CHAPTER 7. Eastern approach to the postpartum
Introduction
In this book we are focusing on postnatal patterns for the mother rather than the baby, although the authors work extensively with babies. In modern cultures, the health of the mother is often neglected as most of the attention is focused on the baby and whether the baby is meeting development and growth goals. In most traditional cultures, by contrast, the health of the mother in the postnatal period was considered to be of vital importance as she is continuing to nourish the baby through physically feeding with her milk as well as emotionally supporting the baby. In Japan if the baby was ill, first the doctors would look to the health and well-being of the mother. The idea in most situations was, ‘Treat the mother and the baby will be well’, although not in cases of severe health situations for the baby.
The modern change in focus is probably due to several factors. It is partly a reflection of the lack of value placed on the role of the mother, partly due to the fact that many women no longer breastfeed their babies, and partly due to the fact that many more ill babies are surviving because of special care, so there are more babies needing medical treatment than before.
In many traditional cultures there was an initial period of 4–8 weeks of recovery which was known as the ‘lying-in’ period’. In the UK until recently it was respected and known as the ‘confinement’. This was a time for the mother to rest and be supported. The period of full recovery was considered to be much longer and in some cultures women were advised to wait 5–7 years to have another child (Goldsmith 1984). This fits in with the idea of Jing flowing in 7-year cycles – it needs time to replenish its quality.
In traditional Chinese medicine the puerperal period is defined as the 4 months following delivery. The first month is ‘small full moon’ or ‘Golden Month’. It was believed that any illness a mother contracted during that month would remain with her for the rest of her life. It was also believed that any existing illness a mother had could be healed. A huge emphasis was placed on healing the mother and during this time she should have plenty of rest, nutrition and support.
In traditional Japan there was an initial rest in period of 21 days ( toko age 21 nichi) and many women still observe this. If the mother had given birth in the midwife’s house she would be looked after by the midwife initially and given special foods or shiatsu for her and the baby, as needed. During the first 24 hours the mother would rest, but afterwards be moderately active in order to help restore the proper flow of Qi and Blood and accelerate the involution of the uterus. The midwife would often massage the mother’s breasts or show her how to massage them, to help with milk flow and prevent mastitis. There were masseurs who specialised in breast massage before and after birth. These are now less common.
The Golden Month was time for the mother away from ordinary life, to avoid excessive stress, emotional disturbances, overwork and fatigue and be supported. It was a special time and there was a sense of family support and connection to the ancestors. The woman would abstain from bathing, washing her hair, exposing herself to cold, swimming and so on. At the end of the Golden Month there was a ritual bath containing a mixture of herbs prescribed by a traditional Chinese medicine (TCM) practitioner which would feel a positive way for the woman to enter the next phase of her life as a mother.
The remaining 3 months of the puerperium are called the ‘big full moon’ and the mother would continue to look after herself and be supported by the community (Zhao 2006).
Postpartum disorders are one of the four major categories of Chinese medicine. A lot is written about the various conditions, which differ from the conditions now identified. For example, there was an emphasis on how the lochia was discharging and even the idea of retained lochia (not really present in Western medicine), the openness to fever and external invasion, as well as current concerns of healing of the abdomen and breast issues.
7.1. General energy patterns for the mother
Excess and combined patterns
The postnatal period is considered a complex time. Although there is an underlying pattern of depletion there can be conditions of excess and deficiency combined with excess. Heat and sweating can build up in the body. There can be deficiency and fullness as well as stasis of Blood. There can be too much Yang energy. Different and opposite patterns can coexist. However, due to the underlying pattern of depletion, we need to be careful with dispersing and cooling techniques. In addition to all of this there is the whole emotional and physical adjustment to life with a new baby – feeding the baby, bonding, lack of sleep, fatigue and so forth.
While it is important to understand the underlying patterns we cannot be too rigid as different things can be going on in the body at the same time. We need to be aware of the complexities and work with the reality for each mother.
Different Chinese physicians would emphasise different aspects of working. Fu Qing-zhu (translation 1995) gave priority to supplementing Qi and Blood and treating other things as secondary to that. This meant he made the following recommendations:
• Do not use Qi consuming or normalising medicines. This could make stuffiness and oppression worse.
• Even though there may be damage to the Qi, do not use dispersing techniques as this may damage the Stomach’s ability to take in food.
• Even though the body may be hot, do not use cold and cooling medicinals as the underlying pattern is of depleted Yin and fluids.
