Lochia
How much bleeding is normal after having a baby?
At first consideration this sounds
like a simple question; actually, it's a question that entails the entire
post-partum period--that six weeks we obstetricians call the "puerperum."
The uterus
is not only ingeniously designed to accept, then carry, then expel a pregnancy;
it is also designed to do it over and over again. After the placenta
comes out, the uterus undergoes a process called "involution,"
or shrinking. This is important, because the site on the inside of
the uterus where the placenta was is rich in blood vessels. Shrinking of
this site reduces the amount of surface area that can bleed.
Involution happens quickly.
There is bleeding, however, and it's bright red for a couple of days ("lochia
rubra"); by two weeks the weeping
effect doesn't have enough blood mixed with it to keep it red, and a pale
discharge is noted ("lochia
alba"). Generally, bleeding
should get less and less over time, but there can be some bursts of activity
for up to a month. But for the most part, most of the real bleeding
should be over within a few days. Any irregular bleeding after a
month is more than likely a result of the body trying to regroup hormonally.
And breast feeding will delay this
regrouping even longer, which aids (but doesn't guarantee) birth control.
The placental implantation
site doesn't just scar over during involution, otherwise it's surface area
would be a dead zone for future implantations (future pregnancies).
What actually happens is that its bed is separated and falls away as part
of the lochia. The tissue underneath it heals and pushes it away,
not unlike a scab that finally falls off. In this way, the number
of babies a woman can have isn't limited by the confluence of previous
areas of placental implantations.
Any bleeding more than a heavy
period should be reported to your doctor. There are serious problems
that can result in heavy bleeding or recurrent large clots. Keep
in mind, though, that a large clot is only the sudden passage of a clump
of partially clotted blood that's been collecting for some time.
What you're seeing may be a whole night's collection, with sudden vertical position upon rising allowing gravity
to cause it to fall out. But recurrent clots aren't normal.
Subinvolution
If there is abnormal involution
of the placental site, it can bleed because it hasn't shrunk ("subinvolution"),
because it's infected, or because there may be a chunk of placenta still
left on it, which can separate causing brisk bleeding. It used to
be thought that a quick D&C (scraping
the lining of the uterus to "clean" it) was indicated with heavy bleeding,
but now a more conservative mind set has evolved: A D&C may traumatize
the lining, jeopardizing subsequent implantation. Also, the piece
of placenta that caused the bleeding is probably washed away with the sudden
bleeding episode, curing itself. Lately, ultrasound has been used
to great advantage to indicate the need for D&C (when placental-like
impressions are seen on the scan).
Tenderness with or without
fever is never normal (not to be confused with cramping, or "after-birth"
pain). Inflammatory states can delay the normal healing and involution
processes, resulting in bleeding. In this case, antibiotics and medicines
to contract the uterus are indicated. (A D&C for this may do
nothing more than seed the bloodstream with the infection.)
Eating my words, in any of
these conditions D&C may still be necessary if heavy bleeding continues
in spite of the above management. Also, clotting studies should be
considered, since bleeding may be due to problems with the normal abilities
of the blood to clot, and not because of any problems with normal involution.
The typical puerperum
is marked by lochia rubra for a few days, growing paler as the lochia alba
by 10-14 days. Bleeding can occur off and on for up to six weeks.
An occasional clot is forgivable, but recurrent clots or significant bleeding
after the first few days should prompt an evaluation by your doctor.
