by Dr. Kymberlee Lake

Most women know that there may be some bleeding after giving birth but often women are surprised by how much and how long and they aren’t aware of the difference between postpartum bleeding and discharge and menstruation. The first bleeding after you give birth is called lochia.

What exactly is lochia? 

Lochia is the discharge consists of blood from the area on the uterine wall to which the placenta was attached during pregnancy, the sloughed off endometrium (uterine lining which makes a bed for the fetus) which gets considerably thickened during pregnancy, blood and mucus from the healing cervix,  and dead (necrotic) tissue. Your blood volume increases by approximately 50% in pregnancy, all that extra blood also has to go somewhere after birth. Most women will experience blood and lochia discharge for 3- 6 weeks though that time span can very from pregnancy to pregnancy and can be directly influenced by a healing mother’s activity level.

Why do we have lochia and where does it come from?

The blood in the lochia comes mainly from the large raw area left in the uterine wall after the placenta detaches from it. While bleeding from this area is controlled by contraction of the uterine muscles immediately after delivery, it takes on the average about two weeks for this area to heal. It is important to remember that this is a wound and it is possible to do too much before it has healed and reopen the wound, causing fresh bleeding. You will experience this bleeding for around four to six weeks postpartum.

For the first few days it will be a heavy flow (kind of like a heavy period) and will be  colored dark red, with some clotting.  About the end of the first week the flow should start to taper off, becoming lighter in saturation and color; as time passes, it will fade to a brown, yellowish or even almost-white discharge. 

One thing to remember is that the placental area as well as the sites of sloughing endometrium are raw and open during this time and bacteria can easily spread from the vagina. So, the use of tampons should be avoided – sanitary pads are the best options to be used during this time. 

What is normal and when should I be concerned?

You might notice a ‘gush’ of blood with clotting when you stand up – this is very normal. Also, if you’re breastfeeding, you might notice that you lose more blood after feeding baby; this is caused by your hormones doing their work to help shrink your uterus back to it’s pre pregnancy size. The lochia is sterile for the first 2-3 days but then becomes colonised by bacteria giving off a typical distinct lochial smell which is normal and should not be confused with the bad odor from lochia in postpartum infection.

If the discharge smells foul, you’re still noticing a lot of blood loss after the first four weeks, or the blood is bright red, these are signs of infection and you should speak to your health care provider as soon as you can. This is especially true if you also have a fever (no matter how slight)  or are generally feel ill. Likewise, if your blood loss is so heavy that you’re going through more than a pad an hour, you should get medical help immediately – this can be a sign of a hemorrhage. If in question and something feels “off” it is worth a call to your health care provider for advice.

Types of Lochia

Depending on the color and consistency, lochia can be of three types:

• Lochia Rubra: Lochia rubra occurs in the first 3-4 days after delivery. It is reddish in color – hence the term ‘rubra’. It is made up of mainly blood, bits of fetal membranes, decidua, meconium, and cervical discharge.
• Lochia Serosa: The lochia rubra gradually changes color to brown and then yellow over a period of about a week. It is called lochia serosa at this stage. The lochia serosa contains less red blood cells but more white blood cells, wound discharge from the placental and other sites, and mucus from the cervix.
• Lochia Alba: The lochia alba is a whitish, turbid fluid which drains from the vagina for about another 1 – 2 weeks. It mainly consists of decidual cells, mucus, white blood cells, and epithelial cells.

Do women who give birth by c-section still have lochia?

Many women believe that the flow of lochia is less after a cesarean section since the uterine cavity is cleaned out after the birth of the baby. This is not true. The flow of lochia is not dependent on the type of delivery –  The amount and duration is the same in both cases.

Return of Menses

There’s no hard rule as to when your period will return post-baby – it can vary from woman to woman, and pregnancy to pregnancy. Here are some general guidelines:

• Women who bottle-feed can see their menstrual cycle return within six weeks of birth – and most will have menses back by ten to twelve weeks.
• Women who exclusively breastfeed may not get their period back for some time. When you breastfeed, you body releases the milk-producing hormone prolactin, which, in turn, keeps our levels of progesterone and estrogen low. Progesterone and estrogen are the hormones responsible for signaling ovulation and menstruation. Night nursing directly effects these levels, a decrease in breastfeeding at night may lead to a return of menses.

Once your period returns, it can take even longer for it to get into a regular cycle. If you are bottle feeding it can take around six months, while exclusively breastfeeding your baby can take 12-18 months. But keep in mind that this does vary from mom to mom and pregnancy to pregnancy. Even with exclusive breastfeeding on demand and no artificial nipples, there are women who see a return of their menses as early as 6 weeks while others may not breastfeed and still experience a considerable delay. Each woman is different. Some women experience lighter flows and/or less cramping with their menses after having a baby, others experience the same, and still others may experience an increase. The range of normal variations is considerable but very heavy bleeding, soaking a full size pad in 1-2 hours, may indicate a problem and should be addressed with your health care provider. There are a variety of factors that contribute to possible changes with the return of your period but keep in mind that diet, physical activity, and your menstrual products can all contribute to cramps and duration.

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Please be aware that your first egg (ovulation) will be released two weeks before your period starts, so if you have unprotected sex without realizing that you are ovulating, you could get pregnant before you have even began menses again. It’s a good idea to speak to your healthcare provider about contraception even before you start thinking about sex again, so you can be confident in your choice ahead of time.

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Kymberlee is a Physician/midwife, Therapeutic foster/adoptive parent with 6 kids ranging in age from 31 to 3 and three grandchildren. She is living life to the full with MS in the Pacific NorthWET.  As an international travel enthusiast and fan of teleportation you can find her under the name “Dr_Kymberlee” live streaming and on social media, or on her often neglected blog, TheMamaMidwife.com