Lochia, Postpartum Bleeding and Physical Changes and Healing After Vaginal Birth

A woman’s body experiences many physical changes during the months after childbirth as it returns to its non-pregnant state.  It may take as long as two months for the body to begin feeling “normal” again.  One of the most noticeable changes is the return of the uterus to its pre-pregnancy size, called involution.  It does so with uterine contractions called afterpains.  As this process occurs, the abdomen gradually becomes smaller.  In addition to these changes, a post-birth discharge, called lochia, is expelled from the uterus thru the vagina.  Some women call this a post-birth period, and it usually lasts three to six weeks.


Lochia is the residual uterine lining that is shed after giving birth.  It is a normal part of the healing process, and not a cause for concern.  Lochia consists of blood, tissue, and mucous, and is similar to a menstrual period.  It is heaviest during the first three to four days postpartum, then slowly decreases.  Initially, the bleeding may be heavier when standing after a period of sitting of lying down.  The standing itself does not cause the heavier flow;  it instead occurs due to pooling of blood within the vagina while in a seated or flat position.

Furniture and bedding can be protected from accidental leaks using plastic-covered pads (chux) under your hips.  Until the lochia stops completely, it is safer to wear sanitary pads instead of tampons. Tampons increase the risk of infection within the uterus, and should be avoided for six weeks.  It is also important to recognize when uterine bleeding is lochia or a sign of losing too much blood.  Postpartum hemorrhage is the loss of more than 33 ounces (1000 mL) of blood in one day.  80 percent of cases occur within the first 24 hours after childbirth due to insufficient post-delivery uterine contractions.  In other cases, instruments used during the delivery may have caused uterine trauma.  Any area that doesn’t heal properly may continue to bleed.  Women with a history of a blood clotting disorder are also at risk for hemorrhage.

Postpartum hemorrhage, however, can occur at any time.   When it develops after the first 24 hours, it is likely caused by an intrauterine infection or retained piece of placenta.  Most cases of uterine hemorrhage do not involve a large “gush” of blood.  The blood loss is very gradual.  For example, consider how fast a cup fills in the sink if you let the faucet drip, drip, drip.  If your bleeding soaks a sanitary pad within 15 minutes or less, call your doctor immediately.  If the doctor is not available, have someone take you to the emergency room, or call 911 if you are alone.

Too much activity such as going up and down stairs can cause a heavier lochia.  If you notice a heavier flow after movement or physical activity, this indicates a need to slow down or rest.  Moms should avoid lifting anything heavier than the newborn baby.  If the use of stairs is unavoidable, then do it slowly.  It may be better, however, to set up a recovery area for you and your baby on the main floor of your home.

The amount of lochia should decrease over time.  If it becomes heavier, more rest may help.  Small blood clots, up to the size of a plum, are normal.   Larger clots and heavy bleeding warrant a call to a doctor.

There are three stages of lochia.  Knowing them is important in order to determine whether or not something may be wrong.   The number of days in each stage is less significant than the gradual decrease in amount of flow.  The color of lochia should also change from red to pink, then creamy or white.

Lochia Stages

1. Lochia rubra — first 2 to 4 days after delivery
• the lochia is mostly blood
• the blood looks bright red
• the blood flow can be heavy to moderate
• you may see small blood clots

2. Lochia serosa — starts around day 4 and lasts until day 12
• the color becomes pink or pinkish-brown
• there is less flow
• blood clots or bright red blood during this time may be signs of a problem.

3. Lochia alba — from day 12 until up to 6 weeks
• the discharge is light yellow to a cream color
• the flow has nearly stopped and has no odor
• the presence of clots, a foul odor, or bright red blood are signs of a problem.

This progression of stages should not reverse.  The color should always become lighter as the amount of discharge decreases.  If a red color develops after the flow has been pink or white, call your doctor right away.

