How much bleeding is normal after having a baby?

Immediately Postpartum

Immediately postpartum, the healthcare team should closely evaluate both the birthing person and baby for any complications, including abnormal bleeding.1 According to the American College of Obstetricians and Gynecologists (ACOG), blood loss ≥500 mL immediately after vaginal delivery and ≥1,000 mL for cesarean delivery is considered abnormal and prompt evaluation should take place.2 Both ACOG and American Family Physician practice guidelines advise that a physical examination of the uterus, cervix, vagina, vulva, and perineum can help identify the etiology of excess bleeding.1,2

ACOG defines postpartum hemorrhage as cumulative blood loss ≥1,000 mL or bleeding accompanied by symptoms of hypovolemia within 24 hours after the birth process regardless of the route of delivery. Hypovolemia may include tachycardia, hypotension, tachypnea, oliguria, pallor, dizziness, or altered mental status. However, hypovolemia in pregnant and postpartum patients does not present until after considerable blood loss, so guidelines advise that abnormal postpartum bleeding and postpartum hemorrhage be recognized well before the onset of these signs and symptoms.

There are different ways to measure postpartum blood loss, namely visual estimation, quantitative methods involving the weighing of blood-soaked materials and subtracting their dry weight, and certain software options that assess pictures of blood collected in canisters. Studies in clinical have found that quantitative methods are more likely to accurately detect postpartum hemorrhage than visual estimation. A 2011 study was conducted among 150 women who gave birth vaginally in Saudi Arabia with the aim of measuring the accuracy of blood loss measurement methods.3 When comparing gravimetric calculation of postpartum blood loss to obstetrics nurses’ and physicians’ visual estimates, the numbers were significantly different (304.9 ± 114.9 mL quantitatively, 213 ± 86.2 mL nurses’ visual estimate, 214.3 ± 88.1 mL physicians’ visual estimate). The level of inaccuracy of the estimated postpartum blood loss was assessed to be about 30%. In the clinical setting, ACOG recommends using quantitative methods over visual methods for measuring blood loss.4,5

While visual estimates can be inaccurate, a 2004 study of 53 medical professionals using simulated blood-soaked materials found that educational interventions can improve accuracy.6 Pre-intervention, the median estimate for a drape soaked with 350 mL of blood was 250 mL with a median percent error of -29%. Post-intervention, the median estimate was 355 mL with a median percent error of 1%.

Lochia

Lochia is defined as vaginal bleeding during the postpartum period.7 After delivery, whether vaginal or cesarean, birthing persons experience vaginal bleeding for 3-8 weeks, sometimes stopping and restarting. Lochia has traditionally been divided into three phases: lochia rubra (initial phase during which lochia is comprised of red-brown blood), lochia serosa (secondary phase during which lochia is brown-pink), and lochia alba (final phase during which lochia is yellow-white).8,9 Lochia begins as a flow of blood and rapidly diminishes to reddish brown, becoming lochia serosa within about four days postpartum.7 Lochia serosa, which lasts a median of 22-27 days, is mucopurulent and has been described as malodorous.

There can also sometimes be heavier bleeding when the placental eschar sloughs 7-14 days postpartum.7 Myometrial vessels present for up to two weeks postpartum can cause short episodes of heavy bleeding for 1-2 hours. While bleeding or spotting for up to eight weeks after delivery is normal, if patients experience excessive bleeding, they should seek medical attention. There are no consensus statements or practice guidelines regarding what is considered excessive bleeding. ACOG’s Alliance for Innovation on Maternal Health (AIM) education initiative and the Center for Disease Control and Prevention (CDC)’s HEAR HER campaign list heavy bleeding as soaking through one or more pads in an hour or passing clots bigger than an egg, although neither of these resources substantiate these estimates. It appears to be based on a 1999 study seeking to identify the characteristics of normal lochia that defined heavy bleeding as saturating a pad within one hour.9

Pads are recommended for catching lochia, which allows for a general assessment for the amount of bleeding.7 If there are no perineal, vaginal, or cervical lacerations and the delivery was otherwise uncomplicated, tampons can be used if the patient is comfortable with their use.

