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Re-Establishing Optimal Health Postpartum

 
By Cindy Micleu

During pregnancy, the focus is often on supporting the health of the mother as it directly affects the growth and development of the fetus.  But in traditional Chinese medicine, maintaining a woman's health is also highly emphasized in the postpartum period and the care she receives during this time often sets the scene for her state of health far into the future.  In general, younger women have an easier recovery from the demands of pregnancy and labor and delivery than do older women, but of course that is all relative to the woman’s constitutional strength, her health before conception, and how well she takes care of herself during the pregnancy. 

In Chinese medicine, the “postpartum period” refers to the four months following labor and delivery, the first month being the most important time to take special care.  It is not until the end of the 4th month after delivery that the yin and blood are considered full again and the womb and Ren and Chong mai are fully recovered.  There are some general tendencies to imbalance that may be expected during this time, which can be mild or severe, brief or prolonged, and are evident particularly when postpartum disorders arise. 

baby illusration

Postpartum Diagnostic Considerations

Primary postpartum imbalances:

  1. Qi and blood deficiency
  2. Spleen / Stomach qi deficiency
  3. Yin and blood deficiency
  4. Pathogenic cold entering the Uterus
  5. Blood stasis in lower burner

During pregnancy, a woman’s blood volume almost doubles in order to support the placenta and the developing fetus.  The “work” of labor and delivery and blood loss during delivery of the baby further deplete the mother’s qi and blood.  And because breast milk is formed from the same substrate as blood, breastfeeding is comparable to a constant loss of blood.  For all these reasons, women are often qi and blood deficient postpartum.  For all these reasons, the spleen is often temporarily taxed by the need to replenish blood, resulting in poor digestion, poor appetite, and possibly poor breast milk production.  Difficulty falling asleep due to Spleen qi and Heart blood deficiency is common and the ensuing fatigue and sleep deprivation can be a cause of postpartum depression.  Therefore supporting the middle burner and tonifying qi and blood with food and herbs is highly recommended.

Blood deficiency is also commonly seen in conjunction with yin deficiency.  Again, due to the high demand of Kidney yin and Liver blood by the growth of the fetus, mothers are often left deficient after delivery.  This seems particularly true with older women, those who had difficulty conceiving due to poor egg quality or other kidney deficiency issues, and those who conceived with procedures such as IVF (invitro fertilization).  Some potential problems due to yin deficiency are dry constipation, excessive night sweats, and insomnia with waking and inability to fall back to sleep easily (even when given the opportunity to sleep without interruption).  Blood and/or yin deficiency can also lead to excessive hair loss, headaches, dizziness, rashes, or anxiety.

Because the “womb” is blood deficient after labor and delivery, and the channels and collaterals that traverse the uterus and low abdomen are left empty and open, pathogenic cold can enter easily.  Care should be taken to avoid environmental wind and cold, and foods that are cold in temperature or nature.  Cold in the uterus can cause blood stasis, resulting in abdominal pain, retention of the lochia, or scanty bleeding with clots.  Severe postpartum depression and mania may occur due to blood stasis in the uterus affecting the Heart.

 

Recommendations for Postpartum Moms

There are several simple recommendations made to help women regain their health and balance in this postpartum period.  In Chinese medicine, this is viewed as a critical period in a woman's life and taking the time to care for and nourish one’s health after childbirth can have a great impact long-term health.

1) In the postpartum period, women should take special care to get enough rest and nourishment.   Many cultural traditions incorporate a specific rest postpartum, often for a moon cycle (28 days) pr 40 days.  When feeling stronger, women should try to find time for moderate activity such as walking, in order to help restore the circulation of qi and blood.

2) Digestion tends to be somewhat weak after delivery and because there is a great demand for nutritious food in order to replenish blood and form breast milk, warm, nourishing and easy to digest foods are recommended.  Traditionally, soups are particularly emphasized.  Herbs, food or drink that are cold in temperature or energetic nature should be avoided.  Using a small amount of fresh ginger root as a tea or added to soups can be helpful.

