JOURNAL OF WOMEN’S HEALTH

Volume 21, Number 12, 2012

ª Mary Ann Liebert, Inc.
DOI: 10.1089/jwh.2012.3668

Lochia Patterns Among Normal Women:

A Systematic Review

Susan Fletcher, Ph.D.,1 Chad A. Grotegut, M.D.,2 and Andra H. James, M.D., M.P.H.2

Abstract

Background: We conducted a systematic review of the literature to determine the amount and duration of blood
loss 24 hours to 12 weeks after delivery.
Methods: We searched MEDLINE, CINAHL, and PubMed for studies between the years 1950 and 2011 that
prospectively evaluated the amount and duration of blood loss from 24 hours to 12 weeks after delivery.
Excluded were those that were only case studies, retrospective studies, studies not published in English, studies
outside of the time frame, and studies that included only subjects from special populations.
Results: From the 333 identified studies, 18 met inclusion criteria. There was variability in how the amount of
blood loss was determined, ranging from subject self-assessment to objective measures, such as pad weight and
spectrophotometric readings of hematin concentration. The reported duration of normal blood loss after delivery
varied among the studies. Whereas the average duration of blood loss in these studies ranged from 24 to 36 days,
in only 1 study was bleeding followed to cessation.
Conclusions: An understanding of bleeding patterns after delivery is important for clinicians to recognize
deviations from normal, identify women at risk for delayed postpartum hemorrhage, and limit unnecessary
interventions, yet studies reveal significant variability in amount and duration of normal lochial blood loss and
methods of assessment that are inconsistent. This review draws attention to the need for the establishment of
valid, reliable, and feasible methods to quantify normal and abnormal postpartum blood loss.

Introduction affects anywhere from 0.8% to 2% of all deliveries, the actual

incidence is not known because of a lack of standard assess-
D elayed or secondary postpartum hemorrhage (PPH)
has been defined as excessive, abnormal, or heavy vag-
inal bleeding or bleeding in sufficient amounts to require
ment, quantification, and clinical criteria.7,15,16 This is in
contrast to primary PPH, which affects approximately 2%–5%
of all deliveries.17–20
medical attention occurring between 24 hours and 12 weeks
This article provides a systematic review of the published
after delivery.1–4 Secondary PPH is associated with significant
literature on assessing lochial loss between 24 hours and 12
maternal morbidity, including pain, interference with activi-
weeks postpartum in order to better understand the median
ties of daily living, anemia, and fatigue, and it can also be fatal,
duration and amount of lochial loss and variables associated
particularly in underdeveloped countries.3,5–7
with increased loss and duration. Such data are vital for the
Some bleeding between 24 hours and 12 weeks after de-
establishment of reliable criteria to differentiate between
livery is expected and is called lochia. Women experience this
normal and pathologic states, for the diagnosis of delayed
bleeding after they are no longer under the direct observation
PPH, and for the development of guidelines for prophylactic
of a nurse, midwife, or physician, yet standard references are
treatment to reduce patient risk of delayed PPH and related
not available for either patients or providers to discriminate
signs and symptoms.
between acceptable bleeding and bleeding that requires clin-
ical intervention. Despite continued calls for sound estimates
Materials and Methods
of what constitutes excessive lochial loss, there is a severe lack
of normative data on secondary lochial loss, and there are MEDLINE, CINAHL, and PubMed were searched for lit-
no standard methods for quantifying or treating delayed erature published between 1950 and 2011 using combinations
PPH.2,3,6,8–14 Although literature that states that delayed PPH of the following terms: delayed postpartum hemorrhage,

1
Hemophilia of North Carolina, Morrisville, North Carolina.
2
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina.

1290
LOCHIA, A SYSTEMATIC REVIEW 1291

of study, population, number of women in study, variables

examined, methods for measurement, survey instruments
used, and primary results. Statistics were extracted directly
from original publications.

