Post Natal Acupuncture

Abstract Traditional Chinese medicine has very firm ideas on the amount of care and rest appropriate to the first month or longer after childbirth that contrast with the modern emphasis on returning to normal activities within a week or two. Recovery after childbirth can be promoted by appropriate tonifying acupuncture treatments and dietary advice. Furthermore specific problems post-birth, for example persistent uterine bleeding, afterpains, night sweats, perineal discomfort, breast feeding problems and postnatal depression can all be helped with acupuncture. Keywords: acupuncture, childbirth, pregnancy, postnatal. WESTERN MEDICAL INFORMATION The postnatal period refers to the six weeks directly following childbirth. Initially women experience: • A bloody vaginal discharge (termed lochia) that will diminish and turn a lighter pinkish colour as the week progresses. Initially this discharge of leftover blood, mucus and tissue is as heavy as a period and lasts for three to four days. It will then turn a watery pink, progressing through brown, yellow and white over the next few weeks. Women may need to continue to wear sanitary protection to absorb this flow as it can continue for six weeks. • Abdominal cramps (termed afterpains) as the uterus contracts. These tend to occur when oxytoxin is released as the baby latches on to breastfeed. They are usually at their most intense in the first 48 hours following birth, subsiding naturally and disappearing within four to seven days. • Women who have given birth vaginally and have a tear will generally experience some perineal discomfort. This can range from numbness to acute pain on walking, sneezing and coughing in those women who have had stitches. This pain or discomfort is expected to diminish as the perineum heals, within seven to ten days. • For women who have had a caesarean section there will be incision pain and later numbness around the scar site. It is important to remember that although recovery will compare to somone who has undergone any kind of abdominal surgery, there will be the additional factor of recovering from childbirth. In other words there will still be afterpains, lochia discharge, breast engorgement and breast-feeding to establish. • There may well be difficulty passing urine or having a bowel motion in the first 24 hours postpartum. It is considered essential that the bladder is emptied within two to three hours of the birth so that the uterus can descend without a distended bladder physically obstructing it. Having the first bowel motion following delivery (usually around day three), often involves a perceived fear of pain, especially if there are perineal or abdominal stitches. • There will usually be some breast discomfort, with the breasts becoming engorged with milk on day three or four as the milk flow comes in and changes from rich colostrum to breast milk. This is a natural process and will occur even if a woman does not breastfeed. Colostrum is a rich premilk that will be present in small amounts (a teaspoon or so is all that is required for each feed). It contains antibodies and is ideally designed to aid the baby’s digestive system. The arrival of breast milk around the third day can occur within a time period of a few hours, resulting in breasts that are hard, painful and perhaps swollen to three times their normal size, often making breastfeeding difficult. This engorgement is usually brief (lasting two to three days) and settles as the body’s milk production supply becomes established and adjusts to the baby’s feeding demands. Sore or cracked nipples are often present during the first few days of breastfeeding before the nipples “‘toughen up”. This should only be temporary, often peaking around the 20th feed and then diminishing until breastfeeding is established as pleasant and painless. • Emotionally the postnatal period can be very different from some mothers’ expectations. Immediately following the birth it is common for women to feel relief that the birth is over rather than experience that “magical bonding moment” so often written about in childbirth books and displayed on film and television. The first few days are often filled with feelings of both elation and depression, with many swings between the two. Often around day three the “baby blues” kick in. These are thought to be associated with changes in the woman’s hormone levels and manifest as unexplained bouts of crying or mood swings. These feelings are expected to subside after a few days. BOX: Immediately following the birth it is common for women to feel relief that the birth is over rather than experience that “magical bonding moment” so often written about in childbirth books and displayed on film and television. At six weeks the