CLINICAL
Physiological changes
of the puerperium
By Julie M Harrison
T
he changes that take place during
the puerperium enable the reversal
of metabolic adaptations that
occurred in pregnancy. The pelvic organs
return to their non-pregnant state, and the
body prepares for the onset of lactation.
Traditionally, this is a period that extends
from the end of the third stage of labour
until the sixth to eighth week after delivery
(Sweet, 1997).
It is also a time of adjustment in which
the woman recovers from her labour and
the relationship with her baby becomes a
reality.
Although it has been thought that most
women experience few problems in the
puerperium, research by Glazener (1997)
identified that as many as 17 in every 20
women did have a health problem. In addi-
tion to this, life threatening complications
can still arise as illustrated in the
Confidential Enquiries into Maternal
Deaths in the United Kingdom (Department
of Health, 1998). This necessitates the con-
tinued attendance of a skilled practitioner.
The midwife’s role is unique in that she
has the opportunity to continue monitoring
progress, recognize abnormalities and
offer appropriate support and advice to
women and their families (UKCC, 1998). A
sound knowledge of the underlying physi-
ology is essential if the midwife is to
achieve this.
The aim of this article is to explore the
physiology of the puerperium and the rele-
vance of this to midwifery practice. The
physiology of lactation will be discussed in
a future article.
Involution of the uterus
The exact mechanism of uterine involution
is not entirely clear but may be caused by
the withdrawal of placental hormones
(Steer and Johnson, 1998). However,
ischaemia as a result of the collapse of
BRITISH JOURNAL OF MIDWIFERY, AUGUST 2000, VOL 8, NO 8
ABSTRACT
Remarkable changes take place during the puerperium, which enable the
woman’s body to revert to the non-pregnant state. This article focuses on
the physiology of the puerperium and illustrates how antenatal care and
management strategies used in labour influence the recovery of the
woman. Knowledge of physiology is essential if the midwife is to fulfil her
unique role in continuing to monitor progress, recognise abnormalities and
offer appropriate support and advice at this time.
blood vessels has been suggested as a pos-
Julie M Harrison is Senior
sible explanation for the rapid decrease in
Lecturer at the School of
size and weight (Montfort and Perez- Midwifery, Faculty of Health
Tamayo, 1961). Care Sciences, Kingston
Autolysis is the physiological process by University and St George’s
which involution of the uterus is achieved Hospital Medical School.
and involves the breakdown of intracellular
This article was accepted for
protein by the action of proteolytic and publication on 26 November
hydrolytic enzymes. This results in a 1999
decrease in the size of the myometrial cells,
which become shorter and thinner as the
hyperplasia of pregnancy is reversed
(Monheit et al, 1980).
Traces of fibrous elastic tissue remain as
evidence of the pregnancy and the pre-
pregnant dimensions of the uterus are
never quite reached. The largest decrease
in tissue mass and weight occurs during the
first week and by the twelfth day the uterus
is no longer palpable as a pelvic organ, and
by 6 weeks it has returned to the non-preg-
nant state (Figure 1).
More recent research on the puerperal
uterus using ultrasound (Lavery and Shaw,
1989) demonstrated that there was no cor-
relation between route of delivery and
speed of involution, although there was sig-
nificant correlation between birth weight of
the baby and uterine size.
Interestingly, the choice of infant-feeding
method does not appear to influence invo-
lution of the uterus. This indicates that
other factors are involved and, although
there are many benefits of breast-feeding,
483
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CLINICAL

this is not one of them (Rodeck and Newton,

1976; Lavery and Shaw, 1989).
In addition to this, Cluett et al (1997)
found considerable variability in the rate of
involution among women who have a nor-
mal puerperium, which led them to ques-
tion the practice of assessing uterine invo-
Uterus after delivery
lution by measuring the symphysis fundal
distance by using a tape measure — a prac-
tice intended to detect endometritis or
retained products of conception.
The lack of reliability of uterine palpation
in the detection of infection and retained
products of conception emphasizes the
importance of taking into account other
clinical signs when infection is suspected,
such as pyrexia and tachycardia.
It also highlights the significance of the
management of labour in relation to post-
partum events. Midwives (and obstetri-
cians) need to be aware that certain man-
agement strategies have been found to
increase the incidence of uterine infec-
tion, and that some women may be partic-
ularly at risk because of a lack of antena-
Uterus at 6th day
tal care or poor nutrition during pregnan-
cy (Table 1) (Faro, 1994). The Audit
Commission (1997) reiterated this theme
in its recent report First Class Delivery,
Improving the Maternity Services in
England and Wales, where it stated that:
‘postnatal health problems are closely
associated with particular interventions
during delivery’.

