Lochia

December 14, 2007

Bleeding and Delivery: 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.

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