woman will usually have a postnatal check with her midwife or doctor. It is expected that by this time: • The uterus will have returned to its pre-pregnancy shape, size and location. • The vagina will have contracted and regained much of its muscle tone. • Any episiotomy or lacerations to the perineum will have healed. • The vaginal discharge of lochia will have stopped. • Breast-feeding will now be established with no engorgement, discomfort or nipple soreness. For those women who are bottle-feeding, their breasts will also have “normalised” with no residual discomfort, swelling or pain. • For those women who had a caesarean delivery, their scar will have healed and they will be recovering well from the abdominal surgery. Possible complications 1. Retained products If the uterus does not expel the placenta or membranes completely following delivery, there is the potential for haemorrhaging, or for a uterine infection to develop. A woman must contact her midwife or doctor immediately if one or more of the following develops: • There is bleeding that saturates more than one pad an hour for several hours in succession after the first 12 hours. • Persistent bright red heavy bleeding that continues after the fourth day postpartum. • Lochia that has a foul odour; anything that smells offensive or different from a normal menstruation discharge should be considered suspect. • Large blood clots in the lochia; while small clots are considered normal in the first few days, anything that is larger than the size of a lemon should be reported to a midwife or doctor. • The complete absence of any lochia during the first two weeks can also indicate the presence of retained products. • Increasing pain or discomfort in the lower abdomen following the first few days after delivery. • An elevated temperature of 37.8 degrees or above that is present for 24 hours during the first 3 weeks postpartum. (It is considered normal for the woman’s temperature to rise slightly immediately after delivery for up to 24 hours). 2. The development of a deep vein thrombosis This is the danger of a clot developing within the deep vein of the leg. Warning signs which need to reported to the women’s midwife or doctor include: • Localised pain, warmth or tenderness in the calf muscle. There may or may not be redness and swelling over the area. • Sudden sharp chest pain with or without difficulty in breathing as this can be a sign that a blood clot has travelled to the lungs. 3. Infection of the caesarean scar There will be localised swelling, tenderness and redness at the incision site. While a small amount of clear serous ooze is considered normal in the first few days following surgery, persistent oozing is not. If there is pus present the woman’s doctor or midwife should be notified. 4. Mastitis This can result from a blocked milk duct within the breast or from bacteria entering into the breast, often through a cracked nipple. With a blocked milk duct there will initially be some localised redness in the area. If this does not become unblocked through feeding or expressing, there will be localised pain, swelling, redness and feelings of heat in the breast (or a certain section of the breast) as milk is pressured into the breast tissue. There will also be generalised chills, and a fever or ‘flu like symptoms as the mother’s immune system responds. When a bacterial infection is involved, the symptoms will be as above but due to the presence of bacteria (usually Staphylococcus aureus) there is the potential for a breast abscess to develop. 5. Depression While it is thought that as many as half of all women experience some depression in the first week following birth, if this depression is extended or severe, professional help should be sought. Depression (often termed “the baby blues”) following a birth can range from sudden mood swings with unexpected bouts of crying (even though the woman would state she feels happy most of the time), to feelings of exhaustion and an inability to cope, or even to feelings of guilt or anger about aspects of the delivery that did not go as planned. Persistent depression is often termed ‘postnatal depression’ while ‘puerperal psychosis’ refers to an acute psychiatric illness that develops postnatally and will require prompt medical treatment. Indications of a depression that is not merely the “baby blues” include depression that persists for more than 2 weeks and is accompanied by any of the following: • Sleeplessness (this can feel like a high energy burst so that woman are suddenly up and cleaning the house at 2am). • Lack of appetite. • Persistent feelings of hopelessness and or helplessness. • Suicidal thoughts or urges. • Violent or aggressive feelings towards the baby. BOX: While it is thought that as many as