Lochia is a temporary vaginal bleeding or discharge that occurs after childbirth, a period called the postpartum period or puerperium.  It occurs following a vagina or caesarean section. 

The Postpartum period or puerperium is a period when the vagina and uterus return to normal after childbirth. 

Lochia originates from the vagina, uterus and cervix.¹

This discharge contains:

• Blood
• Urine
• Uterine tissues

Lochia lasts for four to eight weeks after childbirth.

This natural phenomenon is a crucial aspect of a woman's recovery after giving birth. Understanding the normal and abnormal, significance, stages and management of lochia is essential for both new mothers and healthcare providers.  This article takes you through all you should know about lochia. In general, when the duration and amount of lochia in normal women are not clearly established, the impact of various factors on the duration and amount of lochia is difficult to assess.

Risk factors for prolonged lochia duration 

• Studies show that the lochia is more prolonged among women who use an intrauterine device (IUD) immediately after childbirth compared to those who do not use any modern postpartum contraceptive method.²
• Also women with a history of bleeding disorder have tendencies of increased duration and amount of lochia.³
•  More than one study, however, found an association between birth weight and lochial loss.(reference needed)
•  women who had a long  (labour and underwent instrumental delivery, have increased duration and amount of lochia.⁴
• Complications during labour and infection by microorganisms.

Note: Lochia smells like normal menstrual fluid, but the presence of an offensive smell or colour change to green indicates contamination by microorganisms. 

Overview

Stages of lochia 

This discharge appears red at the onset which comprises blood and fragments of decidual, endometrial tissues and mucus which lasts 1-4 days.

Lochia then changes colours to pink or pale brown colour lasting 5-9 days and is composed mainly of blood, mucus and leukocytes. 

Finally, the lochia turns white and is composed of mucus, lasting 10-14 days The lochia can persist up to 5 weeks postpartum. The persistence of red lochia beyond one week might be an indicator of uterine subinvolution. The presence of an offensive odour or large pieces of tissue or blood clots in lochia or the absence of lochia might be a sign of infection The cervix and vagina may be edematous and bruised in the early postpartum period and gradually heal back to normal.¹

Lochia normally has three stages, each of which is distinguished by alterations in colour, consistency, and duration:

• Red Lochia (Lochia Rubra): This is the initial stage, which often lasts for the first couple of postpartum days. Bright red Lochia rubra has a profuse menstrual flow-like appearance. Blood, tiny blood clots, mucous, and tissue fragments make up the majority of it. The body naturally clears out blood and tissue fragments from the uterine lining during this period.
• Lochia Serosa (pink or Brown Lochia): Serosa, which takes place between days 4 and 10 postpartum, develops after the rubra stage. The discharge changes colour and contains fewer red blood cells, turning pink or brown. Serous fluid, mucus, leukocytes, and tissue debris make up the majority of what it is made of. The discharge decreases compared to rubra
• The last stage, known as Lochia Alba (White Lochia), often lasts from day 10 to six weeks following childbirth. The discharge's hue lightens, becoming yellow or white and the discharge is minimal. Mucus, leukocytes, and a smaller number of red or brown blood cells make up the majority of lochia alba. The uterine healing process appears to be complete at this time.

Complications of lochia

• During uterine involution, complications such as uterine atony, residual placental membrane, and insufficient decidualization occur. When these issues stop the lochia from discharging successfully, lochiostasis results. In this scenario, red lochia typically lasts longer than seven days and discharges at an extraordinary volume, unlike the typical three-stage lochia discharge.

• Lochia retention can cause uterine subinvolution and raise the likelihood of endomyometritis, two labour problems that put the health and even life of the mother in danger.
• Lochia emerges in three stages, and all three colours are either variations or standard lochia. Clinically prolonged lochia after 8 weeks may be a sign of placental polyps or residual foetal tissue.
•  Lochia is clean for the first two days but may become contaminated by the third or fourth day as vaginal flora including non-hemolytic streptococci and E. coli start to colonise the uterus also foreign microorganisms like chlamydia and staphylococcus

What cause lochia

• Uterine Contractions: After childbirth, the uterus contracts and shrinks back to its pre-pregnancy size, shedding blood and tissue fragments that are later expelled as lochia.
• Healing Process: Lochia is a typical component of the body's recovery after placenta delivery. It is essential for clearing out the uterine cavity and promoting healing.