Also, call a doctor immediately:
☎ if you have heavy bleeding that soaks more than 1 pad per hour for 3 hours
☎ if you see blood clots or bright red blood after the 4th day postpartum
☎ if the lochia has a foul odor, it could be a sign of infection
☎ if you have no lochia during the first 2 weeks
☎ if you experience severe cramps and heavy bleeding
☎ if you develop a fever over 100.4˚ F
☎ if you have severe pain in your lower abdomen

If you are not breastfeeding, your menstrual periods should return within 4 to 8 weeks.  The first menstrual flow tends to be heavy, and may contain blood clots.  It can start, stop, then start again.  The second menstrual period should be more or less as it was before your pregnancy.  Breastfeeding mothers, however, may not resume menstruating for several months.  When it does occur, it won’t interfere with breastfeeding.

Perineal Swelling and Soreness

Some swelling and soreness of the perineum is expected due to the pressure and stretching that occurs during childbirth. This area will also be more sensitive if you experienced a tear, or have stitches from an episiotomy.   Discomfort from an episiotomy is usually temporary, but other women develop complications.  Pain that lasts longer than a week should be evaluated by a doctor.

During the first 24 hours postpartum, ice packs can reduce perineal swelling.  It also acts as a local pain reliever.  By the second day, moist heat application for 20 minutes, 3 to 4 times a day, can be helpful.  A sitz bath or a warm, moist cloth can increase blood circulation in the area, and speed healing (see Perineal Care).

Sitz Bath

Here’s how to do a sitz bath at home.  You may want to doo these 2-3 times a day, or per your doctor’s orders.  Pick a time when your baby is asleep, or someone else is watching her.

• Wash your feet and legs, then rinse out the bath tub.
• Place a clean towel on the bottom surface of the tub, and add 4 to 5 inches of warm water.  NO SOAP or BUBBLE BATH.
• Sit on the submerged towel for 15 to 20 minutes.  If the water becomes too cool,  let some of it out, and replace it with warm water.
• After the sitz bath, stand up slowly to prevent feeling lightheaded or falling.

Bladder Distention

Bladder distention occurs during the third trimester of pregnancy, and may persist after childbirth.  Some amount of muscle tone is lost, and the nerves that control the bladder may become damaged during the birthing process.  An over-stretched bladder can frequently fill with urine which may be difficult to pass.  Bladder distention can particularly be a problem in women who have epidural anesthesia and/or an episiotomy during childbirth.

In these scenarios, bladder distention occurs because:

• the perineal area is swollen, including the opening where urine exits the body, called the urethra
• anesthesia puts the nerves that control the bladder “to sleep, “preventing enough relaxation to allow urine to flow.
• the bladder is too full to contract and squeeze out the urine.

This is a common problem, and cannot prevent it during the delivery.  Keeping your bladder empty during the early stages of labor may help reduce urinary retention.  When epidural anesthesia is used, a urinary catheter may be placed to prevent bladder distention.  After delivery, an ice pack on your perineum during the first 24 hours can help reduce swelling.  

When attempting to void, try to relax.  Other things to try include:
• squirting warm water over your perineum
• turn on the faucet; sometimes the sound of running water helps
• bear down slightly in order to push the urine out
• rub your belly and gently press on your bladder to initiate the urine flow

If all attempts are unsuccessful, a nurse may remove the urine from your bladder with a catheter.  Over time, the perineal swelling will improve, and it will become easier to urinate.


Hemorrhoids are swollen veins of the rectum.  Some remain within the rectum, but others can protrude through the anal opening.  They are often painful, and can make passing a stool uncomfortable.  Although they may develop during the third trimester of pregnancy, hemorrhoids can be caused by pressure from the baby’s head or pushing during the final stage of labor.  It’s easy to confuse the pain of episiotomy stitches with that caused by hemorrhoids.

Regular application of ice packs, 20 minutes every 4 hours, can relieve pain, reduce hemorrhoid size, and facilitate the return of normal stooling.  Ice should not be applied directly onto your skin because it could cause a freeze “burn.”.   Add the ice to a plastic bag, then wrap it in a towel.  Sitting in a bathtub of warm water, or a sitz bath, for 20 minutes (see Sitz Bath above) can also reduce the discomfort of hemorrhoids.  Cold witch hazel pads reduce minor discomfort and itching.   If these measures do not provide relief, it is time to call a doctor.