half of all women experience some depression in the first week following birth, if this depression is extended or severe, professional help should be sought. A TRADITIONAL CHINESE MEDICINE VIEWPOINT In terms of patterns of disharmony, women in the postnatal period are prone to suffering from: i. deficiencies of qi, blood and yin. ii. blood stasis. iii. invasion of pathogenic cold and/or wind. From a traditional Chinese medicine viewpoint the first three days post-birth are seen as a time of elimination or purgation. During this time treatment should only be given for problems arising from stagnation. This is then followed by thirty days of tonification (up to one hundred days in certain texts), seen as necessary to rebuild the blood and qi lost through pregnancy and childbirth. This concept of tonification applies to all women, not just those who feel exhausted following a difficult pregnancy or labour. It is also seen as important that following childbirth women avoid exposure to wind and cold, and anything that will disrupt the harmony of their emotions, as women are particularly vulnerable to these factors becoming pathogenic at this time. BOX: From a traditional Chinese medicine viewpoint the first three days post-birth are seen as a time of elimination or purgation. During this time treatment should only be given for problems arising from stagnation. Exposure to cold during and after labour was considered to be particularly harmful in China in the past, and with more basic living conditions was obviously more of a risk. For example many Chinese women had long hair and no hairdryers. In fact midwives report than even today there are women from China who avoid the use of electric fans during and after labour, will not drink iced drinks and do not take a bath for a week. Giovanni Maciocia quotes Dr. Chen Jia Yuan 1642 "Of post partum problems most are due to wind cold or improper diet"1. Clinical practice 1. General postnatal tonification treatment It is only too common in clinical practice to see women presenting with a range of depletion problems that originated or worsened following the birth of a child, and there are very real benefits in using traditional Chinese medicine during a pregnancy and during the postnatal period to prevent disharmonies developing. As the initial three days following childbirth are seen as a purgation period, it is important that qi and blood tonification treatments should only be commenced after this time. “Mother roasting”, a moxibustion technique, is a useful treatment to start with, as this can be done by the woman herself and her support people in the convenience of her home. This is a one off treatment, given around day four or five post-birth, that can be utilised to energise women and aid their recovery. The woman, or preferably her partner, can be shown how to use a moxa stick to warm the woman’s abdomen, travelling from Qugu REN-2 up to Shenque REN-8 and back down again for five to ten minutes or until the woman feels pleasantly warm. If possible, (that is, the woman has someone willing to do this for her) moxa can also be used on the Governing vessel from Yaoshu DU-2 to Mingmen DU-4 in the same way. Shenshu BL-23 also lends itself well to be tonified with moxa as part of this post birth treatment. It is important to stress that ‘mother roasting’ should not be done if the woman has a temperature, or is experiencing night sweats, as the use of moxa in cases of internal heat or yin deficiency will potentially cause further problems. It would also be a wise precaution to avoid using moxa over a caesarean scar if there is any suspicious redness or pus-like discharge. Acupuncture, moxibustion and dietary therapy can then be utilised on a follow up visit to facilitate the body in building good quality qi and blood. Suggested points for tonification treatments during the month following childbirth include: • Gaohuangshu BL-43 to tonify and nourish the Lung, Heart, Kidneys, Spleen and Stomach. • Zusanli ST-36 to tonify the Spleen and Stomach. • Zhongwan REN-12 to tonify the Spleen and Stomach. • Guanyuan REN-4 to tonify the Kidneys. • Qihai REN-6 to tonify Kidney yang. • Shenshu BL-23 to tonify the Kidneys. • Mingmen DU-4 to tonify the Kidneys. Further points may be added to calm the mind to aid relaxation and sleep, for example: • Baihui DU-20 • Yintang (M-HN-3) • Neiguan P-6 • Shenmen HE-7 • Sanyinjiao SP-6 As a guideline, two or three points from the above can be used at each visit, with the woman receiving treatment once a week for two to three weeks. From a practical perspective it can be useful to suggest that women come for this follow up appointment with a support person approximately ten to fourteen days following the birth. Women can then be individually