labor, it readily admits two ingers. By the end of the first week, this opening narrows, the cervix thickens, and the endocervical canal re-forms. The external os does not completely resume its pregravid appearance. It remains somewhat wider, and typically, ectocervical depressions at the site of lacerations become permanent. These changes are characteristic of a parous cervix (Fig. 36-1). Cervical epithelium also undergoes considerable remodeling. This actually may be salutary because almost half of women have regression of high-grade dysplasia following delivery (Ahdoot, 1998; Kaneshiro, 2005).