As promised, here is part 2 of postpartum care:
When I see a woman just after she has given birth I try to come with an open mind as to what the whole picture might look like. As Dr. Qiu Xiao-Mei strongly asserts, we must address what we see and not jump to conclusions. Careful diagnosis is of the utmost importance. Appropriate care and treatment during the postpartum time can benefit the mother and child for years to come. On the other hand, inaccurate diagnosis can cause problems with far ranging repercussions as well. Of course in these kind of mixed excess/deficiency situations when so much is at stake one want to really make sure your diagnostic skills are precise and clear. In good measure, this is the foundational focus of the upcoming White Pine Institute Graduate Mentorship Program. Without these skills, mixed patterns can be confusing and we may miss an opportunity to really help because our lack of confidence makes us over cautious.
During my asking diagnosis with a postpartum woman I pay special attention to the following:
- Bowel movements
- Feverish feelings
- Body pain
- Nursing and breasts
- Healing of torn or cut tissue
Now, in terms of stasis in the womb postpartum, it is actually extremely common. Many women go on for many years without this stasis ever clearing. It does not always cause obvious or immediate pathology. However, it can cause chronic issues such as body pain, allergies, vaginal dryness and pelvic pain. Just after birth is the best time to help the woman’s natural clearing process be complete.
When doing listening diagnosis, I try to listen to the strength and liveliness of the woman’s voice and for any signs of depression or disconnection.
Looking diagnosis involves looking at the spirit in the woman’s eyes and complexion as well as at the quality of her flesh and constitution. Looking diagnosis also involves looking at the tongue. I especially look for signs of stasis and heat.
The remaining part of Dr. Qiu Xiao-Mei’s chapter below primarily talks about the general approach for treating women after they have given birth. There is so much more in her text that takes these general principles and puts them into practice. She has chapters on
- postpartum fever
- postpartum body pain
- postpartum urinary retention
- postpartum lochia failing to stop
- treatment of birth wounds
and more, all of which is covered in the Graduate Mentorship Program
Dr. Qiu Xiao-Mei’s Chapter on Postpartum Care Continued:
2. Concerning dispelling stasis postpartum
Another distinguishing pathological characteristic of post partum illness is static blood obstructing internally. After deeply examining the source cause I can say that it is either from external cold invading internally, trauma from delivery causing the blood pathways to stagnate and flow un-smoothly, evil blood remaining internally or the partuent woman used excessive strength and after the baby is delivered she has no strength left to push out the placenta. The placenta isn’t dispelled in a timely way and stagnates in the uterus causing the establishment of stasis and obstruction. Static blood is a problem and the conditions arising from it are many. One can see the lochia failing to descend, the lochia bleeding without stopping, postpartum dry blood, lower abdominal pain or postpartum fever all arising form static blood. With the passage of time, the stasis gets more silted up and can undergo pathological changes or cause body fever, steaming bones, poor appetite, marked emaciation, five heart vexation heat or amenorrhea. It can even develop into dry blood nodules in which case the evil has become deep and complex. Because of this, medical masters place great importance on the presence or lack of blood stasis in the diagnosis ~and treatment of postpartum women. They considered it necessary to carefully guard against it. For example, Fu Qing-Zhu stated, “The way to greatly support a newly birthed woman is to first observe the condition of the lochia and ask whether or not there are clots. The author of the Synopsis of Prescriptions of the Golden Cabinet (金匱要略 Jin Gui Yao Lue） established Zhi Shi Shao Yao San Immature Bitter Orange and Peony Powder for the treatment of “partuent women’s abdominal pain” and Xia Yu Xue Tang Lower Blood Stasis Decoction for the treatment of “partuent woman’s inner abdomen dry Blood below the navel.” This author also established Da Cheng Qi Tang Major Order the Qi Decoction. This prescription was used for the treatment of postpartum women who, seven to eight days after birth develop lower abdominal solid pain, continuing flow of the lochia, lack of bowel movement, agitation and vexation fever, pulse slightly excess, repeated fevers, daytime agitation and vexation, no food intake but upon eating there is delirium and around nightfall there is some recovery. Although these dispelling herbs have differences in their ability to treat heavy, light, acute and non acute illnesses, it is a given that they all are able to dispel and eliminate stasis accumulation. Later generations have had many opportunities to create clinical examples of these principles.