Results
The 18 studies included in this review were published be-
tween 1950 and 2007. Seven studies were from the United
States,1,2,4,10,21,22,28 four from the United Kingdom,8,9,14,23 two
from India,3,6 one each from Sweden,24 Mexico,25 Israel,29 and
Egypt,26 and one was a multinational study.27 Four stud-
ies6,10,25,28 were nonrandomized experimental studies asses-
sing the impact of variables on postpartum lochial loss, which
included the uterotonic agent oxytocin1,25,28 or kutapressin (a
nonsteroidal anti-inflammatory drug [NSAID])10 or an intra-
uterine device (IUD).6 Although 2 studies included data on
lochia immediately after delivery up to 24 hours postpartum,
the information is not included in this review.24,25 Results not
specifically related to the amount or duration of lochial loss
are not included in this review even if they were part of the
original study.
FIG. 1. Study search and selection. *Some articles may have The sample size of subjects ranged from 98 to 3955.27 Al-
been excluded for multiple reasons. Only the initial reason though not all articles included patient ages, the youngest
for exclusion is cited. known age was < 15,3 and the oldest documented age was
42,8 although other studies reported having patients in the
sample who were > age 40.4,9,10,14
secondary postpartum hemorrhage, lochial and/or lochia, Definitions related to clinically significant bleeding varied.
blood loss, and puerperium. The bibliographies from the Bang et al.3 defined delayed PPH as the use of > 5 pads a day 5
identified references were also reviewed to identify additional days after delivery or increased vaginal bleeding after
relevant studies. We identified 419 records through database bleeding had decreased or stopped or any increased use of
searching, and 2 additional records were identified through pads by at least 2 after bleeding was less or none and found
other sources for a total of 421 records. Duplicate records were that 15% of the women reported delayed PPH in their study.
identified and removed, leaving 333 records for consideration Fronczak et al.2 defined delayed PPH as passing fresh or
(Fig. 1). clotted blood more than 3 days postpartum; 30% of partici-
pants in this study reported secondary PPH. Bleeding com-
Study selection plications were defined by Sokol et al.22 as any postpartum
bleeding requiring medical intervention. No participants in
We considered all published studies that assessed the
their study reported complications.
amount or duration or both of lochia loss between 24 hours
Table 1 presents the 8 studies that reported the duration
and 12 weeks after delivery among normal patients. We ex-
of normal lochial loss after delivery using tests of signifi-
cluded studies that investigated specific populations, such as
cance.6,9,14,21–23,27,29 The mean duration of blood loss reported
patients with bleeding disorders or those with primary PPH.
in these studies ranged from 24 days9 to 36 days.29 The
Studies were also excluded if they studied only special patient
shortest recorded duration was 2 days,27 and the longest was
populations, did not pertain to obstetrics, did not assess lo-
90 days6 (Table 1).
chial loss lasting longer than 24 hours postdelivery, did not
Average lochial loss varied greatly depending on time
specify a method to assess either amount or duration of loss,
frame and methods of assessment. There were 6 studies
were case studies, were retrospective studies, were not pub-
lished in English, or were published before 1950.
Studies assessing the amount of lochial loss 24 hours post- Table 1. Average Duration of Lochial
natal using self-report were included even if amounts were not Loss in Studies Reviewed
quantifiable. Additionally, studies using self-report to assess Average duration
duration of lochial loss were included even if averages were not Study (in weeks)a
determined. For the purpose of this article, lochia was defined
as normal blood loss or discharge occurring between 24 hours Hingorani et al., 19706 5.82
and 12 weeks postpartum. Secondary/delayed hemorrhage Oppenheimer et al., 198623 8.25
was defined as clinically significant blood loss. Visness et al., 199721 6.75
All decisions were discussed and reviewed by the co- Marchant et al., 19999 6
authors. Eighteen articles were eligible for inclusion in this Sherman et al., 199929 9
World Health Organization, 199927 6.75
review and a summary of these articles is presented in Table S1
Sokol et al., 200422 6.4
(Supplemental material available online at www.liebert Chi et al., 201014 4.43
online.com). Data were abstracted using an electronic form,
a
including the following headings: country, study design, year Only includes control groups.
1292 FLETCHER ET AL.

