Abstract: Post partum bleeding may lead to a prolonged niddah status that can be challenging for the halacha observant couple. On the other hand, if bleeding is of relatively short duration, halachic questions may arise regarding mikveh immersion before intercourse is medically recommended. Continued bleeding should be evaluated for possible cervical or vaginal causes. Halachic considerations can also affect decisions on contraceptive methods and timing. Post partum counseling of a halacha observant couple should include anticipatory guidance on these issues.
Discussion: Recent studies show that postpartum vaginal bleeding (lochia) reported by women is considerably more varied in duration, amount and color than the description in current textbooks and patient education material . It lasts substantially longer than the conventional assumption of two weeks. In one study, the median duration of continued bleeding was 33 days, with lochia persisting up to 60 days (the length of the study) in 13% of women . Postpartum spotting and bleeding is often intermittent, stopping and then starting again . Therefore, the post partum period is challenging for the halacha observant couple. It is very important that they be given accurate information so that they have realistic expectations.
On the other hand, some women will have stopped bleeding and completed the requirements for mikveh immersion prior to the standard six week post partum examination  . This raises the halachic question of immersion during the medically recommended period of abstinence. Most authorities permit immersion without intercourse if both members of the couple agree. This allows other forms of physical affection and makes it easier for the husband to assist in household tasks and care of the baby, as the couple are free to touch and pass objects to each other. However, some halachic authorities discourage this practice out of concern that physical contact without the possibility of intercourse could lead to hotza'at zera levatalah. Therefore, the desired medical timing of resumption of sexual intercourse should be discussed before hospital discharge. This will enable the couple to discuss the issue with their rabbi if the situation arises.
Standard practice at the post partum visit should include asking whether the woman has been able to use the mikveh. This affords the opportunity to investigate the possibility of other causes for the bleeding. If a woman is not actively bleeding but cannot get valid internal self examinations, the physician should perform a careful speculum examination to check for any vaginal or cervical lesions (e.g., unhealed stitches, significant vaginal dryness) that could explain the phenomenon . Any findings should be reported to the woman, who will then convey them to her rabbi for halachic guidance.
If active bleeding continues, consideration should be given to an ultrasound examination to look for other treatable causes. If no other explanation is found, the woman should be given clear instructions about how soon to contact the health professional if the bleeding persists. Even if bleeding is felt to be a "normal" post partum phenomenon, discussion should ensue as to whether hormonal treatment could be considered to alleviate the impact on the couple's quality of life.
Post partum bleeding is often compounded by contraceptive methods. Progesterone-only contraceptives (such as micronor) are often prescribed for breastfeeding women . This is particularly true for observant women, since hormonal methods are, according to most opinions, the halachic first choice. Bleeding is a very common complaint with this method. In one study, 53% of users reported frequent bleeding, 22% reported prolonged bleeding and 13% reported irregular bleeding , all patterns of marked concern to the halacha observant woman.
As the halacha observant couple will not have marital relations prior to mikveh use, consideration should be given to delaying hormonal contraception until after the woman has immersed. Many couples find it easier to manage approximately two weeks of niddah from the bleeding that often accompanies the initiation of progesterone only pills if they have already had a chance to be reunited after childbirth. Furtheremore, if the wife has already succeeded in using the mikveh, it is easier to manage spotting halachically.
It should be remembered that for a woman who is exclusively breastfeeding a baby less than 6 months old and has not resumed menses (defined as bleeding after 56 days), chances of conception are 1% (see article on Lactational Amenorrhea Method - LAM). Therefore, LAM alone or in combination with spermicide provides adequate contraception for most women for first time mikveh use (generally less than three months post partum). This option should be seriously considered.
Implications for practice:
Post partum bleeding has a significant impact on the quality of life of this patient population.
Anticipatory guidance should be given prior to hospital discharge as to the normal range of post partum bleeding. This should include management of the situation of mikveh use being permitted before sexual intercourse is medically advisable.
If possible, contraceptive methods and timing should allow for use of the mikveh, enabling couples to have physical contact prior to the potential onset of a new niddah status from initiation of hormonal contraception.
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