3) Heavy lifting should be avoided for the first four months in order to minimize the risk of uterine prolapse and to allow the pelvic tissues to completely heal and renew.  Heavy physical work or exercise should not be resumed until the 4th or 5th month postpartum.

moxabustion stick4) Moxabustion is an effective treatment to help warm the uterus and uterine collaterals, and has been shown to help dry up the lochia, prevent or treat hemorrhage, shrink the uterus back to normal size, and stimulate milk production.  At delivery, the Mingmen "life gate" opens, allowing passage of the infant.  Postpartum the Mingmen must close and become strong again or the Kidney qi will be chronically diminished.

In this technique, indirect moxa is burned over the lower abdomen and/or low back for 20-30 minutes until a sensation of deep warmth penetrates the area.  The treatment may be repeated often and is usually experienced as very comfortable, relaxing and revitalizing.  It can be useful to teach the postpartum woman's partner or other family member to administer the moxabustion treatment at home.

 

Prescribing Herbs for Breastfeeding Mothers

When giving herbs to breastfeeding mothers, the main thing to remember is that the baby will receive some of the herb constituents through the breast milk, therefore some caution should be used.  There are some exceptions, but the general rule is to choose herbal formulas that are moderate, neither too hot nor too cold, and neither too drying nor difficult to digest.  Herbs should not be used that deplete the qi such as purgatives, diaphoretics, or strong qi and blood regulators.  Although these guidelines may seem limiting, herbs are still quite helpful, particularly general qi and blood tonic formulas. 

The exception to this rule is when the mother has an emergent condition for which western drugs are likely to be prescribed.  For example in cases of mastitis, antibiotics are often prescribed, and the use of Chinese herbs may prevent the need for such cold drugs.  If antibiotics are necessary, using herbs in conjunction may limit the need for high doses or prolonged use of the antibiotics. 

Common sense and good diagnostics are the best guideline for treating a breastfeeding woman. If she tends to qi and blood deficiency, make sure to support the middle burner and use care with cloying herbs.  If she tends to yin and blood deficiency, avoid ascending herbs and herbs that are too warm or dry in nature.  If she has signs of cold causing stagnation, warm and dispel cold gently, and avoid cold or cloying substances.  In most cases, be sure to tonify any deficiencies as they are commonly the root of various problems that arise during this time.

 

Two Major Herb Formulas to Consider in the Postpartum Period

A popular formula for treating various postpartum disorders and assisting women in their postpartum recovery is Sheng Hua Tang, however Xiong Gui Tiao Xue Yin is another excellent formula to consider and one that is more appropriate for many situations where qi and blood deficiency predominate.  Both formulas are effective, and easily modified to treat a variety of postpartum situations, but Xiong Gui Tiao Xue Yin is more efficient at tonifying the qi and blood, while Sheng Hua Tang emphasizes the dispelling of cold and blood stasis.  A more detailed discussion of the two formulas is given below.

statue

Xiong Gui Tiao Xue Yin

(Chuan Xiong and Tang Kuei Drink to Regulate the Blood)

Shu Di Huang  (Cooked Rehmannia)  6-9g
Dang Gui  (Tangkuei)  6-9g
Chuan Xiong  (Ligusticum)  4.5-9g
Bai Zhu  (Atractylodes)  6-9 g
Fu Ling  (Poria)  6-9g
Mu Dan Pi  (Moutan)  6-9g
Chen Pi  (Citrus peel)  6-9g
Xiang Fu  (Cyperus)  6-9g
Wu Yao  (Lindera)  6-9g
Yi Mu Cao  (Leonurus  6-9g
Sheng Jiang  (Fresh Ginger)  6-9
Gan Cao  (Licorice)  3-6g
Da Zao  (Jujube)  3-6 g
Gan Jiang  (Dried Ginger)  3-6g

Functions: Nourishes Liver blood, tonifies Spleen-Stomach qi, harmonizes Liver and Spleen, regulates qi

Xiong Gui Tiao Xue Yin is a postpartum formula targeting the typical qi and blood deficiency situation of new mothers with an underlying weakness of the Spleen and Stomach.  This qi deficiency leads to a compromised ability to produce and replenish blood.  The formula also regulates the qi, but unlike Sheng Hua Tang, it does not treat invasion of pathogenic cold causing blood stasis. 

