Is the passage of postpartum (after childbirth) blood clots as large as an orange considered normal in a postpartum woman?

Passing Blood Clots as Large as an Orange is NOT Normal and Requires Immediate Medical Evaluation

Blood clots as large as an orange during the postpartum period are abnormal and indicate postpartum hemorrhage requiring urgent medical assessment. While some small blood clots in the first few days after delivery are normal, clots of this size suggest excessive bleeding that may lead to life-threatening complications.1

Normal vs. Abnormal Postpartum Bleeding

What is Normal:

• Small blood clots during the first few days postpartum are expected, with initial bright red bleeding that gradually changes to brownish or yellowish discharge over the 6-week postpartum period.1
• Normal postpartum bleeding is heaviest in the first 24 hours and gradually decreases over time.1
• The volume of bleeding should progressively reduce throughout the 6-week recovery period.1

What is Abnormal (Your Situation):

• Clots as large as an orange represent excessive blood loss and meet criteria for postpartum hemorrhage, defined as blood loss ≥500 mL after vaginal delivery or ≥1000 mL after cesarean section.2
• Large clots suggest either retained products of conception (RPOC), vascular abnormalities like pseudoaneurysms, or subinvolution of the placental bed.1, 3
• This pattern of bleeding can indicate progression to severe hemorrhage, which occurs in approximately 2% of deliveries and carries significant maternal morbidity risk.2

Immediate Actions Required

Seek Medical Attention Now If:

• You are passing clots larger than a golf ball (and certainly as large as an orange).1
• Bleeding suddenly increases in volume or continues beyond what was initially experienced.1
• You experience severe pain, fever, or foul-smelling discharge alongside the bleeding.3
• You feel dizzy, lightheaded, or have signs of significant blood loss.2

What Your Healthcare Provider Will Do:

Initial Assessment:

• Obtain complete blood count, coagulation studies, and hemoglobin measurement to assess severity of blood loss.2
• Perform focused history regarding delivery mode (cesarean increases risk of complications), breastfeeding status, and associated symptoms.3

Diagnostic Imaging:

• Transvaginal ultrasound with color Doppler is the primary diagnostic tool, with 90-95% sensitivity for detecting retained placental tissue and 95-98% specificity for ruling out RPOC.3
• Doppler imaging identifies vascular complications like pseudoaneurysms (appearing as hypoechoic masses with turbulent flow) that require different management than RPOC.3
• If ultrasound is inconclusive and you are stable, CT angiography may be performed to localize bleeding sources.3

Common Causes of Large Clot Passage

Retained Products of Conception (Most Common):

• RPOC is the most common cause of late postpartum hemorrhage, occurring in 24-88% of women after cesarean delivery but also after vaginal delivery.3
• Presents as heavy bleeding with large clots, often with severe pain.3
• Treatment involves ultrasound-guided gentle suction curettage with 80-90% success rate when RPOC lacks significant vascularity.3

Vascular Abnormalities:

• Pseudoaneurysms or arteriovenous malformations can cause intermittent heavy bleeding with large clots.3
• Uterine artery embolization is first-line treatment for pseudoaneurysm with >90% success rate for controlling hemorrhage.3
• Critical pitfall: Never perform blind digital examination before excluding vascular abnormalities with imaging, as this risks perforation or catastrophic bleeding.3

Subinvolution of Placental Bed:

• Failure of normal uterine involution leads to persistent bleeding.3
• May respond to tranexamic acid 1g IV/PO three times daily for its antifibrinolytic effect.3

Timing Considerations

Early Postpartum (First 24 Hours):

• Large clots in this period indicate primary postpartum hemorrhage requiring immediate medical attention.1
• This is the highest-risk period for severe hemorrhage.1

Late Postpartum (24 Hours to 6 Weeks):

• Large clots during this period indicate secondary postpartum hemorrhage, most commonly from RPOC, infection, or subinvolution.1
• Bleeding that continues beyond 6 weeks or suddenly increases should always be evaluated, as it may indicate complications requiring treatment.1

Critical Warning Signs

Seek emergency care immediately if you experience:

• Soaking through more than one pad per hour for several consecutive hours.2
• Passing multiple large clots (golf ball-sized or larger).1
• Dizziness, weakness, or feeling faint when standing.2
• Rapid heart rate or difficulty breathing.2
• Severe abdominal pain.3

Why This Matters for Your Health

• Visual estimation of blood loss systematically underestimates actual hemorrhage, so large visible clots indicate substantial blood loss that may not be immediately apparent.2
• Hypovolemia from hemorrhage can be asymptomatic until a large amount of blood is lost due to maternal hematologic adaptation to pregnancy.4
• Severe postpartum hemorrhage (>1000 mL) requires aggressive intervention including possible tranexamic acid administration and blood product transfusion.2
• A small subset of women (1.06/1000 maternities) develop acute obstetric coagulopathy characterized by massive fibrinolysis and hypofibrinogenemia, associated with poor outcomes.5

Bottom line: Contact your obstetrician or go to the emergency department today for evaluation. This is not a "wait and see" situation, as early identification and prompt intervention are crucial for preventing progression to life-threatening hemorrhage.6