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6 Sexuality During andAfter Pregnancy
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Changes andPotential
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Complications During Puerperium
FilipeCordeiro andMónicaGomes-Ferreira
7
Take-Home Points
• The puerperium is dened as the period of
6–8weeks after delivery, in which the reversion of anatomical and physiological changes
seen during pregnancy happens.
• The important physiological events that occur
during the postpartum period include, among
others, the return of the reproductive organs
and the levels of the female hormones to their
pre-pregnant state.
• It is important that mothers are informed of
what normally happens during this period, and
about the danger signs which can compromise
the health of the mother or the newborn.
7.1 Introduction
The puerperium corresponds to a variable period
of time in which there are several phenomena of
a hormonal, psychic, and metabolic nature that
characterize the readaptation of the female organism (altered by pregnancy and childbirth) to the
nonpregnant state [1].
F. Cordeiro (*)
Obstetrics and Gynaecology, Hospital São Francisco
de Xavier—Centro Hospitalar de Lisboa Ocidental,
Lisbon, Portugal
M. Gomes-Ferreira
Department Obstetrics and Gynecology,
MS Medical Institutes, Lisbon, Portugal
e-mail: info@drmonicagomesferreira.com
7.2 Denition ofthePostpartum
Period
The puerperium is dened as the period of
6–8weeks that begins after delivery, in which the
regression of anatomical and physiological
changes seen during pregnancy occurs. However,
this denition is purely conceptual, as it is known
that not all systems return to their basal state
within this range [1].
In a practical way, three periods can be
considered:
– Immediate puerperium: rst 24h
– Early puerperium: from the rst to the seventh
day
– Late puerperium: after the seventh day
7.3 Postpartum Findings
andChanges
7.3.1 Uterus
The uterus is an organ that shows expressive
growth during pregnancy, so after the discharge,
it gradually returns to its normal size. This process, known as uterine involution, is mediated by
a set of strong and rhythmic contractions in which
the muscle bers undergo a progressive shortening Myometrial retraction (brachystasis) [2].
These can often be perceived by the puerperal
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_7
123
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F. Cordeiro and M. Gomes-Ferreira
woman as painful, being more frequent in the
rst days, and intensied by breastfeeding, a consequence resulting from the production of oxytocin (Fig.7.1).
The contraction of muscle bers around the
existing vessels in the myometrium, as well as
the thrombosis of the placental vessels, also promotes a blood transfusion process, which thus
limits the hemorrhage of the uterine scar where
the placenta was located.
After delivery, the uterus is at the level of the
umbilical scar, assuming a reduction of approximately 1cm/day. It is completely intrapelvic in
about 2 weeks and will reach its prepregnancy
status in 6weeks [2].
Fig. 7.1 Uterusmammary reex
In parallel with the reduction in volume, there
is also a reduction in weight. After delivery, the
uterus weighs approximately 1000g; at the end
of the rst week, it is halved, and it returns to its
basal state (60–100g) after 6weeks [2].
The uterine involution process can be affected
by several factors, such as uterine overextension
(e.g., twin pregnancy), multiparity, cesarean
delivery (uterus is slightly larger), and breastfeeding (uterus is smaller in those who breastfeed) [2].
On physical examination, a well-involuted
uterus is considered if it assumes the characteristics referring to the size mentioned above for the
determined time interval, as well as when it
- Stretch of the uterus and
the uterine cervix
- Mechanical stimulation of
the nipples of the breasts
1
Hypothalamic neuron
Hypothalamohypophysial
Increased
uterine
contraction
tract
2
Posterior pituitary
3
Oxytocin
4
Milk released
from breast
7 Changes andPotential Complications During Puerperium
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125
acquires a rm consistency. When it combines
these characteristics, it is often called a safety
globe (by Pinard).
Ultrasound assessment is not routinely recommended, as it is common to see hyperechogenic
material inside, which has no indication for
removal, except in situations where fever or
heavy bleeding occurs [2].
Take a Note
Uterine involution is faster in breastfeeding
women. The suction performed by new-
borns stimulates the release of oxytocin by
the neurohypophysis, which in turn pro-
motes milk ejection and uterine contractil-
ity. This process is usually referred to as the
uterus-mammary reex.
7.3.2 Lochia
After placental separation, there is exposure of
the decidua.
The decidua is divided into two layers: supercial (which akes) and deep (regenerates new
endometrium). The most supercial layer is
weakened and becomes irregular, suffering
necrosis, being eliminated in the form of lochia
[2].
According to the temporal evolution and in a
schematic way, we can consider [2]:
– Hematic lochia (lochia rubra): until the fth
day (fragments of decidua and erythrocytes)
– Sero-hematic lochia (lochia serosa): from the
fth to the tenth day
– Serous lochia (lochia alba): after the tenth day
(leukocytes)
Hormonal contraceptives containing estrogen
and/or progesterone do not appear to inuence
the characteristics of lochia.
Take a Note
Microscopically, lochia is formed by deciduous fragments, epithelial cells, erythrocytes, leukocytes, and bacteria. If the
patient has had a c-sectio, is more likely to
have less abundant lochia.
Persistent hematic lochia >2 weeks
accompanied by uterine subinvolution
should raise the hypothesis of placental
retention.
7.3.3 Cervix
Similarly to the uterine body, the cervix also
loses its pregnancy characteristics.
After delivery, the cervix is thin and soft in
consistency, but as a result of contractions, it
becomes thicker, allowing the restoration of the
cervical canal. The diameter of the cervical canal
also undergoes a signicant reduction, and after
2days, it will only be permeable to two ngers,
and after a week, it will no longer allow digital
exploration [2].
