Introduction
The period considered here is the first few weeks after delivery, called the puerperium in Western medicine. In Chinese medicine, this period was called chan ru (
): chan means ‘childbirth’ and ru means ‘cotton mattress’. This name gives an immediate indication about Chinese recommendations regarding the length of bed rest required after childbirth.
The old doctors placed the emphasis on different aspects of the period after delivery: some said that the three main conditions at this time are convulsions (now rare), invasions of external pathogenic factors and constipation. These three conditions were called san bing (
), i.e. the ‘three diseases’.
Others considered the three main problems as being vomiting, sweating and diarrhoea: these were called san ji (
), i.e. the ‘three emergencies’. Yet other doctors emphasized the san chong (
), meaning ‘three upward rebellions’, i.e. depleted Blood rebelling upwards in the Penetrating Vessel (Chong Mai) towards the Heart, Lungs or Stomach.
Zhang Zhong Jing says in his Synopsis of Prescriptions from the Golden Cabinet:
After childbirth the three main diseases are convulsions, collapse and constipation. After delivery, Blood is exhausted, the woman has perspired profusely, so that internal Wind develops and leads to convulsions. Exhaustion of Blood and profuse sweating may also allow Cold to invade leading to collapse. The exhaustion of body fluids leads to dryness of the Stomach and therefore constipation.1
Whatever the problems after childbirth, the puerperium is characterized by two major possible conditions: a deficiency of Qi, Blood or Yin, or Blood stasis. The force required for delivery taxes the woman’s Qi, the loss of blood during childbirth injures Blood and Yin, the sudden expulsion of the placenta injures the Original Qi, the Directing and Penetrating Vessels are depleted and the blood vessels and channels are Empty and prone to invasions by Exterior pathogenic factors. All these factors mean that a deficiency (of Qi, Blood, Yin) is the overriding pathological condition of women after childbirth.
However, this is not to say that there are no Full conditions after delivery. Zhang Jing Yue says in the Complete Works of Jing Yue (1624):
After childbirth Blood is lost and there is often a Deficiency. However, there are conditions of Deficiency, conditions without Deficiency, and Excess conditions. In these three cases, one must consider the woman and the pattern to differentiate between Deficiency and Excess. In treatment, one must not stick to one’s views complacently and when one tonifies one must also pay attention to eliminating pathogenic factors.2
Dr Chen Jia Yuan also places the emphasis on deficiency of Blood as the main condition after birth but he does not overlook pathogenic factors either:
After birth Blood is deficient and one must therefore tonify Blood. However, there may also be other patterns which must be treated and one should drive out the stale and generate the new.3
As a general decoction to be used after childbirth, Dr Chen recommends Dang Gui Radix Angelicae sinensis, Chuan Xiong Rhizoma Chuanxiong, Shu Di Huang Radix Rehmanniae preparata, Rou Gui Cortex Cinnamomi, Bai Zhi Radix Angelicae dahuricae, Shan Zha Fructus Crataegi, Wu Yao Radix Linderae, Chen Pi Pericarpium Citri reticulatae, Jie Geng Radix Platycodi, Gan Jiang Rhizoma Zingiberis, Gan Cao Radix Glycyrrhizae, Chuan Niu Xi Radix Cyathulae and Wu Ling Zhi Faeces Trogopteri. From an analysis of this formula’s ingredients, we can see that Dr Chen nourishes Blood but also invigorates Blood and eliminates stasis after childbirth.
Apart from the above deficiencies, a stasis of Blood is the other common pathological condition after childbirth. Stasis of Blood after delivery may be due to retention of old blood in the uterus or retention of lochiae. Deficiency of Blood or stasis of Blood after childbirth are, in fact, the two underlying conditions for mental changes in the puerperium: deficiency of Blood may cause post-natal depression while stasis of Blood may cause psychosis.
Apart from a deficiency and stasis of Blood, another consequence of the strain of childbirth is the propensity to invasions of external pathogenic factors. As mentioned above, after childbirth when the blood vessels and channels are Empty due to the loss of blood during delivery, they are prone to invasion of Wind.
As for diagnosis, apart from the usual diagnostic tools, three questions, called san shen (
), are often referred to as crucial after delivery. The first question is whether or not there is abdominal pain: this tells the doctor whether there is retention of lochiae or not. The second question concerns whether or not there is constipation: this indicates the extent of exhaustion in the body fluids, Blood or Yin, i.e. the more constipation there is, the greater the exhaustion. The third question is whether or not the mother’s breast milk is flowing: this tells us how much Stomach-Qi has been weakened, i.e. the less milk there is, the more Stomach-Qi has been weakened.
