Recently the child of one of my early fertility and pregnancy patients has become pregnant!  If you practice long enough you get to see these generations forming.  It is wonderful work to do in a community.

There is so much focus these days on the use of Chinese medicine for fertility.  This is important work but the goal is not always fully met with conception.  Of course the goal is a happy healthy mom and a happy healthy babe.  To help meet this goal as practitioners we also need to pay attention to women during pregnancy and during the postpartum time.  We have to develop tools to work with the issues that come up.

In this blog I’ve written about my experience, and that of others, in working with patients during pregnancy.  You can click on the obstetrics and gynecology categories on the right here to see all the posts on these topics.  This post is a follow up to the last post was on insufficient lactation, including some more thoughts and teachings on the postpartum treatment of women with Chinese medicine.  

Below I’ve included the first part of a chapter from my teacher Dr. Qiu Xiao-mei’s book Qiu Xiao-Mei’s Experience in Gynecology (裘笑梅妇科临床经验选) entitled An Inquiry Into the Treatment Laws for Postpartum Illnesses.  This chapter expands upon some of what I was discussing in the last blog entry.  I’d like to point out how Dr. Qiu always encourages us to consider the admonitions of our predecessors while at the same time to rely on our direct contact and diagnosis of the person in front of us.  She points out that historically, our predecessors express  strong prohibitions against any kind of technique for dispelling stasis in postpartum women.  She then points out their equally strong prohibitions against tonification!  We have to understand the meaning behind these prohibitions so we can use them as guides and not allow them to shackle us against effective treatment.  There is a place for dispelling stasis in the postpartum time, even to the point of purging.  However it must be done properly and with the special characteristics of the postpartum time kept closely in mind.  The same is true for strong tonification.  It is clear that Dr. Qiu saw practitioners rashly dispersing postpartum women without understanding their special circumstances and that she also saw practitioners over tonifying women as if all postpartum conditions were solely due to deficiency.

In the last post I mentioned some of the checks I do for my postpartum patients.  I will often do a home or hospital visit after the baby is born and always include these checks.  I learned about these checks and their importance from Dr. Qiu and she discusses them in this chapter. I have included the first part of the chapter here and will add the second part on dispelling stasis during the postpartum time in the next post.   I hope this information is as helpful to you all as it has been for me!

An Inquiry into the Treatment Laws for Postpartum Illnesses

 From Qiu Xiao Mei’s Gynecology

Due to the trauma of childbirth, a partuent woman’s source Qi may be damaged and her resistance may be reduced. This makes a woman susceptible to the external six excess evils and internally she is vulnerable to damage by the seven emotions, food and drink. In addition postpartum blood stasis can obstruct internally. For these reasons all manner of complaints can arise, the most common of which are postpartum fever, post partum bleeding, retention of lochia, persistent flow of lochia and scanty breast milk.  The Diseases, Pulse, Symptoms and Treatment of Post Partum Women’s Diseases of the Golden Cabinet, (金匱：妇人产后病脉并治 Jin Gui Ru Ren Chan Hou Bing Mai Zheng Bing Zhi） points out that a woman who has just given birth has three possible illnesses. The first is convulsions, the second is oppression and dizziness[1], and the third is difficult bowel movements.  This book illustrates this as follows:  “Having just given birth, blood is vacuous and profuse sweat goes out. This creates a tendency to seizures and convulsions. The combination of blood loss, further sweating and an abundance of cold leads to oppression and dizziness. Loss of Jin and Ye fluids leave the stomach parched and cause the bowels to be difficult.”

In view of the fact that a special characteristic of a postpartum woman is physical exhaustion combined with excess stasis, our predecessors had three examinations for the diagnosis and treatment of postpartum women.

• The first is to examine whether or not the lower abdomen is painful or not. This will tell you if there remains any lochia.
• The second is to see if the bowels are open or blocked. This will tell you whether the fluid is abundant or lacking.
• Finally, examine the breast milk to determine if it is flowing well and if the woman has a desire for food and drink. This will show you the strength or weakness of the Stomach Qi.

In order to carry out a synthesized analysis, this information is combined and compared with the partuent woman’s body type, pulse, tongue and other symptoms. Only in this way is one able to carry out the correct differential diagnosis and treatment for postpartum diseases.

In relation to postpartum illnesses, our predecessors speak of three emergencies, three surgings and three illnesses. The three emergencies are sweating, vomiting and diarrhea. When all three of these are seen simultaneously it is considered critical. The three surgings are, first, vanquished Blood surging into the Heart in which one out of ten recover. The second surging is surging into the Lung in which one or two out of ten recover. The third surging is surging into the stomach of which half live and half die.  These surgings are the way our predecessors viewed the prognosis of serious post partum Blood stasis patterns. Finally there are the problems mentioned above, convulsions, encroaching depression and difficult bowels, which the  Synopsis of Prescriptions of the Golden Cabinet (金匱要略 Jin Gui Yao Lue） speaks of as the three illnesses. The above-mentioned ideas about differential diagnosis and prognostic determinates have great guiding significance for us.