The external orice never takes on the same
punctiform conguration typical of the prepregnancy state, adopting the aspect of transverse slit
from birth (Fig.7.2) [2].
Stroma edema and cell inltration are
changes found histologically for up to 3months.
For this reason, the evaluation in the context of
fetal losses only makes sense after the third
month.
The total volume of lochia is estimated at
approximately 200–500 mL over a period of
1month.
The duration of discharge is variable, and in a
small percentage of cases (15%), it can exceed
6–8weeks of puerperium [2].
Changes in volume and duration can often be
seen in women with changes in hemostasis.
7.3.4 Vagina
In the immediate postpartum period, the vagina
loses its soft consistency and undergoes a reduction in its diameter, acquiring its usual characteristics around the third week. Mucosa folding and
mucus production are later restored in lactating
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Fig. 7.2 Cervical changes after pregnancy
F. Cordeiro and M. Gomes-Ferreira
women, since they depend on the action of estrogens, whose production is reduced during breastfeeding [2].
7.3.5 Vulva
The remaining fragments of the hymen give rise
to small protrusions, known as myrtiform
caruncles.
The trauma and stretching of the fascia
induced by vaginal delivery cause a relaxation of
the pelvic muscles, which can acquire a persistent character in the postpartum period, giving
rise to dysfunctions of the pelvic oor [2].
7.3.6 Abdominal Wall
Abdominal distension seen during pregnancy,
particularly if accompanied by excessive weight
gain, leads to a marked reduction in the tone of
abdominal muscles, which may not be fully
restored several months after delivery. The weakening and removal of the rectus abdominis are the
most obvious pathological alteration, which is
known as diastasis. In addition to the resulting
aesthetic problems, pain should not be underestimated, which is a frequent manifestation of this
process [2].
7.3.7 Breast Engorgement
After delivery of the placenta, there is an important decrease in the production of steroid hormones that reduce the blockage of the mammary
gland to the action of prolactin. As a consequence
of this process, milk secretion begins, which
gives the breast greater volume and consistency
(breast engorgement) that is often associated
with edema and pain [2].
Primary breast engorgement occurs between
the rst 24 and 72 h after delivery, due to the
occurrence of interstitial edema and the increase
in milk production. The painful symptoms seem
to be more intense between the third and fth
days after delivery.
Secondary breast engorgement occurs when
the emptying of the breast is lower than the rate
of milk production (Fig.7.3). For this reason, frequent breast emptying is important, usually never
longer than an interval of 4h, in order to minimize the discomfort generated by increased milk
production (Fig.7.4) [2].
During milk production that occurs after
childbirth, it is common to notice a slight transient hyperthermia that is usually self-limiting
and can be relieved with supportive therapy (local
heat, massage, or even painkillers).
Suppression of lactation, whether indicated by
medical pathology (e.g., maternal HIV infection)
7 Changes andPotential Complications During Puerperium
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Fig. 7.3 Breastmilk
engorgement
Not Engorged Engorged
Fig. 7.4 Milk ejection
reex
127
128
ANAGEN PHASE CATAGEN PHASE TELOGEN PHASE (Resting Phase) TELOGEN PHASE (Exogen) EARLY ANAGEN PHASE
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F. Cordeiro and M. Gomes-Ferreira
or by the patient’s expressed desire not to breastfeed, can be achieved by the absence of breast
stimulation and the use of a tight bra and eventually the use of medical therapy (dopamine analogues) [2].
7.3.8 Skin andSkin Attachments
Skin hyperpigmentation is frequent in pregnancy,
being more evident in certain regions of the body,
such as the face (chloasma), mammary areolas,
white line, and vulva. The mechanism by which it
occurs is poorly understood; however, it is
believed to be related to the increase in the production of melanocyte-stimulating hormone
(MSH) [2]. The higher the phototype, the greater
the likelihood of hyperpigmentation. This darker
color completely disappears a few months after
delivery.
Stretch marks are other skin changes that
occur in pregnancy and correspond to solutions
of continuity of the dermis, which are formed
after rupture of the collagen bers that have suffered excessive water retention. They are preferably located on the breasts, abdomen, and thighs.
Initially, they are reddish in color, but in the puerperium, they become clear and bright. The
appearance of skin streaks has a strong association with genetic predisposition, in which estrogens are believed to play an important role [2, 3].
The incidence of stretch marks is higher in
women of young age, with a family history and
who have an excessive weight gain.
Peripheral vasodilation secondary to the state
of hyperestrogenism is responsible for the
appearance of other manifestations, such as palmar erythema and vascular spiders.
There are also important changes at the capillary level. It is known that about 5–10% of hair
follicles are in the telogenic phase (resting phase)
at the end of pregnancy and that this rate quadruples in the puerperium, which causes a signicant hair loss (telogenic efuvium) that it is only
restored about 6–15 months after delivery
(Fig.7.5). This appears to be due to the high levels of circulating estrogen.
7.3.9 Physiological Weight Loss
After delivery, an average weight loss of about
6 kg occurs, corresponding to the sum of the
weights of the fetus, placenta, and amniotic uid.
However, this weight loss is even more signicant due to the reduction in the volume of intravascular and interstitial uid, as well as resulting
from uterine contraction, which corresponds to
an additional loss that varies between 3 and 7kg
[2].
It is believed that there is a loss of about half
of the weight acquired during pregnancy in the
Fig. 7.5 Pregnancy changes at the capillary level
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