The formula includes herbs to nourish and enliven the blood: Shu Di Huang, Dang Gui and Chuan Xiong.  These are three of the four herbs in Si Wu Tang, a primary blood tonic formula.  The fourth herb, Bai Shao, is left out because it has a tendency to “hold in” or astringe slightly, but in the immediate postpartum period it is important encourage the complete discharge the lochia.  Bai Zhu, Fu Ling, Gan Cao, Dao Zao, Sheng Jiang, and Chen Pi all assist Spleen function, supporting the digestion and the ability to produce blood. 

Gan Jiang and Wu Yao gently warm and strengthen the middle, and prevent the invasion of cold.  Xiang Fu and Wu Yao promote the movement of qi and alleviate pain, while Mu Dan Pi clears the heat from deficiency that tends to occur with labor and postpartum blood loss, Yi Mu Cao is well-known in both Western and Chinese herbal practice for its ability to regulate blood in the uterus, to dispel stasis, and to help the uterus contract back to its normal size and position after labor and delivery.


Common Modifications

For excessive sweating, add Fu Xiao Mai
For deficient qi leading to fever and aversion to cold, add Huang Qi, REn Shen

The following are helpful modifications to Xiong Gui Tiao Xue Yin, from “Notes from South Mountain” by Andrew Ellis:

For poor appetite with qi deficiency, add Huang Qi
For postpartum excessive bleeding, add Di Yu Tan, E Jiao
For deficiency headaches, add Bai Zhi
For postpartum blood deficiency constipation, add Huo Ma Ren
For insomnia, add Suan Zao Ren, Mai Men Dong
For heat, dryness, and thirst, add Sheng Di, Huang Qin
With cold pain in low abdomen, add Xiao Hui Xiang

 

Sheng Hua Tang

(Generating and Transforming Decoction)

Dang Gui  (Chinese Angelica)  20g
Chuan Xiong  (Ligusticum)  9g
Tao Ren  (Persica)  9g
Pao Jiang  (Blst-fried Ginger)  3g
Zhi Gan Cao  (Honey-fried Licorice)  3g

Some practitioners consider Sheng Hua Tang to be useful for every woman in the immediate postpartum period.  But upon closer examination, this formula has a very specific function and is most appropriately used to treat postpartum cold and stasis in the low abdomen with an underlying condition of qi and blood deficiency. 

Sheng Hua Tang treats cold entering Uterus due to deficiency of qi and blood, causing blood stasis and is therefore best used in situations where the pregnancy, labor and delivery, and need to produce milk for breastfeeding has left the woman qi and blood deficient, and this deficiency has allowed pathogenic cold to enter easily.  Cold invades and causes blood stasis.  Typical symptoms include pain in the low abdomen relieved by warmth, scanty uterine bleeding, or retention of the lochia.  The blood would be dark and maybe clotted, the pulse would be choppy and tongue is pale purple.  The hallmark diagnostic signs are those of deficient blood, cold, and obstruction. 

In the formula, Dang Gui addresses the root of the situation by nourishing the blood, while Zhi Gan Cao warms and tonifies the middle burner to support the production of blood.  Pao Jiang dispels pathogenic cold and alleviates pain, while Chuan Xiong and Tao Ren warm and unblock stasis.  The formula is quite warm and moving in nature, so is inappropriate for strong deficiency or in heat conditions causing excessive uterine bleeding.

