Postpartum Bleeding and Ovulation
ABSTRACTS & COMMENTARY
Synopsis: Lochial flow for six weeks or more postpartum is not unusual.
Sources: Visness CM, et al. Obstet Gynecol 1997;89:159-163; Visness CM, et al. Obstet Gynecol 1997;89:164-167.
To determine the pattern of postpartum bleeding in a cohort of women who were breast-feeding, Visness et al prospectively studied 477 multiparous Filipina women for one year after a normal vaginal delivery. In addition, 72 breast-feeding women from Australia, Canada, and England were followed prospectively from 42 days postpartum with daily assays of urinary estrogens and pregnanediol to assess ovarian function and ovulation.
In contrast to the traditional teaching that lochia continues for two weeks after vaginal delivery, these investigators found that the median duration of lochial flow was 27 days. The duration of bleeding was not influenced by the patient’s age, parity, weight of the infant, or breast-feeding frequency or supplementation. In only 15% of the women was lochial flow completed within the first two postpartum weeks. Hormonal studies revealed that seven of 72 women had ovarian follicular development before day 56 postpartum. However, none of the bleeding observed in the first 60 days was associated with hormonal evidence of ovulation. Furthermore, all bleeding before day 56 was followed by another episode of bleeding that was non-ovulatory in women who continued to fully breast-feed.
The authors conclude that lochial flow for six weeks or more postpartum is not unusual and that half of postpartum breast-feeding women may bleed for about four weeks. In addition, it is unusual for vaginal bleeding in fully breast-feeding women during the first eight weeks postpartum to represent a return to fertility. However, breast-feeding women who have bleeding after the eighth postpartum week or who begin to supplement their infants regularly should begin to use contraception if they wish to prevent pregnancy.
COMMENT BY STEVEN G. GABBE, MD
These carefully conducted prospective studies of breast-feeding women provide information that is extremely important in counseling patients, especially those who are using lactational amenorrhea for pregnancy prevention. First, Visness et al have demonstrated that lochial flow usually lasts four weeks, and bleeding for up to six weeks is not unusual. Second, they found that, in women who continue to fully breast-feed, ovulation is not observed in the first 56 days postpartum. As the authors indicate, breast-feeding women who have bleeding after the eighth postpartum week or who are supplementing their infants should be advised to use contraception if they wish to prevent pregnancy.