Secondary postpartum haemorrhage: heavy bleeding after the first 24 hours

The NHS says lochia, the bleeding from the vagina after birth, carries on for a few weeks, turns brown and gradually decreases; it usually stops after 6 to 8 weeks but can last longer. You may notice it is redder and heavier when you breastfeed, because breastfeeding makes the womb contract, and you may feel period-like cramps. The RCOG says lochia usually stops by the time the baby is 12 weeks old, and that the colour should change from bright red to brown over a few weeks.

The NHS also says not to use tampons until after the 6-week postnatal check because the wound where the placenta was attached and any tears could make infection more likely; use maternity or period pads instead.

The RCOG says that secondary PPH occurs when you have abnormal or heavy vaginal bleeding between 24 hours and 12 weeks after the birth, in contrast to primary PPH within the first 24 hours. NICE postnatal guidance (NG194) tells clinicians to assess the severity if you seek advice and to be aware that anaemia and a booking weight under 50 kg may worsen the consequences of secondary PPH.

The RCOG says it is often associated with infection in the womb, and occasionally with some placental tissue remaining in the womb. NICE's list of warning signs links sudden or very heavy bleeding, or persistent or increased bleeding, with retained placental tissue or endometritis (infection of the womb lining).

NICE says all women should be told at the first postnatal midwife contact to seek medical advice without delay for sudden or very heavy vaginal bleeding, bleeding that increases, passing clots, placental tissue or membranes, or symptoms of possible infection such as abdominal, pelvic or perineal pain, fever, shivering, or bleeding or discharge with an unpleasant smell. The NHS list is similar: a temperature over 38C, unusual-smelling bleeding, worsening tummy pain, heavier or unchanging bleeding, lumps or clots, and worsening pain between the vagina and anus.

The NHS tells you to call 999 if postnatal bleeding is sudden and very heavy or you feel faint, dizzy or have a pounding heart, as this could be a very heavy bleed needing emergency treatment. The NHS also advises telling your midwife if you pass large clots, as you may need treatment.

The RCOG says that if the bleeding is heavy or continues you may need to go to hospital for further tests. The sources used for this guide do not set out which tests are done, so ask your team what they plan and why. NICE says each postnatal midwife contact includes asking about infection symptoms, pain, vaginal discharge and bleeding, so describe any change as it happens.

According to the RCOG, you may be given a course of antibiotics to treat an infection. If the bleeding is heavy or continues you may need antibiotics through a drip. Less commonly you may need an operation to remove small pieces of remaining placenta from the womb. You may need to stay in hospital for a few days, your baby can usually stay with you if you wish, and you can continue to breastfeed.

Decisions about antibiotics or surgery are made by the clinician examining you. Do not start, stop or change any medicine without advice. Because blood loss can cause anaemia, the RCOG notes that iron treatment and a blood count check at 6 to 8 weeks may follow heavy bleeding, and NICE flags anaemia as a factor that worsens the consequences of secondary PPH.

A readmission after birth can be unsettling, with a new baby at home. NICE says that at each postnatal contact you should be given the opportunity to talk about your birth experience and told about birth reflection services where appropriate. The GP check at 6 to 8 weeks is another point to raise any ongoing bleeding. Postnatal care schedules differ between the UK nations.