Common Modifications:

For qi deficiency, add Ren Shen
Deficiency cold with low abdominal pain, add Yi Mu Cao, Hong Hua
For more severe pain, use Shi Xiao San (Pu Huang 10 gr + Wu Ling Zhi 10 gr)
With retention of lochia, add Dan Shen, Mu Dan Pi, Yi Mu Cao

 

Case Study

Gwen is 40 years old and had difficulty conceiving, finally achieving pregnancy through her second in vitro fertilization (IVF) procedure.  Prior to this pregnancy, she had tried to conceive for 3 years, and lab tests showed her FSH (follicle stimulating hormone) to be high, which generally indicates a decline in egg quality.  Once pregnant, she experienced a particularly difficult third trimester with unusual fainting spells, nausea and anxiety.  She also had difficulty falling asleep at night.  The fainting spells were ultimately diagnosed by her midwife as a vasovagal response to meals that were too large and difficult to digest. 

Postpartum, she had difficulty breastfeeding as her milk was insufficient in quantity, but her main complaint was severe insomnia (difficulty falling asleep), depression and uncontrollable crying.  Her tongue was pale and her pulse wiry, thin and empty on pressure.  She was desperate for help and was considering trying sleeping medications and anti-depressants, though reluctant due to the traces her baby would ingest through the breast milk.

Gwen’s situation postpartum was an exacerbation of the imbalances she presented with during her pregnancy, primarily Spleen and Heart qi deficiency with Heart and liver blood deficiency leading to liver qi stagnation.  She was prescribed Xiong Gui Tiao Xue Yin with the addition of Gan Mai Da Zao Tang, Suan Zao Ren, Bai Zi Ren, and Yuan Zhi.  She began to sleep better and feel calmer after taking the herbs a short while, though she stayed on the formula for 6 weeks until her sleep and emotional well-being became more healthy and stable.  The herbs helped her breast milk production but she continued to need to supplement with formula, so when her sleep stabilized, she was prescribed an herb formula more focused on supporting breast milk production.

 

Recipes For Restoring Health Postpartum

Using Chinese "food" herbs in soups and stews is an ideal way to nourish the qi and blood postpartum. The herbs in these recipes taste good and bring added medicinal value to a warm, nourishing meal.

 

Nourish Blood and Essence Soup

1 ounce Dioscorea root (Shan Yao)                            7 cups chicken or bone soup stock
2 ounces Lycii berries (Gou Qi Zi)                             1 yam, diced
1 ounce Lotus seeds (Lian Zi)                                     5 black or shitake mushrooms,
12 Red Dates (Dao Zao) - soaked and pitted                   slivered (if dry, soak first)
2 cups chopped greens (kale, chard, spinach, etc.)      1/4 cup rice wine or rice vinegar

Break Dioscorea into small pieces and simmer in soup stock along with the Lycii berries and
Lotus seeds for 1 hour.
Add Da Zao, yam, and mushrooms and simmer for another 20 minutes.
Add rice wine and greens and cook for 5 more minutes.  Serve hot.

 

Dang Gui Chicken Soup

2 pounds hormone free natural chicken parts
3 quarts water
1 medium onion, chopped
1 cup chopped carrot
1 cup chopped celery
2 Tablespoons chopped fresh dill or 2 teaspoons dried dill
2 teaspoons salt
1 teaspoon pepper
1 1/2 cups sliced carrot
1 oz. (30 grams) Dang Gui (Chinese Angelica)

Rinse chicken and add to water in a heavy stockpot.  Bring to boil.  Add the onion, celery and carrot then cover and reduce heat.  Simmer for 1 hour.
Remove chicken from broth and shred meat into small pieces.  Strain broth through strainer/sieve and pour back into stockpot.  Add sliced carrots, herbs, salt and pepper.  Bring to a boil, cover and reduce heat.  Simmer for 25 minutes.
Add chicken and Dang Gui and cook for 10 minutes more.  Remove Dang Gui before serving.

                                               
Simple Chicken and San Qi Stew

30 grams San Qi                                             2 teaspoons salt
1 chicken (about 2 1/2 lbs)                              1 teaspoon light soy sauce
4 1/2 cups water                                              1 teaspoon grated ginger

Wash and clean chicken.
Combine all ingredients except soy sauce and cook in a double boiler for 2 hours. 

 

 

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