assessed for any relevant traditional Chinese medicine patterns of disharmony and specific dietary or herbal recommendations can be made. Although this diagnosis may include a range of disharmonies there is often an underlying pattern presenting of Spleen and or Kidney Yang deficiency. Support people can also be shown any relevant tonification points to moxa at home to support your treatment of those women with Spleen or Kidney yang deficiency. Spleen yang deficiency Clinical manifestations Loss of appetite, epigastric distension after eating, tired and heavy sensation in the limbs, loose stools containing undigested food, tiredness, feeling cold and cold limbs, a pale tongue that is swollen and moist and a thready (xi), slow (chi) and deep (chen) pulse. Treatment principle: tonify and warm Spleen yang. Points: Zusanli ST-36. Method: Reinforcing method with moxa. Kidney yang deficiency Clinical manifestations: feeling chilled, cold limbs, tiredness, a lower back that feels cold, weak and aching, a pale tongue that is swollen and moist, a deep and weak (ruo), and maybe slow (chi) pulse. Treatment principle: tonify and warm Kidney yang. Points: Shenshu BL-23, Guanyuan REN-4. Method: Reinforcing method with moxa. Needling Notes Gaohuangshu BL-43 Oblique lateral insertion 0.3 to 0.5 cun. Caution: deep perpendicular or deep oblique needling in a medial direction carries a substantial risk of causing a pneumothorax. Zusanli ST-36 Perpendicular insertion 1 to 1.5 cun. Zhongwan REN-12 Pendicular insertion 0.8 to 1.5 cun. Caution: in thin patients deep needling may penetrate the peritoneal cavity. Guanyuan REN-4 Oblique insertion 1 to 1.5 cun directed towards Shenque REN-8. Caution: deep insertion may penetrate a full bladder. Qihai REN-6 Pendicular insertion 0.8 to 1.5 cun. Caution: in thin patients deep needling may penetrate the peritoneal cavity. Shenshu BL-23 Oblique or perpendicular-oblique insertion towards the spine 1 to1.5 cun. Caution: deep perpendicular needling carries a risk of injuring the Kidney. Mingmen DU-4 Perpendicular insertion 0.5 to 1 cun. Caution: the spinal canal lies between 1.25 and 1.75 cun deep to the skin surface, varying according to the body build. Baihui DU-20 Transverse insertion 0.5 to 1 cun. Yintang (M-HN-3) With the fingers of one hand pinch up the skin over the point and with the other hand needle transversely in an inferior direction 0.3 to 0.5 cun. Neiguan P-6 Perpendicular insertion 0.5 to 1 cun. Shenmen HE-7 Perpendicular insertion 0.3 to 0.5 cun. Sanyinjiao SP-6 Perpendicular or oblique proximal insertion 1 to 1.5 cun. 2. Persistent uterine bleeding Persistent uterine bleeding refers to lochia that continues to contain obvious blood and/or clots after day ten (and certainly by day 14). Often women will experience a slightly heavier period of bleeding around day ten but this will then be followed by the lochia reducing and changing into the expected postnatal discharge (that is clear or brownish in appearance). Women will often wear sanitary protection to cope with this diminishing discharge until three weeks postnatally. From a traditional Chinese viewpoint persistent uterine bleeding may arise from qi depletion, blood stasis or blood heat. Retained products initially indicate blood stasis. If the uterine products are not completely discharged following birth there is a risk of a uterine infection or haemorrhage developing, so it is important that the woman’s midwife or doctor is aware of any suspected retained products. Lochia that is absent, foul smelling, that contains large clots or any excessive vaginal bleeding can indicate the presence of retained products. If an infection develops or there is continual heavy prolonged bleeding, the woman will be admitted to hospital for a surgical D&C (dilatation and curettage) to ensure that all the afterbirth products are removed. Qi depletion Clinical manifestations: blood loss that is heavy and dilute, accompanied by a pale face and exhaustion, a pale tongue and a thready (xi) pulse. Treatment principle: tonify qi. Points: Baihui DU-20, Yinbai SP-1, Sanyinjiao SP-6. Method: Reinforcing, moxa applicable. Needle then moxa, or moxa cones alone on Yinbai SP-1. Blood stasis Clinical manifestations: increasingly painful abdominal cramping that is associated with heavy or clotted uterine bleeding, a purple tongue and a wiry (xian) pulse. If blood stasis presents as a cold pattern, with a woman craving warmth on her abdomen, moxa should be used. Treatment principle: invigorate blood and eliminate stasis. Points: Kunlun BL-60, Sanyinjiao SP-6, Hegu L.I.-4, Guanyuan REN-4, Xuehai SP-10, Diji SP-8. Method: reducing; moxa is indicated if appropriate. Blood heat Clinical manifestations: persistent red dilute bleeding, heat signs such as thirst, a red face and constipation, a red tongue and a rapid (shu) pulse. Treatment principle: clear heat, cool blood and stop bleeding. Points: Quchi L.I.