Reading your lochia like a diary of the uterus

In the weeks after birth, many mothers look at their pad every day and worry: why is it red again today, why hasn’t it stopped yet, why are there clots? Lochia (postpartum vaginal discharge) is really a bit like a diary kept by the uterus. Read it correctly and you worry less for no reason, and you know when it is time to ask a doctor.

What lochia is

Lochia is blood, mucus and tissue from the lining of the uterus, where the placenta was attached, shed in the weeks after birth. You have lochia whether you gave birth vaginally or by C-section. After a C-section the uterus still needs time to heal, so many mothers are surprised that the discharge is not as light as they expected.

The color changes week by week

Books describe it a little differently, but the general pattern is:

• The first few days: bright red, the heaviest flow, sometimes with small clots.
• From about day 4 to the end of week 2: gradually fading to pink or brown.
• From week 2–3: pale yellow or white, getting less and then stopping.

The gynecology book by Xia Guicheng describes nearly the same thing (traditional medicine calls lochia "malign dew", 恶露 / 惡露, è lù): "normal lochia is dark red at first, then pale pink, and finally yellow or white", "it smells of blood but is not foul".

How long it can last and still be normal

Many people hear that lochia clears in about 2–3 weeks. Studies that asked mothers to keep a daily diary found it lasts longer. In the UK, the median duration was 33 days (meaning half of mothers had stopped before day 33 and the other half went on longer), and 13% of mothers still had lochia at day 60. A World Health Organization study of more than 4,000 breastfeeding mothers in 7 countries recorded a median of 27 days. A review of 18 studies gave an average of 24–36 days.

The old medical books were not too strict either. The Nü Ke Jing Lun (女科经纶 / 女科經綸, Classics and Discussions on Women’s Medicine), as quoted by Xia Guicheng, holds that lochia lasting up to a month is not yet considered an illness if its amount, color and consistency are normal and there are no other symptoms.

Most mothers have lochia for about 3–5 weeks. Lasting up to 6–8 weeks can still be normal if the flow keeps getting lighter, with no foul smell, no fever and no belly pain that is getting worse.

Normal things mothers often worry about

Stopping and starting again. The color of lochia does not always move in one direction. In the diary studies, depending on the study, 1 in 5 mothers, and in some places more than 1 in 4, had times when the lochia turned red again, or stopped for a few days and then came back. Around week 2, some mothers see red blood return for a short spell, sometimes with small clots; this may be when the scab where the placenta was attached comes away. Bleeding that returns lightly and briefly, then fades on its own, is common.

Lochia can also increase when you breastfeed, when you walk around a lot, or when you first get up in the morning. Passing a small clot now and then in the first days is normal. The smell is a little musty, like period blood; a fishy or foul smell is what needs your attention.

Traditional medicine reads lochia to see whether anything is still held back

When examining a woman who had just given birth, physicians of traditional medicine in the past had three things they had to ask, called the "three checks" (三审 / 三審, sān shěn): whether the lower belly still hurt, whether the bowels were moving, and whether the milk had come in and how she was eating. The first question tells whether the lochia has all come out. It goes back to the Jīn Guì Yào Lüè (金匮要略 / 金匱要略, Synopsis of the Golden Chamber): if the lower belly is hard and painful seven or eight days after birth, the lochia has not finished.

Traditional medicine does not look at lochia on its own. It reads it alongside the type of belly pain and your overall constitution:

• Lochia that is heavy, pale, thin and not foul-smelling, with an empty feeling in the lower belly, tiredness and shortness of breath: usually points toward qi deficiency (qi, the body’s strength, is weak).
• Lochia that is red or dark red, thick and smelly, with a hot, flushed face, a dry mouth and restlessness: usually points toward blood heat (heat in the blood).
• Lochia that is sometimes heavy, sometimes light, dark purple, with clots, with lower belly pain that hurts more when pressed and eases once clots pass: usually points toward blood stasis (blood that has pooled and not fully come out).
• Lochia that is scanty and dark, with belly pain that eases with a warm compress, and cold hands and feet: points toward cold (cold inside the body).

Xia Guicheng’s book also notes that in the blood stasis pattern, some women also have anxiety, panic and poorer memory, and in severe cases a disturbed state of mind. If you notice you are forgetful and find it hard to concentrate at the same time as lower belly pain and abnormal lochia, tell your doctor about both. Confusion, or hearing or seeing things that are not there, needs emergency care right away.