Another physician, Chen Liang-fang, considered that the first most common cause of problems is emptiness of Blood and consumption of Water fluids. He felt that there were three main patterns, the ‘ san yin’:
1. Blood vacuity with stirring of Fire
2. Frenetic movement of static Blood
3. Damage due to excessive food and drink.
(Chen Liang-fang, Nu Ke Mi Jue Da Quan; quoted in Flaws 2005: 217).
Three examinations
In Chinese medicine it was considered important to ask the following three questions:
1. Is there abdominal pain?This gives indications about what is happening with the uterus and the lochia, and if there may be retention of lochia.
2. Is there constipation?This indicates the relative exhaustion of body fluids, showing if Blood and Yin are abundant or depleted.
3. Is breast milk flowing?This is linked with the intake of food and drink and indicates how much Stomach Qi has been weakened. It also indicates if there is blocked energy in the breasts.
There are some typical patterns which express aspects of these energies:
• Nausea and heavy bleeding: indicates exhaustion of Penetrating Vessel.
• Sweating and fever: indicates exhaustion of Qi and Blood.
• Postnatal depression: indicates Heart Blood deficiency.
Three prohibitions
These are known as the ‘ San jin’ (Flaws 2005). However, different physicians would have slightly different prohibitions and sometimes these would contradict each other. One set is as follows:
1. Do not cause sweating – this is because Blood and fluids share a common source and they are likely to be depleted.
2. Do not precipitate postpartum recovery – the body is sensitive.
3. Do not disinhibit urination.
Depleted patterns
The force required for delivery draws upon the woman’s Qi – especially her Wood and Yang Qi. The loss of blood during birth drains Blood and Yin. The expulsion of the placenta draws upon Original Qi. The huge hormonal changes during labour and the immediate postpartum draw upon the Jing. All these mean that a Deficiency of Qi, Blood, Jing and Yin are the overriding conditions of women after childbirth.
The Conception and Penetrating Vessels are depleted and the blood vessels and channels are empty and prone to invasions by external factors such as cold, heat and infection. Even if the mother had an easy birth and feels well immediately afterwards, it is still important for her to make sure that she looks after herself in the first few weeks to allow her energies to replenish themselves. Unfortunately it is common these days for women to feel pressurised to ‘get back to normal’ and there is little support for them to spend time with their baby. The emphasis is on getting back to work and leaving her child’s care to others. If women do not get enough rest early on, they are drawing on their deeper reserves of energy, especially their Jing. Longer term they are more likely to suffer from exhaustion as well as being prone to other illness, both mental and emotional.
Depletion of Blood
We consider this separately under Blood patterns (below), as Blood is one of the most important energies to work with in the early postnatal period. Depleted Blood means that the mother is more prone to invasion by pathogenic wind.
Depletion of Qi
Sweating, fever and exhaustion are signs of depleted Qi. There will be persistent lochial discharge which is red, profuse, dilute and with no smell as the Qi fails to hold the Blood.
The most depleted area is usually the hara, the abdomen – the result of the sudden change of no longer containing the baby and the laxity of the abdominal muscles. All the meridians which pass through the abdomen, especially the Yin (Conception Vessel and Penetrating Vessel), will be depleted in energy, as will the lower back (Kidney and Governing Vessel) and the Girdle Vessel. The Girdle Vessel is particularly important because it gives support to all the other vessels. This is why women in traditional Japan would wear a wide belt ‘ sarashi’ (girdle), to give support and bring more energy to this area.
For women who have had a Caesarean, the hara is cut through energetically and all these energy flows must be especially supported as they tend to be even more weakened.
It is important for the mother to do some gentle exercise to prevent stagnation of Qi, but not to do excessive exercise which would deplete her energy still further.
Qi will be built up also by ensuring good breathing with gentle exercise (Air) and by following a nourishing diet (Food). This means that the Lung and Stomach meridians are especially important and should not be dispersed. Qi especially needs to build up when the mother is breastfeeding.
Depletion of Jing
Kidney energy and Kidney Jing are depleted postnatally, both due to the fact that the mother nourished the baby during the pregnancy with her Jing and also because through breastfeeding she is transferring her Jing to the baby in the breast milk. Jing is required for the formation of Blood and Blood is the source of breast milk.
While Jing can never be increased it can be replenished to some extent. It is important for the mother not to be in stressful situations, especially working long hours outside the home for some time after the birth, otherwise she will draw still further on her Jing and, rather than replenish it, further deplete it. This need not necessarily be the full cycle of 7 years, but for a few years, she will need to be careful of her energy. This includes ideally spacing children at least a few years apart so Kidney energy has a chance to renew itself. Traditionally sex was avoided in the early postnatal period to allow Jing to renew and while the lochia is being discharged to prevent the counter flow of blood, similar to refraining during menstruation.
