How do I manage lochia postpartum?

Management of Postpartum Lochia

Lochia is a normal vaginal discharge after childbirth that typically progresses through three phases (rubra, serosa, alba) and lasts approximately 4-6 weeks postpartum. Proper management involves understanding normal patterns, recognizing warning signs, and providing appropriate care.

Normal Lochia Characteristics

• The most common pattern (Type 1) involves progression from lochia rubra (red/red-brown) to serosa (brown-pink/brown) to alba (yellow/white), seen in approximately 51% of women and more common in breastfeeding mothers 1, 2
• Median total duration of lochia is approximately 27-36 days (4-5 weeks), significantly longer than the traditionally taught 2 weeks 3, 2, 4, 5
• Lochia rubra (red discharge) typically lasts about 4-12 days in the classic pattern 3, 2
• Lochia serosa (pinkish-brown discharge) typically lasts about 22 days 3
• Lochia may persist up to 60 days in approximately 13% of women 3
• Duration tends to be shorter in parous women and women with smaller babies 3

Assessment of Postpartum Lochia

When evaluating lochia, healthcare providers should assess:

• Emotional, physical, and general wellbeing of the mother 6
• Presence of uterine tenderness, abnormal lochia characteristics, or signs of inflammation 6
• Vaginal discharge or bleeding patterns that deviate from expected progression 6
• Perineal pain and hygiene practices 6

Warning Signs Requiring Medical Attention

• Sudden heavy bleeding or passing large clots after lochia has lightened 1
• Foul-smelling discharge, which may indicate postpartum endometritis 1, 7
• Fever >100.4°F (38.0°C) on more than two occasions >6 hours apart 1
• Severe abdominal pain or uterine tenderness 1
• Lochia that persists beyond 8 weeks postpartum 3, 5

Management Recommendations

1. Patient Education:

   • Explain the normal progression and expected duration of lochia (4-6 weeks) 2, 4
   • Teach patients to recognize the three phases: rubra, serosa, and alba 2
   • Inform patients that variations in patterns are common, including intermittent spotting or bleeding 4

2. Hygiene Practices:

   • Recommend frequent changing of sanitary pads 6
   • Advise proper perineal hygiene to prevent infection 6
   • Discourage use of tampons during the postpartum period to reduce infection risk 6

3. Monitoring:

   • Regular assessment of lochia amount, color, and odor during postpartum visits 6
   • Evaluation of uterine involution through abdominal examination 6
   • Assessment for signs of postpartum complications such as endometritis 6, 7

4. When to Seek Medical Care:

   • Instruct patients to contact healthcare providers immediately for heavy bleeding (soaking through a pad in less than an hour), foul odor, fever, or severe pain 1
   • Explain that some women (approximately 20%) may experience an "end-of-puerperium" bleeding episode around day 40 postpartum, which is generally normal 5

Special Considerations

• Breastfeeding women are more likely to follow the classic Type 1 pattern of lochia progression 2
• Women with higher parity may experience different lochia patterns (Type 2 pattern with prolonged rubra phase) 2
• Return of menses is rare among fully breastfeeding women in the first 8 weeks postpartum 4
• Approximately 11% of women may experience bleeding episodes within 56 days of delivery that are separate from lochia 5

By understanding normal lochia patterns and recognizing warning signs, healthcare providers can effectively manage postpartum vaginal discharge and promptly identify potential complications requiring intervention.