Endometrium regeneration
The dramatic decrease in uterine size that
occurs immediately after delivery brings
the uterine walls into close apposition and

Table 1. Risk factors for

endometritis

Non-gravid uterus Caesarean section

Surgical expertise of obstetrician

Ruptured membranes

Prolonged labour

Repeated vaginal examinations

Internal fetal monitoring

Poor nutrition

No prenatal care
Figure 1. Involution of the uterus (Miller et al, 1997)

484 BRITISH JOURNAL OF MIDWIFERY, AUGUST 2000, VOL 8, NO 8

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transforms the uterus into a hard globular
mass (Monheit et al, 1980). This has the
effect of applying pressure to the placental
site, a factor involved in the prevention of
haemorrhage.
The torn blood vessels, which supplied
the placenta, are constricted by the liga-
ture-like action of the oblique muscle
fibres of the myometrium (Miller et al
1997). This is promoted by the continued
action of the hormone oxytocin from the
posterior pituitary gland.
Immediately after delivery the diameter
of the placental site is reduced by half from
an average of 18 cm to approximately 9 cm
and is round or oval in shape (Anderson
and Davis, 1968).
The rough area of the placental site,
which is not covered with epithelium, is
evident (Sharman, 1952; Howie, 1995). It is
initially covered with a layer of decidua and
a surface layer of fresh blood clot, although
this soon becomes a fibrin mesh and throm-
bosis occurs.
Macrophages, polymorphs and lympho-
cytes arrive, forming a barrier beneath the
placental site which extends throughout the
endometrial cavity (Llewellyn-Jones, 1999).
Towards the end of the first week both
necrotic and viable tissue are apparent at
the site of placental attachment. The
superficial necrotic layer is sloughed off as
part of the lochia, but the deeper layer,
which contains the endometrial glands,
remains. It is from this that the new
endometrium develops.
A new layer of epithelium extends all
over the uterine cavity by 10 days, however,
the placental site takes longer to heal, up to
6–7 weeks (Anderson and Davis, 1968).
The lochia
The decidua is shed down to the basal
layer. The lochia is the discharge from the
uterus following childbirth which initially
consists of fresh blood from the placental
site and necrotic decidua (lochia rubra).
After about 4 days it becomes brownish-
pink in colour (lochia serosa) as the pla-
cental site begins to heal and finally it turns
yellowish white (lochia alba).
Oppenheimer et al (1986) in their study of
236 postnatal women found that the mean
duration of the lochia was 33 days, however,
BRITISH JOURNAL OF MIDWIFERY, AUGUST 2000, VOL 8, NO 8
in 13% of women it lasted up to 60 days.
They also found that it was shorter in mul-
tiparous women and those with smaller
babies.
More recently, Marchant et al (1999), in
their study of 524 postnatal women, found
that the mean duration of vaginal loss was
21 days, with an interdecile range
(10th–90th percentile) of 10–42 days. They
also found that the lochia were consider-
ably more varied in amount, duration and
colour than described in current midwifery
textbooks and health education literature.
As a result of this, leaflets have been
developed which provide women with more
realistic information on the likely range of
blood loss following childbirth which is
important not only for primigravidae, but
for all women to help them to know when
professional advice should be sought.
Cervix, vagina and perineum
At the end of the third stage of labour, the
cervix is oedematous and has little tone.
During the first week it rapidly reforms,
and there is a marked decrease in cervical
size (Bagley-Willms et al, 1995); however, it
does not resume its nulliparous appearance
as the entrance to the vagina remains wider
(Figure 2) and sometimes gapes (Miller et
al, 1997). The vagina is smooth and oede-
matous after delivery and has poor tone,
after 3 weeks the ruggae reappear.
Remnants of the hymen are present known
as the Carunculae myritiformes.
The perineum would have distended dur-
ing the delivery and will either have
Nulliparous cervix Parous cervix
Figure 2. The nulliparous and parous cervix (Reproduced from
Miller et al, 1997 with permission)
485
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CLINICAL
remained intact or have been lacerated and
‘