Family support may help the mother to connect in a positive way with her ancestral energy.
Food will help support the renewal of Jing as the Stomach is the link between the Pre-Heaven and the Post-Heaven Jing.
Depletion of Yin
The loss of fluids, combined with the demands made on Yin during pregnancy, may lead to there being insufficient Yin in the body, which means that the body can become too hot. If the mother is hot, it is important to avoid excessive exposure to heat, as sweating is weakening after birth. Exposure to cold is not recommended either as the Chinese considered it to be one of the main causes of postpartum problems. Cold does not allow the Yin to build up and stagnates the Blood.
Blood: a key energy
There is a loss of Blood with the discharge of the placenta, the lochia and the resulting changes in the uterine lining. Furthermore a lot of the circulating Blood in pregnancy was circulating in the fetus and therefore is also lost. As the Penetrating Vessel is the Sea of Blood this channel will be depleted. Other organs especially affected are those involved with Blood production, namely Heart, Liver, Kidney and Spleen.
Depleted Blood
Signs of deep depletion include: continuous pale lochial discharge, dizziness, constipation, pale skin and tongue, restless Shen leading to sleeplessness, depression, anxiety and depressed milk supply.
As Heart governs Blood it is said that with the loss of Blood, the physical basis of the Heart, the Heart becomes restless as it has no anchor. Restless Heart energy rises, often to the head, and affects the Shen, the spirit, which it rules. This is the Chinese explanation of postnatal depression. Depression was considered linked mostly with patterns of Blood loss and its effects on the Heart.
The other main meridians connected with the Blood will also be affected – Spleen and Liver. It is important that the mother finds a balance between gentle exercise and rest to both move and restore Liver Blood. Spleen is sensitive to the food that the mother eats and therefore proper diet was considered of paramount importance.
It is considered that breast milk is a transformation of Blood, so if the mother’s Blood is low, then the mother may not be able to produce enough milk. Blood is built up with diet and exercise as well as supporting the key meridians.
Stasis of Blood
As there are many changes in blood flow, the Chinese considered this to be a relatively common pattern of imbalance. Blood could remain in the uterus due to old blood or pieces of the placenta or due to retained lochia. Retention of lochia is not considered to be a condition in western medicine, but flow of Blood is considered important in Chinese medicine.
When Blood is stuck in the Uterus, the lochial discharge is dark, purplish and with clots. This can lead to emotional issues, even psychosis. There can be rib pain which would indicate a stasis of Liver Qi, or lower back pain which can indicate a stasis of Kidney Qi.
With Blood stasis, work would need to be done to move the Blood, for example by gentle stretches and working away from the Uterus. However, it is important not to do too much dispersion work as the underlying pattern is of depletion.
Heat in Blood
Heat in the Blood is indicated by heavier bleeding and the lochial discharge will be bright or dark red, often with a foul smell. The mother may feel restless mentally, have abdominal pain and dry stools. There may be infection. In this case, it is important not to use warming techniques, such as applying hot towels or the Chinese herb moxa, as these will aggravate the condition. Calming, holding but not overly cooling techniques need to be used and great care must be taken especially if there is infection. LI 11 and SP 10 clear Heat. Work with Spleen, Penetrating Vessel and Conception Vessel can also help clear Heat.
External pathogenic factors
As the channels are empty they are prone to external invasions. For this reason work with the Extraordinary Vessels is especially important as they circulate Defensive Qi (Wei Qi).
Exposure to cold and heat
The Chinese considered exposure to cold as one of the main aetiological factors of postpartum problems. However, they also considered it important to avoid excessive exposure to heat, as sweating is weakening after birth and loss of fluids may lead to further depletion of Yin.
Exposure to wind
Again due to the depletion of the channels and blood deficiency the body is prone to invasion of wind. This can lead to issues such as joint pain and wind heat invasion which causes fever.
Support for nursing and bonding
This was considered an important aspect of the Golden Month. Herbs and diet would be part of the support to build up the Blood which is the foundation of the milk. Support for the Qi was also vital and bodywork can be helpful to ensure the smooth flow of energy within the breasts.
Work could also be done to support the bonding process. The mother is considered the baby’s emotional and energetic support and she herself needs to be supported so she can support the baby. There would also be specific work to support the Fire, through Heart, Ming Men and Yang Qi.
Sadly, in modern cultures, the mother often has to return to caring for other children, the household or workplace, unable to rest for her own replenishment and to bond with her baby.
Exercise and self-care
There was an emphasis on the need to rest, as lying down benefits Liver Blood and helps the body’s energies restore themselves. However, a need for gentle exercise was also emphasised to prevent stagnation of Qi and Blood.
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