Harboring Blood stasis is a principle cause of illness for a newly partuent woman and so treatment should pay attention to quickening blood and dispelling stasis. For example, the Dan Liao Fang (澹疗方 Tranquil Treatment Prescriptions) stressed that post partum one should “transform evil blood”.
In Fu Qing Zhu’s discussion on the treatment of postpartum illnesses, he elucidates the special essence of the important characteristics of dispelling stasis and generating the new. He also elaborated quite a bit on the use of prescriptions, in particular the use of his highly praised Sheng Hua Tang Generate and Transform Decoction. Within the moving characteristics of this prescription, there is supplementation. It transforms the old while generating the new. It is considered a sacred medicine of blood clots for the treatment of postpartum undispersed blood stasis, which can transmute and generate all variety of pathology. It is often modified according to symptoms. For example, for the treatment of postpartum dizziness he recommended Jia Wei Sheng Hua Tang Generate and Transform Decoction with Additions and Subtractions:
- Chuan Xiong
- Dang Gui
- Hei Jiang
- Tao Ren
- Jing Jie
- Zhi Cao
- Da Zao
To treat collapse patterns he recommended using Jia Shen Sheng Hua Tang Generate and Transform Decoction with the Addition of Ginseng:
- Chuan Xiong
- Dang Gui
- Zhi Cao
- Pao Jiang
- Tao Ren
- Ren Shen
- Da Zao
To treat diarrhea he recommended using Jia Jian Sheng Hua Tang Modified Generate and Transform Decoction, which uses Lian Zi Semen Nelumbinis. All of these prescriptions are modifications of Sheng Hua Tang Generate and Transform Decoction.
Recently there was a report about the use of this prescription in regard to the following functions: Post partum promotion of breast milk secretion, regulating uterine contractions, decreasing the abdominal pain associated with contractions and preventing puerperal fever. In addition a modified use of Sheng Hua Tang Generate and Transform Decoction was used for dispelling retained placenta post partum. The herbs added were:
- Yi Mu Cao
- Mu Dan Pi
- Shu Di Huang
- Hong Hua
- Ai Ye
Altogether there were twenty-two cases and they all obtained excellent results.
Moreover, prescriptions such as Shi Xiao San Powder for Loss of Smile, Du Shen, San Single Sage Powder Fou Shou San Buddha Palm Powder, Gu Mo Jie San Myrrha and Dragon Blood Powder (Mo Yao , Xue Jie), Qing Hun San Clear the Ethereal Soul Powder ( Dang Gui, San Leng, Yan Hu Suo, Xue Jie, Chuan Xiong, Mo Yao). All of these prescriptions are frequently used postpartum in accordance with the pattern to quicken the Blood and dispel stasis.
Most cases of disease patterns arising from post partum Blood stasis are treated with Master Fu’s Sheng Hua Tang Generate and Transform Decoction. For example, I often use this prescription with the additions of Rou Gui and Wu Zhu Yu for the treatment of postpartum cold congealed blood stasis with lower abdominal cold pain. If a woman’s uterus lacks the strength to contract postpartum, I add Yi Mu Cao. If there is post partum infection with stagnant heat throbbing, fever and foul smelling lochia I will use this prescription with Pao Jiang removed and “with the addition of Ren Dong Teng, Huang Qin, Chai Hu, Bai Jiang Cao, Bai Hua She She Cao and Hong Teng.
Clinically there is frequently stagnation postpartum. As we have discussed, it is also appropriate to supplement and nourish post partum women at times. Because of these two conditions, one must pay attention to make sure the supplementation is not exacerbating the stagnation. He Ji Zhi Nan (合剂指南Harmonious Prescriptions Pointing South) states “The blood of a woman who has just given birth is completely vacuous. Yet one can’t greatly supplement for fear of increasing cold or heat. Often it is good to cause the lochia to go out to completion”. Fu Qing Zhu provides even more experience on this. He gave three postpartum warnings: “When there is pain from un-expelled clots, one must not hastily add Bai Zhu or Ren Shen“. He feared using ingredients that supplement and obstruct because they won’t disinhibit the stagnant blood so it can be expelled. He advocated that one must wait for stasis and clots to be dispersed and dispelled. If there is stasis amidst the vacuity he proposed that one “drive out stagnation in the midst of supplementing blood and disperse stagnating clots while generating blood”. The meaning of this is that it is wise to treat both the vacuity and repletion and simultaneously attend to the branch and root. This treatment protocol is fully embodied by Sheng Hua Tang Generate and Transform Decoction and the various modifications of it and is consistent with the experience of the masters.