It is required suturing. Perineal pain is common
remarkable in the puerperium (Glazener, 1997) and not
only occurs in women with perineal trauma
how quickly the but also in those with intact perinea (Sleep,
woman’s body 1995). However, greater trauma and a high-
er risk of infection was found to be associ-
reverts to the ated with episiotomy although there was no
non-pregnant evidence of reduced trauma or urinary
incontinence at 10 days and 3 months (Sleep
state during
’
et al, 1984).
the puerperium Another important finding in this study
was that women who had an episiotomy
performed liberally to prevent trauma
resumed intercourse later than those in the
group who only had an episiotomy if fetal
distress occurred. This is a factor that could
affect the woman’s relationship with her
partner.
The urinary tract
A marked diuresis is a feature of the first
24–48 hours of the puerperium due to
falling levels of oestrogen following the
delivery of the placenta, which rapidly
decreases the plasma volume of the blood
to non-pregnant levels.
Although the exact mechanism for this is
not fully understood, it is thought that high
levels of oestrogen in pregnancy augment
the effects of the antidiuretic hormone, a
factor involved in the increase in blood vol-
ume (Hynes, 1999).
In addition to the increase in urine out-
put, larger quantities of nitrogen are pre-
sent in the urine because of the waste prod-
ucts of autolysis of the myometrium.
Water retention in the tissues may initial-
ly increase, causing a rise in body weight in
the first 2 days of the puerperium. This is
possibly related to rapid withdrawal of
progesterone temporarily unbalancing the
aldosterone-renin-angiotensin axis, which
in turn causes retention of water and sodi-
um (Howie, 1995).
While some of the changes related to the
urinary tract occur early in the puerperium,
others may take up to 3 months before the
non-pregnant state is achieved, especially
those caused by the effects of the hormone
progesterone, which led to dilation of the uri-
nary tract in pregnancy (Faundes et al, 1998).
However, this does not immediately
resolve postpartum, exposing some
486
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women to the continued risk of urinary
tract infection. Some women may experi-
ence difficulty with urination and may
have retention of urine in the early puer-
perium if bruising of the urethra or blad-
der neck has occurred during labour. Fear
of, or actual, perineal pain resulting from
trauma can also be a factor.
The cardiovascular system
The blood volume, which has increased in
pregnancy, decreases rapidly over the first
24 hours following a normal delivery, lead-
ing to a haemoconcentration and subse-
quent rise in haemoglobin level. It then
decreases at a slower rate during the
remainder of the puerperium (Duvekot and
Peeters, 1994).
Non-pregnant blood volumes are reached
by 6–9 weeks after delivery. However,
anaemia can still be present despite the
haemoconcentration if a postpartum haem-
orrhage has occurred or the woman was
anaemic before the delivery.
Patterson et al (1994) highlighted the
importance of treating anaemia in their
study of the effects of low haemoglobin lev-
els in the postnatal period. They found that
anaemia did have adverse effects on
women’s physical health and their ability to
cope with their baby, in that they experi-
enced breathlessness, tingling of the fingers
and toes, felt dizzy and had low energy lev-
els at ten days post delivery. They were also
more likely to have a painful perineum. The
problem of tiredness was still present at
6 weeks after delivery.
The cardiac output initially remains
raised for the first 24 hours and then falls
progressively until the tenth day (Hunter
and Robson, 1992), reaching normal levels
by 2 weeks. This is caused by a decline in
both the heart rate (which has increased by
approximately 15 beats per minute in preg-
nancy) and stroke volume (the amount of
blood pumped out by the ventricle with
each hearrtbeat).
The coagulation system is altered in
pregnancy and remains altered during the
puerperium, predisposing women to
thromboembolic disorders. Although fewer
women die as a result of this condition dur-
ing the puerperium than in the past
because of early mobilization, pulmonary
BRITISH JOURNAL OF MIDWIFERY, AUGUST 2000, VOL 8, NO 8
 CONCEPTS OF REFLECTION AND REFLECTIVE PRACTICE