A 2012 meta-analysis of 18 studies found that lochia lasted on average from 24-36 days.10 A 1999 study of 39 women who delivered vaginally found that the average duration of lochia was 36 ± 7.5 days (range 17-51 days, median 37 days).9 A 1986 study (n=236) in the United Kingdom found that the overall duration of lochia was a median of 33 days with rubra lasting for a median of four days and serosa 22 days.8 At 42 days postpartum, 15% of participants still had serosa and 4% continued to have serosa at 60 days.

A 1999 World Health Organization prospective longitudinal study investigated postpartum bleeding and lochia in 4,118 breastfeeding mothers from seven countries.11 The median duration of lochia was 27 days (range 22-34 days). Approximately 11% of women had lochia for more than 40 days, and 20.3% of women reported experiencing another bleeding episode at around 40 days postpartum. About 11% of women experienced a bleeding episode within 56 days of delivery separated from their initial lochia by at least 14 days.

In 1997, a study was conducted in Manila, Philippines, to compare the length and characteristics of postpartum bleeding among 477 nursing mothers. The median length of lochia was 27 days (range 5-90 days), with 46.3% of participants still experiencing bleeding four weeks postpartum dropping to 9.8% at six weeks and 2.5% at eight weeks.12 Lochia frequently stopped and restarted, with 26.4% of women experiencing a stoppage of bleeding for at least four days followed by another bleeding episode.

One of the first studies on lochia, conducted in 1951 in a Philadelphia hospital on 40 patients, found that the average discharge per pad ranged from 3-10 g for 65 hours before reaching a peak of 40 g after 80 hours.13 Another peak of 30 g occurred at 120 hours, after which discharge decreased to 2-5 g. Those aged 16-20 had the least discharge, while those 40-45 had the most. Discharge was lower at night than during the day, when patients were more active. There was not a significant difference in lochia volume between vaginal and cesarean birth.

References

1. Evensen A, Anderson JM, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. American family physician. Apr 1 2017;95(7):442-449.
2. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstetrics and gynecology (New York 1953). 2017;130(4):e168-e186. doi:10.1097/AOG.0000000000002351
3. Al Kadri HM, Al Anazi BK, Tamim HM. Visual estimation versus gravimetric measurement of postpartum blood loss: a prospective cohort study. Arch Gynecol Obstet. Jun 2011;283(6):1207-13. doi:10.1007/s00404-010-1522-1
4. Quantitative Blood Loss in Obstetric Hemorrhage: ACOG COMMITTEE OPINION, Number 794. Obstet Gynecol. Dec 2019;134(6):e150-e156. doi:10.1097/aog.0000000000003564
5. Alliance for Innovation on Maternal Health: Obstetric Hemorrhage Patient Safety Bundle. American College of Obstetricians and Gynecologist; 2022.
6. Dildy GA, 3rd, Paine AR, George NC, Velasco C. Estimating blood loss: can teaching significantly improve visual estimation? Obstet Gynecol. Sep 2004;104(3):601-6. doi:10.1097/01.Aog.0000137873.07820.34
7. Isley MM. Postpartum care and long-term health considerations. Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021:459-474.e4:chap 24.
8. Oppenheimer LW, Sherriff EA, Goodman JD, Shah D, James CE. The duration of lochia. Br J Obstet Gynaecol. Jul 1986;93(7):754-7.
9. Sherman D, Lurie S, Frenkel E, Kurzweil Y, Bukovsky I, Arieli S. Characteristics of Normal Lochia. American journal of perinatology. 1999;16(8):0399-0402. doi:10.1055/s-1999-6818
10. Fletcher S, Grotegut CA, James AH. Lochia patterns among normal women: a systematic review. J Womens Health (Larchmt). Dec 2012;21(12):1290-4. doi:10.1089/jwh.2012.3668
11. The World Health Organization multinational study of breast-feeding and lactational amenorrhea. IV. Postpartum bleeding and lochia in breast-feeding women. World Health Organization Task Force on Methods for the Natural Regulation of Fertility. Fertility and sterility. 1999;72(3):441-447.
12. Visness CM, Kennedy KI, Ramos R. The duration and character of postpartum bleeding among breast-feeding women. Obstetrics and gynecology (New York 1953). 1997;89(2):159-163. doi:10.1016/S0029-7844(96)00482-6
13. Bernstine JB, Bernstine RL. LOCHIA: A QUANTITATIVE STUDY. Obstetrical & gynecological survey. 1951;6(5):650-651. doi:10.1097/00006254-195110000-00004