-11, Diji SP-8, Yinbai SP-1. Method: Even method, no moxa. Clinical notes Feedback from midwives suggests that utilising acupuncture at two or three of the points indicated above for blood stasis is an effective way to stimulate the passing of any suspected retained products. The woman reports the passing of a clot or membranes soon after or within a day of treatment, after which time the bleeding begins to subside. If this does not occur the woman’s midwife or doctor will need to be notified so that a further medical assessment can be completed The women I have seen in clinical practice with persistent uterine bleeding most commonly present with some signs of blood stasis. Treatment is therefore initially aimed at clearing any retained products that may be contributing to the prolonged bleeding, utilising points such as Sanyinjiao SP-6, Hegu L.I.-4 , Guanyuan REN-4, Xuehai SP-10 and Diji SP-8 as outlined above for blood stasis. This initial treatment is then followed by a treatment approximately two to three days later, when points such as Yinbai SP-1 and Baihui DU-20 are used to tonify qi and stop uterine bleeding. If there are indications of blood heat, Quchi L.I.-11 needled with a reducing method can be included. It  is important to note that any signs of heat in the postpartum period should be considered as signs of a possible uterine infection. For women presenting with blood heat, therefore, it would be prudent to check for additional signs such as slight fever, vague lower abdominal pain and any foul smelling vaginal discharge. These  indicate a possible uterine infection and the woman’s midwife or doctor should be notified. Point discussion Baihui DU-20 Raises qi to stop bleeding2. Yinbai SP-1 With moxa stops uterine bleeding3. Sanyinjiao SP-6 Tonifies the Spleen and invigorates blood; indicated for uterine bleeding and retention of lochia4. Kunlun BL-60 Promotes expulsion of the placenta5. Hegu L.I.-4 Increases the intensity and frequency of contractions6. Guanyuan REN-4 Indicated for persistent flow of lochia and postpartum abdominal pain7. Xuehai SP-10 Invigorates the blood and dispels stasis8. Diji SP-8 Regulates the uterus and stops bleeding9. Quchi L.I.-11 Clears heat, cools the blood10. Needling notes Baihui DU-20 Transverse insertion 0.5 to 1 cun. Yinbai SP-1 Perpendicular or oblique insertion directed proximally 0.1 to 0.2 cun. Sanyinjiao SP-6 Perpendicular or oblique proximal insertion 1 to 1.5 cun. Kunlun BL-60 Perpendicular insertion 0.5 to 1 cun or directed superiorly to join with Taixi KID-3 1.5 to 2 cun. Hegu L.I.-4 Perpendicular insertion 0.5 to 1 cun or oblique insertion directed proximally 1 to 1.5 cun. Guanyuan REN-4 Perpendicular insertion 0.5 to 1 cun or oblique insertion directed inferiorly 1 to 1.5 cun. Caution: deep insertion may penetrate a full bladder. Xuehai SP-10 Perpendicular or oblique insertion 1 to 1.5 cun. Diji SP-8 Perpendicular or oblique insertion 1 to 1.5 cun. Quchi L.I.-11 Perpendicular insertion 1 to 1.5 cun. 3. Afterpains These short sharp cramp-like pains occur as the uterus descends back into the pelvis following childbirth. This is a normal occurrence and begins shortly after the placenta has been delivered, often with the first breastfeed. The pains may continue to occur over several days and will resolve as the uterus returns to its normal position. Afterpains tend to become increasingly severe with subsequent births so that while they may be mild and more of an inconvenience following the birth of a first child, following the birth of subsequent children they have been described by women as more intense than labour pain. Women may be advised to take pain relief such as paracetamol prior to breast-feeding if the afterpains are interfering with the let down reflex (a term used to describe the process by which the initial milk stored in the breasts begins to pass into the nipple).    As  the  baby first latches on, oxytocin is stimulated, allowing the milk flow to begin. For some women this can be a straightforward process, but for others milk flow can be hindered at the beginning of a feed even though the baby is sucking.   