3. Concerning the treatment of other illnesses arising postpartum.
As previously stated, the Qi and blood of a woman who has recently given birth has been expended and her strength to resist illness is weakened. On her exterior, it becomes easy for her to contract the six excess evils. On her interior it is easy for her to be injured by the seven emotions as well as food and drink. Often many illnesses arise simultaneously. 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) mentions Yang Dan Tang Yang Dawn Decoction or Zhu Ye Tang Bamboo Leaf Decoction for the treatment of postpartum stroke. It also mentions Bai Tou Weng Tang Jia Gan Cao E Jiao Pulsatile Decoction with the Addition of Licorice and Ass Hide Glue for the treatment of postpartum vacuity diarrhea. One Thousand Ducat Prescriptions（千金方 Qian Jin Fang) also states “Women with who have contracted wind in the birthing process with symptoms of heat vexation and agitation and spontaneous sweat should be treated with Xiao Chai Hu Tang Minor Bupleurum Decoction if she also has a headache. If there is vexation heat it is appropriate to use San Wu Huang Qin Tang Three Substance Scutellaria Decoction. This is all for postpartum contraction of evil.
Fu Qing-Zhu elucidates in great detail the treatment of the illnesses effecting post partum women. He proposes “Heavy birth, light evil” meaning that supporting the righteous is the main principle and dispelling evil is next. It also means, “attend to the root and weed out the branch”. For example, he said “For all women who have just given birth, the Ying and Wei are very vacuous making it easy to develop cold or heat, body pain, abdominal pain and a practitioner definitely can’t rashly give out effusing prescriptions. The principle prescription should be Sheng Hua Tang Generate and Transform Decoction. There then should be slight assisting with effusing herbs. During the postpartum time, a woman’s spleen is vacuous and she becomes susceptible to food blockage. This can cause whole body feverishness. Commonly practitioners will see that there is body feverishness and informally consider it an external contraction and hastily create a sweat. This may invite a speedy death. One should use Sheng Hua Tang Generate and Transform Decoction adding herbs to support the spleen and disperse food stasis”. He also said “On the whole, when a postpartum woman suffers from the two patterns of Qi counter-flow from indignation or food blockage, one must first supplement Qi and blood. In the case of Qi counter-flow one should then assist this with harmonizing the liver and putting the Qi in order to treat her properly. Afterwards, the depressive anger will spontaneously disperse. In the case of food stoppage, one can lightly assist by fortifying the spleen, dissipating and abducting and then the food stasis will spontaneously move”. If you exclusively rectify Qi and scatter stasis, not only will there be no improvement, there will be harm.
Nu Ke Jing Lun (女科经论) The Treatise on Gynecology also warns “When a woman has recently given birth and receives cold damage, one can’t rashly create a sweat.” In general, a postpartum woman’s blood is very empty and vacuous. Sweating can transmute into jerking sinews and twitching flesh (spasms), depressive encroachment coma, convulsions or constipation. The harm that can be done is not superficial.
In making a comprehensive survey of the above masters, I would say that for postpartum contraction of evil, contraction of Qi or food stoppage, overall, the principle is to support the righteous and consolidate the root. Dispelling evils is a branch treatment designed to assist. This corresponds to the idea that one mustn’t focus on methods that cause sweat, vomit or down bearing. This may cause a vacuity to become a serious vacuity and cause a rapid disaster.
In my clinic I have treated women who have contracted various illnesses, like fever, during the postpartum period. It is presupposed that one always differentially diagnoses in order to seek the cause and determines treatment upon examining the cause. At all times I pay attention to and give aid to the righteous Qi. Especially after the evil has retreated it is even more important to do such things as nourishing the blood and boosting the Qi, using banking up and supplementing methods.