The treatment principle in treating women during the puerperium is to assess the relative importance of deficiency and excess, i.e. deficiency of Blood and/or Yin versus stasis of Blood. In any case, one must not adhere rigidly to the accepted, conventional ideas about the pathology after childbirth discarding any manifestation that might not fit into the accepted patterns. The Chinese explain this in a succinct saying that, translated, states: “Do not adhere rigidly to ideas about the post-partum conditions, but, on the other hand, do not forget the post-partum pathology.”
Thus, the treatment principle should be based on a clear differentiation between deficiency or excess (in the form of stasis of Blood): if a deficiency predominates, one must nourish Blood, tonify Qi or nourish Yin, and if there is stasis of Blood, one must invigorate Blood and eliminate stasis. However, it is of course possible for these two conditions to occur simultaneously and, indeed, one would probably never nourish only or eliminate only to the exclusion of the other. For example, if we believe that a deficiency of Blood predominates and prescribe a Blood-nourishing prescription, it would be a good idea to include one or two herbs to invigorate Blood: the closer in time to delivery, the more important it would be to invigorate Blood also.
Vice versa, if one were using a formula to invigorate Blood and eliminate stasis, it would be a good idea to add one or two Blood tonics. The problem of preventing stagnation when tonifying does not really exist with acupuncture as practically any acupuncture point moves Qi and Blood. For example, if we use ST-36 Zusanli and SP-6 Sanyinjiao to tonify Qi and Blood, there will be no danger of creating some stagnation, a risk we would run with Blood-tonic herbs due to their cloying effect.
Zhang Jing Yue says that three treatment methods should not be used after childbirth, i.e. sweating, moving downwards and promoting urination. He says that using sweating may damage Qi, moving downwards will damage the Spleen and cause the pulse to become scattered, and promoting urination will damage the Body Fluids and cause Stomach dryness.4
Dr Chen Jia Yuan differentiates between treatment methods to be adopted according to a time scale. He says:
The treatment principle must be adapted according to timing: within 20 days from the birth Qi and Blood are still unsettled, the lochiae are being discharged and the main treatment principle is to ‘break Blood’ [i.e. strongly invigorate Blood]. After 20 days from the birth, Qi and Blood are settled and they have returned to the channels, even if there is still a lochial discharge, one should not move, but tonify Qi and Blood as well as simultaneously invigorate Blood.5
Fu Qing Zhu emphasizes that the central pathology of post-partum conditions is deficiency of Qi and Blood and of Stomach and Spleen. He advises against using too many Qi-moving herbs, or cold herbs such as Huang Qin Radix Scutellariae or Huang Lian Rhizoma Coptidis, or too hot herbs such as Fu Zi Radix Aconiti lateralis preparata. He also advises against applying a diaphoretic treatment with Ma Huang Tang Ephedra Decoction, or a purgative one with Cheng Qi Tang Conducting Qi Decoction, or a harmonizing one with Xiao Chai Hu Tang Small Bupleurum Decoction.6
Fu Qing Zhu also lists ten common mistakes made in the treatment of post-partum conditions:
Although the above rules provide an interesting insight into Fu Qing Zhu’s thinking regarding treatment strategies after childbirth, they should not be accepted without question. In fact, some of them contradict what Fu Qing Zhu himself says earlier. For example, he considers a deficiency of Qi and Blood and of Stomach and Spleen as central to post-partum pathology, but in rules 4 and 5 above he cautions against using Huang Qi Radix Astragali or Shu Di Huang Radix Rehmanniae preparata; on the other hand, he uses the formula Sheng Hua Tang Generating and Transforming Decoction (which invigorates Blood and eliminates stasis) for very many post-partum conditions.
When using herbal medicine in the weeks immediately after childbirth, one must exercise caution, especially when expelling pathogenic factors. Thus, when moving Qi, one should not use too many scattering herbs; when dissolving masses, one should support the Spleen; when expelling Cold, one should not use too hot herbs, which may dry up Yin; when cooling, one should not use too many cold herbs, which may damage the Stomach.