As for the treatment of postpartum illnesses, it very much depends on what I have discussed from our honorable predecessors combined with my own practical experience. The patterns are as discussed below:

1. Concerning postpartum supplementation

One Thousand Ducat Prescriptions（千金方 Qian Jin Fang)  says ‘The woman who has just undergone birth has vacuity of her five Zang. She is emaciated and so we must only strengthen and supplement. We mustn’t drain because if we do then there will be illness. We must not be hasty with our application of medicine. Hastiness could make the vacuity worse.”  Zhu Danxi also said “Don’t cause vacuity after birth! One must first greatly supplement Qi and Blood. Even if there are pathogens mixed in, treat them with only slight emphasis”. Fu Qing Zhu has great esteem for Dan Xi’s writings and states “For the most part, the illnesses arise due to depletion of Blood and Qi and vacuity of the Spleen and Stomach. This is especially so for postpartum women. It is master Dan-Xi’s great dictum on the treatment of birthing illnesses that we should greatly supplement the Qi and Blood as the priority and even if there are other pathogens, we should treat them with only slight emphasis. This idea of master Dan, as a general method, really can’t be beat!”  Moreover, the two doctors Li Dong-yuan and Ye Tian-she also advocated supplementation postpartum.

Still, there is some disagreement. For example, Master Zhang Zi-he says “postpartum one must be cautious not to only treat vacuity.”

Of course blood loss and injury to Jin fluid both leave the Blood empty and vacuous with consumed source qi.  This is the fundamental issue for postpartum women. It is appropriate to supplement and nourish. Though this is the common opinion, I view it differently. Cases of evil excess are also not insignificant in numbers, especially cases of excess within vacuity. Therefore one mustn’t be presumptuous and over generalize by only supplementing and nourishing. The symptom characteristics must be meticulously investigated in order to differentially diagnose and treat. As the Medical Ancestor’s Golden Cabinet（医宗金鉴 Yi Zong Jin Jian) states: ‘The ancients say that before birth a woman is without insufficiency and after birth she is without surplus”. This is a common way to look at things.

However, before the fetus is born, although illnesses are primarily due to excess, upon proper detailed examination one finds that there are also cases of insufficiency.  And on the other hand, although postpartum illnesses are mostly due to insufficiency, upon detailed inquiry, one finds that there is often harbored excess. Zhang Jing-yue also said, “Post partum a woman’s Qi and blood have been discharged and actually there is an abundance of vacuity illnesses but sometimes there is no vacuity. Sometimes there are cases of complete excess. All of these are possible so one should differentiate vacuity and excess and treat according to the illness. One must not wholeheartedly and categorically greatly supplement or you will help the evil”. The arguments of these two specialists, Zhang Zi-he and Zhang Jing-yue, are comprehensive and are consistent with clinical reality.

In past dynasties many doctors have placed emphasis on the supplementation method for postpartum women. The Synopsis of Prescriptions of the Golden Cabinet (金匱要略 Jin Gui Yao Lue）author established the prescription Dang Gui Sheng Jiang Yang Rou Tang Angelica, Ginger and Sheep Decoction for the treatment of “postpartum abdominal pain”. Dang Gui Radix Angelica Sinensis and Yang Rou Caprae seu Ovis Caro are chosen for their supplementing ability, which removes weakness. Sheng Jiang Rhizoma Zingiberis OfficionaIis is pungent and is able to dissipate cold. Doctor Lu Yuan-lei [2] further elucidates by stating “postpartum abdominal pain is caused by inner vacuity and this is the principle prescription”. For the treatment of postpartum illness, this is the leading prescription for warming and nourishing. The influence of later generations is very profound. The One Thousand Ducat Prescriptions（千金方 Qian Jin Fang) says “Nei Bu Dang Gui Jian Zhong Tang Internally Supplementing Angelica Fortify the Middle Soup is for the treatment of postpartum women who suffer from vacuity, insufficiency emaciation, continuous abdominal pain and weak breathing. If a month postpartum, the abdominal pain is rigid and urgent, extending to the back, and the woman has a poor appetite then it is good to give the woman four to five ‘packages a day” .

