Learn — Postnatal care & breastfeeding

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Lochia — types (rubra, serosa, alba)

Lochia is the vaginal discharge of the puerperium — blood, decidual shreds, leucocytes, mucus, serum and epithelial cells shed while the uterine lining regenerates. Its colour follows a fixed sequence over about 4–6 weeks (rubra, then serosa, then alba), and any deviation from that sequence — a return to red, a foul smell or a rising volume — is the earliest bedside sign of retained products or endometritis.

Lochia rubra: red, days 1 to 4 — blood, decidual shreds, chorionic remnants, amniotic fluid, lanugo and vernix.
Lochia serosa: pink-brown or yellowish, days 5 to 9 — less blood, more leucocytes, serous exudate, cervical mucus and organisms.
Lochia alba: pale white or yellowish, from about day 10 to 14 and continuing up to 6 weeks — leucocytes, mucus, cholesterol, fat and micro-organisms.
The total volume over the puerperium is about 250–300 mL; the odour is fleshy or stale, never offensive; the reaction is alkaline at first and becomes acidic.
Assessment of amount: scant is a stain under 2.5 cm in an hour, light under 10 cm, moderate over 10 cm, heavy is one pad soaked in an hour, and excessive is a pad soaked in 15 minutes. Weigh the pad when accuracy matters — 1 gram equals 1 mL.
Lochia normally increases on standing after lying down, during breastfeeding (oxytocin release contracts the uterus) and after exertion; it is less after caesarean section.
Deviations that matter: rubra persisting beyond a week or returning after it has cleared suggests retained products or subinvolution; offensive lochia with fever and a tender uterus is endometritis; and a sudden heavy red loss between days 5 and 14 is the classic secondary postpartum haemorrhage.
Lochiometra is lochia retained behind a blocked outflow (a clot or an acutely retroverted uterus): the uterus is enlarged and tender, the lochia is scanty and there is a low-grade fever — it responds to uterine massage, an oxytocic and correcting the position.

Normal puerperium

The puerperium is the six-week period from the delivery of the placenta until the reproductive organs and the maternal physiology have returned to the non-pregnant state. It is divided into the immediate (the first 24 hours), the early (up to 7 days) and the remote puerperium (up to 6 weeks), and because a large share of maternal deaths occur in it, India schedules postnatal home visits rather than waiting for the woman to return.

Involution: the uterus weighs about 1000 g immediately after delivery and 50–60 g by 6 weeks. The fundus is at the level of the umbilicus on day 1, descends about 1–1.25 cm a day, lies midway to the symphysis by day 6, and is no longer palpable per abdomen after day 10 to 12.
The cervix admits one finger by the end of the first week and the internal os closes by about 2 weeks, while the external os remains a transverse slit for life. The vagina regains tone by 6–8 weeks and the perineum heals in about 5–7 days.
Lochia follows rubra on days 1–4, serosa on days 5–9 and alba from day 10 to about 6 weeks.
Breast: colostrum for the first 2–3 days (rich in protein, vitamin A and IgA), transitional milk to about day 10, then mature milk. Prolactin makes the milk and oxytocin ejects it, and suckling drives both — so breastfeeding is started within one hour of birth and continued exclusively for 6 months.
Menstruation returns at about 6–8 weeks in a woman who is not breastfeeding and is delayed for 3–6 months or longer in one who is. Ovulation can precede the first period by as much as 4 weeks, so contraception is discussed before discharge.
Normal physiological changes: a puerperal diuresis with about 2 kg of weight loss in the first week, a physiological leucocytosis, a transient temperature rise below 38 °C in the first 24 hours only, after-pains from oxytocin (worse in multiparae and during feeds), and third-day blues in up to half of women, settling by day 10.
Postnatal care: check pulse, blood pressure, temperature, fundal height, lochia, perineum, breasts, bladder and bowel; encourage early ambulation to prevent venous thromboembolism; continue iron and folic acid and calcium; and follow the SSBSK (2026) ASHA home-visit schedule of days 3, 7, 14 and 42 for a healthy newborn, with an extra visit on day 1 after a home delivery, and nine visits (days 1, 3, 5, 7, 10, 14, 21, 28 and 42) for an at-risk newborn.
Contraception: the lactational amenorrhoea method works only while she is fully breastfeeding, amenorrhoeic and under 6 months postpartum. Progestogen-only pills, the postpartum IUCD (within 48 hours of delivery or after 6 weeks) and condoms are safe with breastfeeding; combined oral pills are avoided until 6 weeks.

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