Symptoms should begin to improve after a few days of sitz baths and icepack applications.  Dietary changes can also help.  High fiber foods such as fruit, whole grains, and raw vegetables promote softer stools.   Kiwi fruit is known to both soften stools, and improve intestinal motility.  Drinking plenty of fluids can prevent the formation of hard stools which can irritate your hemorrhoids.  It is recommended that lactating women drink between two to three liters of water daily.  In some cases, your doctor may recommend a stool softener to make stool easier to pass, and to prevent straining.  Docusate (Colace) is safe to take while breastfeeding, and is not transmitted to the baby.  Holding a wad of toilet paper against your stitches during a bowel movement can also help reduce episiotomy pain.


Uterine contractions continue even after childbirth.  They are normal, and allow the uterus to shrink to its pre-pregnancy size, a process called involution.  These contractions are important because they constrict the blood vessels that were attached to the placenta, preventing postpartum hemorrhage.  The discomfort felt from these contractions is called afterpains.  They are particularly intense during the first 48 hours after delivery, and usually last three to four days.  They are a good sign that your uterus is getting smaller.

Afterpains can range from mild to somewhat uncomfortable.   They are often severe if the uterus has been stretched because of a large baby, multiples, or prior pregnancies.  Your doctor may recommend acetaminophen (Tylenol)  or other pain medications to ease the discomfort.  Voiding frequently to keep your bladder empty, or lying on your stomach with a pillow under your abdomen may also provide some relief.

Afterpains can be more intense while breastfeeding.  The baby’s sucking releases a hormone, oxytocin, that causes the uterus to contract.  This hormone also promotes breastmilk production, and maternal bonding with her infant.  Ask your obstetrician if it is OK to take Tylenol 30 minutes to an hour prior to breastfeeding.  If this does not provide relief, and the afterpains become too uncomfortable, call your doctor.

Other Physical Changes

The vagina stretches to a larger than normal size during childbirth, but will return to its pre-pregnancy size during the first 6 weeks after birth.  Kegel exercises can improve vaginal strength and tone as well as promote normal bladder function.

Stretch marks may have formed on your abdomen during your pregnancy, and may now be more noticeable.   They will remain a red to purple color for a while.  After 6 months they will become lighter on fair skin, or darker on more pigmented skin.  A dermatologist can recommend topical creams and other treatments to help reduce the appearance of stretch marks.

More About Self Care After Vaginal Birth

Introduction to Self-care After Vaginal Birth
Preventive Self Care
Perineal Care
Physical Changes and Healing
Breast Care
Activities and Healthy Exercise
Nutrition and Diet
Family Planning and Birth Control
Normal “Baby Blues” or Postpartum Depression
Your Postpartum Check-Up
Get as Much Rest as You Can
When to Call Your Doctor

If you use one of the microwave gel packs, don’t apply the heated pack directly to the skin.


If you call your doctor about any type of pain, tell him where the pain is coming from, such as your perineum or your abdomen, and how much pain you are having. This information will help determine if the pain is to be expected or a possible warning sign.

Tip 3
If you must strain to move your bowels, support your stitches by gently pressing against them with a pad of toilet paper as you bear down. This support will reduce the discomfort from your stitches.

Leah Alexander, MD, FAAP
Leah Alexander, MD, FAAP

Dr. Alexander began her pediatric career at Elizabeth Pediatric Group of New Jersey in 2000, and has practiced at Pediatricare Associates of New Jersey since 2005. After graduating from Kalamazoo College and Michigan State University College of Human Medicine, she completed her pediatric training at Overlook and Morristown Memorial Hospitals. She is board certified in General Pediatrics. In addition to pediatrics, Dr. Alexander pursued her interest the culinary arts with study at the French Culinary
Institute. In 2007, she opened Global Palate, LLC, catering small group events for six years. Dr. Alexander has also been a professional writer and editor since 2018, engaging in a variety of medical editing and writing projects.