quantifying the amount of lochial loss.1,4,8,24,25,28 Two studies those not receiving oxytocin,25 whereas the other study re-
weighed perineal pads as a means of assessing loss,1,4 1 study ported that those receiving oxytocin lost significantly more
used spectrophotometric readings,24 and 3 used alkaline he- blood than those not receiving it ( p < 0.05).28
matin methods for assessment.8,25,28 Although all studies as- Results from the Bernstine and Bernstine study4 suggested
sessed lochial loss 24 hours postdelivery and longer, as that the greatest amount of lochial loss was found among
required by our study inclusion criteria, there was great di- older mothers (40–45 years) and the least among the youngest
versity in the time of initial assessment, with 2 studies in- mothers (16–20 years), although statistical tests of significance
cluding lochial loss during delivery.4,25 Only 1 study were not documented. The same study noted greater loss
measured lochial loss until cessation.29 among nursing mothers, but the differences were not statis-
Five studies used only self-reported measures to assess tically significant. Results from 4 other studies comparing
quantity, providing a nonvalidated scale for light to heavy nursing and nonnursing mothers did not note any significant
bleeding and clinically significant bleeding without compar- differences.1,14,28,29 One study found a correlation between
ison to an objective test.1,2,26,28,29 None of the studies used length of labor and mode of delivery with amount of lochia,14
identical definitions or parameters for operationalizing the and another study found a correlation between having one or
terms light, moderate, heavy, excessive, or delayed PPH. One more risk factors and delayed PPH.26 Risk factors included
study used a modified Pictorial Assessment Blood Chart premature rupture of membranes (PROM), induced labor,
(PBAC).14 oversized uterus, pregnancy-induced hypertension, ante-
Subjects in 1 study reported a moderate amount of lochial partum hemorrhage, prolonged labor, operative delivery,
loss for an average of 4.6 days ( – 5.1) after delivery, a light obstructed labor, and precipititous labor.
amount for 15.2 days ( – 7.2), and scant amount for 36 days Two studies assessed the color pattern of lochia over time
( – 7.5).29 In another study, 49% of subjects reported light using a graduated color slide including rubra (red-brown);
bleeding at day 14, 9 % reported heavy bleeding at day 14, and serosa (brown-pink-brown), and alba (yellow-white).23,29 In
38% reported light bleeding at day 42 compared to 2% re- Oppenheimer et al.,23 the median duration of lochia rubra was
porting heavy bleeding.26 A third study using self-report 4 days (range 2–6), lochia serosa 22 days (16–35), and total
compared women with and without an IUD.6 Within the duration of lochia was 33 days (23–48). Thirty-six percent of
study group, 40% of the women with an IUD reported ex- participants did not experience lochia alba. In the Sherman
cessive lochia loss compared to 11% of the women without an et al. study,29 the median duration of lochia was 37 days
IUD. A study examining postdelivery complications reports (range 17–51). Three types of color patterns were identified:
that primiparas were significantly more likely to report de- type 1 was a prolonged rubra phase, type 2 had two rubra
layed PPH.2 phases, and type 3 had nearly equal rubra and alba phases.
Significant relationships were found between variables The rubra phase lasted 12.1 – 6.7 days in type 1, 24.8 – 5.0 in
examined and both duration and amount of blood loss. One type 2, and 5.5 – 2.5 days for the first rubra in type 3. Although
study found a significant relationship between duration of there were no statistically significant differences in overall
blood loss and parity, with increasing parity significantly re- duration of lochia, significantly more lactating women were
lated to decreasing median duration of bleeding ( p < 0.05).23 in the type 1 group than type 2 ( p < 0.05), and women with
Five studies examined the relationship between duration of higher parity were significantly more likely to have type 2
bleeding and birth weight.8,14,21,23,27 Of these 5 studies, 2 compared to type 1 ( p < 0.05).29 The amount of lochial loss
found that increasing birth weight was significantly related to was not included in either of these studies.
increasing median duration of bleeding ( p < 0.05) and birth
weight was related to increased duration at two of the seven
Discussion
centers in the study by the World Health Organization
(WHO).23,27 From the 18 studies included, the average duration of lo-
Patient location, which may have been affected by differ- chia was 24–36 days, although studies included in this review
ential reporting from various sites, was significantly associ- suggest lochial flow beyond the 6 weeks time period is not
ated with duration in the WHO study, with the two samples unusual.21,23,27,29,30 The definition of duration of lochia was
of white women from developed countries having the longest not consistent among the studies, as the majority of studies
durations (Melbourne/Sydney, Australia, and Uppsala, terminated the period of observation before the actual cessa-
Sweden)( p < 0.001).27 Significant relationships were also tion of bleeding. Two studies followed the bleeding to cessa-
found between duration of lochia and the use of a nonhor- tion.14,29 Because of the truncated period of observation, there
monal IUD inserted postpartum.6 IUD use was associated is an inherent bias toward shorter duration, making the du-
with longer duration of lochia. rations cited in these studies unreliable. Therefore, one cannot
No study found a statistically significant relationship be- rely on 24–36 days as the average length until cessation of
tween duration of lochia and history of prior cesarean birth, bleeding.
duration of normal menses, gestational age at delivery, infant It is impossible to discern the average quantity of blood loss
sex, mother’s racial or ethnic background, mode of delivery, from the studies included in this review. In general, lochia
maternal weight, administration of oxytocic drugs, oral con- diminished over time, but there is no universal way of mea-
traception postpartum, resumption of sexual activity, or suring lochia. Very little can be said about the quantity of
smoking. lochial blood loss, as no standardized and validated measures
Of the 2 studies that examined the impact of oxytocic or scales exist. Whereas some of the studies used the weight of
agents given immediately after delivery on the amount of perineal pads or other objective methods to quantify the
lochia loss, one study reported no statistically significant amount of blood loss, the majority of studies relied on the
differences between those women receiving oxytocin and subjects’ subjective description. A woman’s own description
LOCHIA, A SYSTEMATIC REVIEW 1293