embolism remains the single major cause
of maternal death in the UK (Department
of Health, 1998).
The majority of deaths reported in the
Confidential Enquiry into Maternal Deaths
in the UK 1994–96 (Department of Health,
1998) occurred postpartum, with 15 deaths
following caesarean section and 10 follow-
ing vaginal delivery. This was an increase
on the numbers of the previous triennia.
This has implications for postnatal care
and particularly care in the community, as
the majority of deaths occurred between
15–28 days after delivery.
In view of these findings, the
Department of Health made specific rec-
ommendations for midwifery practice, as
illustrated in Figure 3 (Department of
Health, 1998).
tends to be different, with less frequent
night feeds and the introduction of supple-
mentary feeds, which reduces the efficacy
of this physiological process and necessi-
tates additional methods of contraception.
Conclusion
While it takes up to 40 weeks for all the
physiological changes to occur in pregnan-
cy, it is remarkable how quickly the
woman’s body reverts to the non-pregnant
state during the puerperium. However, the
physiological changes or that occur in the
puerperium, cannot be seen in isolation,
but in relation to the events of pregnancy
and labour and as such are individual to
each woman.

The return of fertility Recognition of risk factors for venous thrombosis

The potential for fertility can return at what pulmonary embolism
may seem to most women as surprisingly
soon after delivery. Studies monitoring the
basal body temperature have indicated that
ovulation may occur as early as 4 weeks
after delivery. Screening for women at risk
However, Howie (1995) found that it was Previous history of thromboembolism
unusual before 5 weeks and more common- Family history of thromboembolism
ly occurred between 8–10 weeks postpar-
tum, and most non-breast-feeding women
would have ovulated and menstruated by
15 weeks following delivery.
Recognition of women at risk
Breast-feeding modifies the changes that
Bed rest before and after delivery
occur in the hypothalamic-pituitary-ovari-
Obesity
an axis, resulting in the hormone levels
and endometrium remaining in what Wang
and Fraser (1994) describe as a ‘static’
state. This has advantages for the baby and
can be seen as a protective mechanism in Educate women regarding symptoms requiring
that he is not supplanted at the breast by urgent medical attention
another sibling or his milk supply reduced
by the effects of a subsequent pregnancy.
Another advantage is that prolonging the
birth interval enables the woman to recov-
er adequately from the current pregnancy Recognition of symptoms requiring urgent referral
and care for her baby. Nevertheless, in Breathlessness
breast-feeding women, the return of ovula- Chest pain
tion and menstruation is variable as it is Calf pain
influenced by the duration and frequency of
suckling.
High levels of prolactin produced by fre-
quent suckling inhibit ovulation. However, Figure 3. Recommendations for midwifery practice in relation to the recognition of risk
in the Western world the feeding pattern factors for venous thrombosis and pulmonary embolism (Department of Health, 1998)

BRITISH JOURNAL OF MIDWIFERY, AUGUST 2000, VOL 8, NO 8 487

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CLINICAL
Midwives are influential as they provide
care which encompasses both the antena-
tal period and labour. As a consequence
they need to be aware of how different
management strategies affect the recov-
ery of the woman and her enjoyment of
the baby. This is an essential component
in the enhancement of the experience of
motherhood and the prevention of long-
term health problems. BJM
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KEY POINTS
■ Involution of the uterus is one of the most remarkable changes during
the puerperium.
■ Antenatal care and the management of labour influence the recovery
of the woman and the prevention of long-term health problems.
■ Knowledge of physiology is essential if midwives are to monitor
progress and recognize abnormalities.
■ Life-threatening complications can still arise during the puerperium.
488
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