Bleeding after birth (lochia)

Why does bleeding after birth happen?

Every new mum bleeds after having her baby (lochia), whether the birth was vaginal or by caesarean section.

Most of the bleeding is from where the placenta comes away from the wall of your womb (uterus), but it can also come from any cuts and tears caused when your baby is being born (RCOG 2013).

Straight after the birth, the bleeding can be heavy, but it gradually gets less and less over the following days and weeks.

The bleeding starts off as bright red and then over the next few days it changes colour and becomes browner as your womb heals and returns to its pre-pregnancy size (Kansky 2016).

The bleeding should have stopped altogether by the time your baby is about six weeks old (Kansky 2016).

The flow will gradually become less, but if you try to do too much too soon, it may start flowing again. If your bleeding gets heavier or it changes colour, after exercise, for example, it's a sign that you need to slow down (NHS 2016).

If you're breastfeeding it can make the bleeding redder or heavier. You can also get cramps like period pain, called after-pains. This happens because breastfeeding causes your womb to contract (UK DH 2016). After-pains can be more intense if you've had twins or more. You can ease the pain with ibuprofen, which is a non-steroidal anti-inflammatory (NSAID) (Deussen et al 2011).

Do I need to do anything about the bleeding?

Not really. Just stock up on maternity pads. Two or three packs of 12 should do.

Don't use tampons until you've had your six-week postnatal check. While your vagina and womb are still healing, using tampons (or menstrual cups) could increase your chances of getting an infection (NHS 2017).

You may need to change your pad every hour or two to start with, then every three hours or four hours in the coming days and weeks.

Always wash your hands before and after changing your pad (NHS 2015), to reduce the chances of infection.

You may also have a wound between your vagina and back passage (perineum). You'll need to keep this part of your body clean to prevent infection there as well. Take a bath or shower at least once a day, and change your maternity pad regularly (NCCPC 2006).

Some mums like to add salt to their bath water, but your wound will heal just as well with clean water alone (Fernandez and Griffiths 2012).

When should I call my midwife or doctor?

There are two important times to get medical advice after you've just had a baby:

• if you start to bleed very heavily
• if you think you may have an infection

Sometimes, bleeding that's much heavier than normal lochia happens. This is called postpartum haemorrhage (PPH).

PPH can happen within 24 hours of giving birth (primary PPH), or between 24 hours and 12 weeks after the birth (secondary PPH) (RCOG 2016).

Primary PPH can develop if your placenta doesn't come away from your womb properly, if you have an injury during birth or if your womb doesn't contract down properly after you've delivered the placenta (Harding 2015).

Secondary PPH is usually caused by an infection (Harding 2015).

If you have postpartum haemorrhage you can lose 500ml or more of blood very quickly and can need urgent treatment (RCOG 2016). If you bleed heavily in the 24 hours after your baby is born, you're likely to be in hospital, in which case you'll be treated quickly by the staff there. If you're at home and you start to bleed heavily, call an ambulance if:

• The bleeding suddenly becomes very heavy, and soaks more than one pad an hour.
• The bleeding becomes persistently fresher (bright red) and heavier four days or more after giving birth, even after you rest.
• You pass lots of large blood clots that are bigger than a 20-cent piece.
• You start to feel faint or dizzy.
• Your heart starts to race, or your heartbeat becomes irregular.
  (Marchant 2009, NCCPC 2006)

What treatment you need for postpartum haemorrhage will depend on what's causing it. Treatments include:

• Your midwife or doctor massaging your womb through your belly to stimulate a contraction.
• Having an injection to help your womb contract.
• Medicines to help stop the bleeding.
• A blood transfusion and fluids through a drip.
• An operation to stop the bleeding, often to remove fragments of placenta that have not passed out.
  (RCOG 2016)

Once you're getting the right treatment for postpartum haemorrhage, you should recover completely. But it may take time, good care and rest for you to recover fully.

You should call your midwife or doctor if you develop the symptoms of an infection too. The main symptoms are:

• pain in the lower part of your abdomen (tummy) and your groin
• lochia that has an unpleasant smell
• a fever and/or chills, and generally feeling unwell
• headache
  (Moldenhauer nd)

Make sure you know all the postnatal symptoms you should never ignore.