I have also found it important to pay attention to harmonizing and supplementing the spleen and stomach in order to provide for the source of Qi and blood generation and transformation.
However, in terms of the varieties of illnesses contracted post partum, one certainly mustn’t use the principle of supporting the righteous without exception for all of these illnesses. In the event of an abundant evil being the principle problem one should rely heavily on the principles of root and branch, moderate and acute and adopt the saying “when acute, treat the branch”. This means that, in this kind of case, the principle method will be to dispel the evil Otherwise, if the evil is not gone, it will be a problem to nourish vacuity. How could the Zhen Qi be restored? The illness becomes difficult to heal. Therefore there is no rigid or mechanical answer to the above-mentioned concern.
4. Concerning useful medicinals for the postpartum woman
The early masters were very prudent in their use of herbs for the postpartum woman. Generally they recommended calming and· harmonizing prescriptions and were against the use of harsh prescriptions for attacking. There are also acupuncture treatments for the treatment of the special constitutional needs of a postpartum woman. As Fu Qing-Zhu pointed out “A postpartum woman may experience worry, fright, taxation and fatigue and have sudden vacuity of her Qi and blood. All of these pathological situations make it easy for vacuity to enter. If there is Qi depression, do not only apply herbs to consume and dissipate. If there is food accumulation do not only apply herbs to disperse and abduct. If there is heat, don’t use Huang Qin Radix Scutellariae Baicalensis or Huang Lian Rhizoma Coptidis. If there is cold, don’t use Rou Gui Cortex Cinnamomi Cassiae or Fu Zi Radix lateralis Aconiti CarmichaeIi Praeparatae”. He also said “All Qi consuming and blood cracking herbs as well as diaphoretics, ejectors, diffusers and purgatives are usually applied in strong and repletion cases but not in the case of pregnancy or postpartum”. Master Zhu made a special list of the ten errors in the use of herbs postpartum. He did this in order to help practitioners correct themselves in times when harm has been done. These really deserve a lot of thought.
There is an old saying that “postpartum it is appropriate to warm.” This is because, during the postpartum time, it is appropriate to help the pathway of the lochia to open through. When blood contracts cold it congeals and when it receives warmth it can move. If cool and cold herbs are used, the blood will congeal which will cause the evil blood to accumulate and stagnate, giving rise to pathology. Therefore it is generally appropriate for the treatment of postpartum women to use herbs that are warm in order for the lochia to promptly discharge.
Generally it is wise to approach the treatment of illnesses during the postpartum period flexibly and not mechanically. If you indeed come across an excess pattern in a postpartum woman, changing then to using attacking herbs is an approach that may apply. Zhang Zhong-Jing used Xia Yu Xue Tang Lower Blood Stasis Decoction and Da Cheng Qi Tang Major Order the Qi Decoction for the treatment of postpartum women. Fu Qing-Zhu treated his three syndromes of dead blood, food accumulation and phlegm with San Xiao Wan Three Dissipating Pill, which includes Huang Lian and Shan Zhi Zi, which are very cold. It also includes San Leng and E Zhu, which are both breaking through herbs.
Occasionally I have treated the serious problem of the lochia failing to descend post partum with the harsh, attacking prescription Tao He Cheng Qi Tang Peach Pit Decoction to Order the Qi. In the treatment of postpartum contraction of evil toxin fever, I have often used Hong Teng, Bai Jiang Cao, Huang Qin, Ren Dong Teng and other cool and cold herbs. In this way it’s clear that I followed the principle of not being rigid, neglectful or rash in the treatment of postpartum women. When there is vacuity, supplement. When there is excess, drain. When there is cold, warm. When there is heat, clear. Still, for the specific use of herbs, one must pay attention to the special characteristics of a woman when she is post-partuent. Pay attention when opening depression not to consume and dissipate. When dispersing food, one must simultaneously support the spleen. When heat is profuse, it is not appropriate to excessively cool when cold is excessive; it is not appropriate to excessively dry with fragrant herbs. It is important to know what is common and normal as well as to understand the transmutations. Only like this will one be able to obtain satisfactory results.
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