of lochia loss ‡ 24 hours after delivery is often the sole de- There are limitations to this systematic review. The studies
terminant for seeking medical intervention, yet the use included investigated different study populations and used
of self-report without standardized quantification has lim- different outcome variables and assessment techniques. There
ited clinical value. Studies on menstrual loss and primary was also a lack of standardized assessment (e.g., standardized
postpartum lochial loss (between delivery and 24 hours pads, valid surveys) and lack of strong methodology. Chan-
postnatally) suggest visual estimation of loss is often un- ges in diagnosis, assessment techniques, and tools are par-
derestimated.11,12,31 tially due to the variable time periods in which the studies
Some studies attempted to explore variables associated were conducted; methods did strengthen in studies con-
with lochial duration and amount. Results were conflicting, ducted since 1999.2,3,14,22,27 Most of the limitations are inher-
and no associations were found between many plausible ent in the studies themselves and, although these limitations
variables and lochial loss. More than one study, however, are noted, the strength of this review is that we have sys-
found an association between birth weight and lochial loss tematically reviewed research studies on delayed PPH and
and IUD use and lochial loss. Chi et al.14 found that women are able to bring attention to the lack of clinically relevant
with bleeding disorders, as well as women who had long standards for assessing abnormal postpartum bleeding and
labor and underwent instrumental delivery, have increased delayed PPH. This review also draws attention to the need for
duration and amount of lochia. In general, when the duration the establishment of valid, reliable, and feasible methods to
and amount of lochia in normal women are not clearly es- quantify abnormal postpartum blood loss for patients, med-
tablished, the impact of various factors on the duration and ical providers, and researchers.
amount of lochia is difficult to assess. We recommend further studies using methods similar to
The lack of standard definition as to what constitutes that used by Chi et al.14 to compare the amount and duration
clinically acceptable lochial loss during this period is evident of lochia in women with and without inherited bleeding dis-
from this review. For example, light or small bleeding was orders. Patients in this study used standardized pre-
defined as < a 4-inch stain on a perineal pad,29 similar to determined sanitary pads and completed a booklet consisting
menstrual bleeding,26 or < a 2-inch stain on a sanitary pad.9 of weekly modified PBACs to assess the amount of lochia loss.
Heavy bleeding was operationalized as requiring more than These methods are consistent with those suggested to im-
four pads per day for ‡ 10 days26 or a saturated perineal pad prove measuring blood loss by Jacobson et al.11 and Lue-
within one hour.29 genbiehl et al.12 Randomized studies using standard sanitary
There was also variability among studies defining delayed pads in which saturation levels have been predetermined
PPH. Marchant et al. defined delayed PPH as ‘‘any abnormal and standard amounts of loss per PBAC categories have
or excessive bleeding from the birth canal occurring between been validated would allow for a more objective measure of
24 hours and 12 weeks postnatally,’’9 while Bang et al. oper- blood loss.
ationalized delayed PPH as ‘‘after five days post delivery, the Although the need for sound estimates of what consti-
use of more than five pads a day’’ or ‘‘increased bleeding after tutes excessive lochia loss has long been cited, without valid
bleeding had decreased or stopped’’ or ‘‘any increase in use of clinical guidelines, determining normal bleeding vs. bleed-
pads by two or more after it was less or none.’’3 The definition ing requiring medical attention cannot be differentiated in a
used by Fronczak et al.2 was passing fresh or clotted blood reliable manner. This lack of information restricts clinicians’
more than 3 days postpartum. ability to determine if rehospitalization is required. Without
These findings are consistent with a recent review of adequate knowledge of lochial loss, clinicians are also lim-
common obstetric terms.32 In their review of 17 sources (in- ited in identifying those women who may be at risk for
cluding student textbooks, medical dictionaries, and mid- delayed PPH. Risks associated with this lack of clinical
wifery textbooks) for common obstetric terms, the authors criteria include the potential for serious postpartum mor-
noted the lack of consistency in defining delayed PPH among bidity; lack of readmission for patients in need; unnecessary
the 12 sources that included a definition of delayed PPH and hospitalization for others, thereby increasing burden on
stated the need to quantify delayed or secondary PPH.32 It is, families and costs; unnecessary stress to patients and fam-
therefore, difficult to draw any conclusion from these studies ilies based on this ambiguity; and failure to provide ade-
because methods of quantification were so disparate, with no quate prophylactic treatment for those known to be at risk
validated forms of measures and no validated scales. Such for hemorrhage.14,31
variability among definitions and methodologies make de-
termination of clinically significant lochial loss difficult to Disclosure Statement
assess for patients, clinicians, and researchers.
A lack of guidelines contributes to the inconsistency in No competing financial interest exist.
defining, assessing, and treating delayed PPH.7,11,12,14,15
Hospital admission data suggest the incidence of delayed References
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