This way of reading lochia helps the physician choose a direction for treatment. Lochia that smells foul, lochia that suddenly stops completely together with belly pain, or any fever needs a same-day check with an obstetrician first. Maciocia, author of a textbook on obstetrics and gynecology in Chinese medicine, notes that lochia without a foul smell can still be infected; the most important sign is fever.

Why you should not buy medicine to "push out the lochia" on your own

The traditional pharmacology textbook has a principle: stop bleeding without letting blood stagnate. Herbs that stop bleeding, used too early or in the wrong way, can easily make blood stagnate. On the other hand, blood-moving herbs (which get blood flowing and break up stasis) use up blood and stir up bleeding (they can easily cause more blood loss and more bleeding), so they are not used when bleeding is heavy and there is no stasis. The old books also divided treatment by time: for bleeding that would not stop, the classical Vietnamese physician Hai Thuong Lan Ong used a modified Sheng Hua Tang (Generating and Transforming Decoction) for the first 7 days, and after 7 days switched to nourishing blood and stopping bleeding. That is how a physician chooses a prescription; please do not use it as a schedule for taking medicine yourself.

The lương y (traditional medicine practitioner) Nguyen Huu Duc advises that Sheng Hua Tang only suits women with cold (cold inside the body) together with blood stasis, where the stale blood has not fully come out; a woman with qi deficiency who takes it becomes more tired and sweats more. Hai Thuong, for his part, said that if the mother is healthy, the birth was easy, the bleeding is steady and there is no pain, "one should not use random medicines".

Modern gynecology textbooks group Yi mu cao (Leonurus japonicus herb, motherwort) with drugs that make the uterus contract, so it needs a physician’s judgment. Yi mu cao, Sheng Hua Tang and ready-made "lochia-clearing" packets all lack safety data for use while breastfeeding.

Keeping clean while you still have lochia

• Use pads, not tampons, and put nothing into the vagina for at least 6 weeks.
• Change pads often, and wash your hands before and after changing.
• Showers and warm baths are fine. Do not douche deep inside the vagina.
• When resting, lying half-reclined helps the lochia drain more easily. Breastfeeding also helps the uterus shrink back to its size before pregnancy.

If bleeding soaks a large pad every hour for two hours in a row, or you feel faint or pass out, go to the emergency department right away. We have covered the other signs that need urgent care in a separate article in this series, "Warning signs after birth that need care right away". Lochia that lasts too long, or stops and then comes back, is covered in detail in the next article.

References

Sources in Vietnamese

• Nguyễn Hữu Đức. 2022. Cổ phương với Thuốc Nam.
• Hạ Quế Thành. Sổ tay chẩn đoán điều trị phụ khoa (bản dịch tiếng Việt).
• Hạ Quế Thành. Thực dụng Trung y phụ khoa học (bản dịch tiếng Việt của BS. Tâm).
• Hải Thượng Lãn Ông. Hải Thượng y tông tâm lĩnh. Hà Nội: NXB Y học.

Sources in English

• Cleveland Clinic. Lochia [Internet]. Available from: https://my.clevelandclinic.org/health/symptoms/22485-lochia.
• Fletcher S, Grotegut CA, James AH. 2012. Lochia patterns among normal women: a systematic review. J Womens Health (Larchmt). 21(12):1290-4. doi:10.1089/jwh.2012.3668. PMID: 23101487.
• Maciocia G. Obstetrics and Gynecology in Chinese Medicine. Chapter 47.
• Mayo Clinic. Mayo Clinic Guide to a Healthy Pregnancy. 2nd ed.
• NHS. Your body after the birth [Internet]. Available from: https://www.nhs.uk/pregnancy/labour-and-birth/after-the-birth/your-body/.
• Oppenheimer LW, Sherriff EA, Goodman JD, Shah D, James CE. 1986. The duration of lochia. Br J Obstet Gynaecol. 93(7):754-7. PMID: 3755355.
• Sherman D, Lurie S, Frenkel E, Kurzweil Y, Bukovsky I, Arieli S. 1999. Characteristics of normal lochia. Am J Perinatol. 16(8):399-402. doi:10.1055/s-1999-6818. PMID: 10772198.
• Visness CM, Kennedy KI, Ramos R. 1997. The duration and character of postpartum bleeding among breast-feeding women. Obstet Gynecol. 89(2):159-63. doi:10.1016/S0029-7844(96)00482-6. PMID: 9015013.
• World Health Organization (WHO) Task Force on Methods for the Natural Regulation of Fertility. 1999. 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. Fertil Steril. 72(3):441-7. doi:10.1016/s0015-0282(99)00273-3. PMID: 10519614.

Sources in Chinese

• 钟赣生, 主编. 中药学.