Management for lochia

Lochia is not treated since it is a normal physiological process of healing of the uterus. Lochia is managed to prevent infections and aid faster response

• Proper hygiene should be ensured during the postpartum period to prevent exposures to infections 
• Encourage rest to enhance fast healing and minimise lochia flow 
• Close monitoring and observation for the colour and odour of lochia to know when to go see the doctor.
• Over-the-counter painkillers may be used to relieve any pains or cramps

Diagnosis

The diagnosis of lochia is simple and frequently relies on the mother's reports and visual examination.

• Visual Inspection: Medical personnel look at the colour, consistency, and quantity of lochia during normal postpartum check-ups.
• Patient history: Medical professionals may question the mother about any symptoms or worries she may have had following childbirth, such as excessive bleeding, pain, or strange scents. Also, the individual is asked to monitor puerperal loss to differentiate from postpartum haemorrhage.
• Other Examinations: If an infection is suspected, other examinations, such as bacterial cultures or blood tests, may be required for a conclusive diagnosis. 

How to differentiate lochia from postpartum haemorrhage (PPH)

Contrary to what lochia is postpartum haemorrhage is:

• The significant excessive abnormal bleeding which occurs after childbirth is usually life-threatening.
• Postpartum haemorrhage is caused by factors such as atony, labour complications, trauma resulting from childbirth retained placenta or infections.
• Postpartum haemorrhage occurs within 24 hours after childbirth and is usually intensive and may lead to death if bleeding is not controlled.
• It is important to note that postpartum haemorrhage is a medical emergency and may lead to the loss of life of the mother.

FAQs

How can I prevent lochia?

Lochia cannot be avoided because it is a normal and essential component of the postpartum healing process. For the uterus to revert to its pre-pregnancy state, it signifies the shedding of the uterine lining.

How common is lochia?

Almost all postpartum women will go through lochia for a couple of weeks as a part of their healing. It is normal and is expected.

Who is at risk of lochia?

Lochia is not a condition that poses a specific risk to individuals. All postpartum women experience it, regardless of their age, health, or any underlying disorders.

What can I expect if I have lochia?

You can anticipate lochia if you've recently given birth, it presents as vaginal discharge It normally develops through three stages: lochia rubra (red), lochia serosa (pink or brown), and lochia alba (yellow or white). As the uterus heals, lochia can linger for several weeks and resembles a strong menstrual flow.

When should I see a doctor?

If you see any of the following alarming symptoms, you should speak with a doctor:

• Excessive bleeding that requires more than one sanitary pad to be changed every hour.
• Discharge that is very odorous or foul-smelling.
• Severe discomfort or pain in the abdomen that is not relieved by over-the-counter painkillers.
• High temperature or infection-related symptoms like chills, a fast heartbeat, or flu-like symptoms.
• Long bleeding period beyond 8 weeks 

Summary

Lochia is the postpartum vaginal discharge that occurs after childbirth. As the uterus discharges blood, mucus, and tissue fragments, it is a normal component of the body's healing process. 

Lochia discharge indicates uterine involution, and promoting a smooth lochia outflow may help to prevent lochiostasis and advance uterine involution.

The use of IUD contraceptives postpartum, birth weight, history of bleeding disorders, long labours and instrumental delivery have increased lochia duration 

There are three stages of lochia, each of which denotes the uterine lining healing: lochia rubra (bright red), lochia serosa (pink or brown), and lochia alba (yellow or white). Although it may be thick at first, lochia is usual and anticipated in postpartum women. It gradually reduces over several weeks.

A visit to a doctor should be made if there are any notable changes to the lochia, such as heavy bleeding, an unpleasant smell, or chronic pain.