Also crucial in the period after childbirth is paying proper attention to nursing, achieving a good balance between rest and activity, eating a nourishing but light diet, not being exposed to extremes of cold or heat and avoiding emotional stress. In particular, the ancient Chinese placed great stress on avoiding exposure to cold after childbirth, which they considered one of the major aetiological factors of post-partum problems.
Of the post-partum problems, most are due to Wind-Cold or improper diet … In summer, post-partum diseases are mostly due to Wind, while in Winter mostly to Cold; diseases due to improper diet occur independently of seasons. Post-partum diseases occurring after an easy childbirth are easy to treat, while those occurring after a difficult labour are difficult to treat.8
Of particular importance to Western patients is the stress on the need for rest after childbirth which runs counter to modern post-partum practice. It is of the utmost importance for women to have plenty of rest for at least a month after childbirth. By ‘rest’ is meant alternating periods of activity with frequent periods of bed rest as lying down benefits Liver-Blood. The modern tendency is, of course, for women to try and resume a ‘normal’ lifestyle a few days after childbirth: this is definitely wrong from the Chinese point of view and the importance of rest after childbirth cannot be overemphasized. This is all the more important if the childbirth was long, difficult or if there was a larger than normal loss of blood. However, it is also necessary for women to do some gentle exercise after childbirth to prevent the development of stagnation of Qi and Blood.
A woman after childbirth should avoid exposure to cold as the channels and blood vessels are vulnerable and in an ‘open’ state after childbirth and are therefore prone to invasions of external pathogenic factors. However, she should also avoid excessive exposure to heat as sweating is particularly weakening after childbirth (as loss of fluids at this time may easily lead to Yin deficiency). For the same reason, a woman should not sunbathe in the summer.
As for diet after childbirth, this should consist of nourishing but easily-digestible foods. A woman should avoid eating greasy, fried foods which may cause Phlegm and cold, raw foods which may cause Cold in the Uterus. Particularly beneficial foods are beef, free-range chicken, carp, pig’s trotter, carrots and Day Lily (Hemerocallis fulva) vegetables.
Western view
The time after childbirth is called the puerperium and is defined as the time during which the pelvic organs return to their normal condition: by convention, the puerperium is said to last about 6 weeks. One of the main priorities after delivery is prevention of infection from implantation of pathogenic organisms in the birth canal. On this subject, ancient Chinese doctors knew the danger of infection from exogenous pathogenic factors and attributed propensity to infection to the exhausted state of Blood. For this reason, the vulva and perineum should be kept as clean and as dry as possible. From the Western point of view, the main danger of infection is from streptococci or staphylococci organisms and therefore visitors or hospital staff who have septic foci should be excluded from visiting the woman. Western ideas about exercise after childbirth differ from Chinese ones and women are usually encouraged to return home (if they have delivered in a hospital) within 5 days or less. However, moderate exercise is important to restore the tone of the pelvic muscles, improve circulation in the legs and reduce the incidence of venous thrombosis.
The temperature usually rises to 37.9°C (100°F) in the first 24 hours but, under normal circumstances, it soon falls to normal. If the temperature is raised for longer than a few hours and is accompanied by a rise in the pulse rate, an infection of the genital tract should be suspected. The pulse rate also rises shortly after childbirth but it returns to normal the second day. A persistent rise in the pulse rate may indicate severe anaemia, venous thrombosis or infection of the birth canal.
Breastfeeding soon after delivery stimulates the release of oxytocin and the contraction of the uterus. The uterus takes about 8 weeks to return to its normal size. Immediately after delivery the border of the uterus is about 4 cm below the umbilicus and, by the tenth day, it cannot be felt above the pubis.
He Ren 1981 A New Explanation of the Synopsis of Prescriptions from the Golden Cabinet (Jin Kui Yao Lue Xin Jie 
), Zhejiang Science Publishing House, p. 177. The Synopsis of Prescriptions from the Golden Cabinet was written by Zhang Zhong Jing c. AD 200..
Zhang Jing Yue 1986 The Complete Works of Jing Yue (Jing Yue Quan Shu 
), Shanghai Science and Technology Press, Shanghai, p. 669. First published in 1624..
Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong 
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 23. Chen’s book, written during the Qing dynasty (1644–1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang) and published in 1729..
The Complete Works of Jing Yue, p. 670..
Eight Secret Books on Gynaecology, p. 65..
Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke 
), Shanghai People’s Publishing House, Shanghai, pp 70–71. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..