There is also an earlier precedent for using the method of warming and nourishing in the treatment of postpartum illness. Ye Tian-shi considered that most postpartum illness was caused by vacuity damage to the extraordinary channels of the eight vessels. He said ” Postpartum the lower source Yin level has been damaged (by the birth). Hence, the radiant beauty of the extraordinary channels of the eight vessels diminishes. The Liver and Kidneys become timid, weak willed and unconsolidated. The eight vessels loose their ability to manage their duties. Wu Ju-tong[3] also maintains that “postpartum one should investigate the eight vessels”. This is why all medicines stress supplementation and nourishment of the Liver and Kidneys in order to supplement the extraordinary channels of the eight vessels.

Fu Qing Zhu’s diagnosis and treatment of postpartum illness especially deserves to be put forward because it is particularly wise and insightful He considered the most important causative factor and mechanism for past partum illness was Qi and Blood vacuity depletion. For example, in relation to postpartum dizziness, he points out “the partuent woman’s fetal place descends toward the earth and at once there is clouding, dizziness and an inability to. speak. The Qi and Blood have both escaped”. He also. said “the whole reason for a partuent woman to have clouding and dizziness is vacuity and emptiness of the Blood Palace.” In regard to postpartum lower abdominal pain, he points out “Postpartum women experience lower abdominal pain, which feels better with pressure. People believe this is due to. ‘fetal pillow pain’[4], but who would guess that the cause is blood vacuity? He gives other examples of symptoms that occur postpartum such as panting like shortness of breath, raving and hallucination, certain kinds of stroke and convulsion, sweating and breast milk not letting down. In all of these situations, Master Zhu felt that Qi and blood vacuity and depletion played a large role. Consequently, far the treatment of postpartum illness, Master Fu often establishes his method based on supplementing and nourishing Qi and blood. He emphasizes supplementing Qi, explicitly pointing out “Blood has the nature of form and it is difficult to generate it rapidly. Qi is without form in its nature and it is easy to cause it to develop rapidly. One should supplement Qi in order to generate blood. It is easy to supplement blood in order to generate it but blood won’t be generated without Qi. It is by supplementing Qi that blood is generated”. Based on this view he established the prescriptions Shi Quan Da Bu Tang Complete Great Supplementing Decoction for the treatment of postpartum aversion to cold and shivering, Jiu Bai Qiu Sheng Tang Rescue Collapse, Rekindle Life Decoction for the treatment of postpartum Beng Luo, Tong Ru Dan Penetrate the Breast Elixir far the treatment of postpartum breast milk failing to descend and Zi Rong Yi Qi Fu Shen Tang Enrich Construction, Boost the Qi and Restore the Spirit Decoction for the treatment of post partum collapse.[5] The experience of Master Zhu is of great value as a reference and worth drawing lessons from.

When I apply the supplementation method, I extract what I need from the Masters mentioned above, especially Fu Qing Zhu. For example, for the treatment of post partum dizziness arising from Qi and Blood vacuity, Master Fu often used Dang Gui Bu Xue Tang Angelica Supplement the Blood Soup modified as follows:

• Dang Gui
• Huang Qi
• Lu Rong
• Sheng Jiang
• Hong Zao

 In extreme cases he used Du Shen Tang Unaccompanied Ginseng Decoction which was a way to adopt the sayings “When Yang is generated, Yin develops” and “Boost the Qi to generate blood”.

Another example of a postpartum condition requiring supplementation is when great blood loss overcomes the body, giving rise to pituitary ischemia and necrosis. The effect of this is that the ovarian function declines, the uterus atrophies and then there is amenorrhea. This is accompanied by alopecia, low libido, physical emaciation and weakness. The ancestral masters such as Ye Tian-shi and Wu Ju-tong say that the main principle of treatment in situations such as this is to supplement and nourish the Liver and Kidneys in order to harmonize the extraordinary channels of the eight vessels. Using the prescription Yang Xue Bu Shen Zhu Yang Yin Nourish the Blood, Supplement the Kidneys and Assist the Yang Drink obtains very good results.

Of course there are various ways to supplement and nourish a woman postpartum. In addition to the important methods of boosting the Qi, nourishing the blood, supplementing and nourishing the Liver and Kidneys, harmonizing and supplementing the extraordinary channels of the eight vessels, there are also the methods of harmonizing and rectifying the Spleen and Stomach, Nourishing the Heart, boosting the Lung, enriching Yin and moistening dryness. Clinically these methods should be applied according to the pattern.

As the above narration states, the majority of postpartum cases are caused by vacuity patterns. However, there are still excess evils and there can be excess within vacuity patterns. Therefore, to determine the clinical syndrome one must weigh the advance and retreat of the evil and the righteous and the greater or lesser urgency of the root or the branch. It also must be weighed whether to treat just with supplementation, whether to first supplement and then attack, whether to attack first and supplement later or whether to attack and supplement simultaneously. One must use differential diagnosis to seek the cause in order to determine the treatment. Don’t tend to grasp to one extreme.