Women are encouraged to make themselves as comfortable as possible before each feed to encourage this "let down effect". Historically in traditional Chinese medicine, abdominal pain occurring after childbirth was grouped into four categories: • Negligence during labour resulting in an invasion of wind-cold. • Emptiness of blood due to excessive haemorrhage. • Stagnation and accumulation of lochia. • Food stagnation. In clinical practice afterpains commonly occur with no other clinical signs and symptoms that would indicate wind-cold invasion, blood deficiency, blood stasis associated with retained products or food stagnation. It is therefore perhaps more relevant to differentiate these afterpains solely on the nature of their presenting symptom: • Deficient (xu) abdominal pain is relieved by pressure and warmth. • Excess (shi) abdominal pain increases with pressure. In this instance specific advice can be given, for example women experiencing pains that are better for pressure  can use their fist to place direct pressure over the lower abdomen (Zhongji REN-3 and Guanyuan REN-4 )  before breast feeding .  A hot water bottle can also be used if the woman finds this helpful. Those women whose afterpains are worse for pressure should concentrate on using acupressure to distal points such as Sanyinjiao SP-6 prior to breast feeding. Although I have come across a variety of suggested points to provide relief for afterpains, for example Qihai REN-6, Xuehai SP-10, Guilai ST-29 and Tianshu ST-25, my clinical experience has shown me that it is Sanyinjiao SP-6 that provides the most consistently effective pain relief for women. Midwives have confirmed the effectivenss of needling Sanyinjiao SP-6, with no other points, if the woman is experiencing severe discomfort, and report that the afterpains will usually disappear while needling. Acupressure can then be applied to Sanyinjiao SP-6 by support people to provide relief at subsequent breast feeds. If for any reason needling is not possible, Sanyinjiao SP-6 can also be used solely as an acupressure point, with support people applying pressure bilaterally as the woman commences breast-feeding, maintaining firm pressure until the woman feels comfortable. Feedback has been that the instant effect of this point has been “magical”. Point discussion Zhongji REN-3 Specific point for afterpains11. Guanyuan REN-4 Specific point for afterpains12. Sanyinjiao SP-6 Clinically effective point with acupuncture or acupressure for pain relief. Needling notes Zhongji REN-3 Perpendicular insertion 0.5 to 1 cun. Caution: deep insertion may penetrate a full bladder. Guanyuan REN-4 Perpendicular insertion 0.5 to 1 cun or oblique insertion directed inferiorly 1 to 1.5 cun. Caution: deep insertion may penetrate a full bladder. Sanyinjiao SP-6 Perpendicular or oblique proximal insertion 1 to 1.5 cun. 4. Night sweats It is not uncommon for women in the week immediately following childbirth to find that they are waking at night drenched in sweat. From a western medical perspective this is thought to be due to the body eliminating the accumulated fluids post pregnancy and childbirth. From a traditional Chinese medicine viewpoint night sweats most commonly indicate yin deficiency. I have found that treating this as a Kidney yin deficiency night sweating (even if there are no other diagnostic indications) by using points such as Yinxi HE-6 and Fuliu KID-7, is usually sufficient to resolve this problem, often with only a single treatment. Point discussion Yinxi HE-6 Clears deficiency fire and alleviates night sweating13. Fuliu KID-7 Indicated for night sweats14. Needling notes Yinxi HE-6 Perpendicular insertion 0.3 to 0.5 cun. Fuliu KID-7 Perpendicular insertion 0.5 to 1 cun. 5. Perineal discomfort Feedback from midwives using acupuncture suggests that Baihui DU-20 is a useful point to relieve an oedematous perineum. Women often describe this as an uncomfortable swollen feeling that makes it difficult to sit down in the first few days following delivery. Point discussion Baihui DU-20 Experience point for a swollen perineum. Needling notes Baihui DU-20 Transverse insertion 0.5 to 1 cun. 6. Breast feeding problems While acupuncture treatment can be effective for problems such as diminished milk flow or mastitis, it is important to realise that prompt expert advice on feeding positions and correctly draining the breast are also a vital part of treatment. If these are ignored, the long-term success in the treatment of these problems is limited. While outside the scope of this book, this information will be available from the woman’s midwife, doctor or a local support breastfeeding group. a. Insufficient lactation This presents either as qi and blood deficiency (where breast milk is insufficient because the blood required as its source is deficient), or as Liver qi stagnation (where the breast milk appears insufficient due to qi stagnation inhibiting its flow). Qi and blood deficiency Clinical manifestations: insufficient lactation, sallow complexion, poor appetite, tiredness, a tongue that is pale, and a choppy (se) pulse. Treatment principle: tonify qi and blood. Points: Shaoze SI-1, Guanyuan REN-4, Shanzhong REN-17, Zusanli ST-36, Shenshu BL-23. Method: Reinforcing, moxa applicable. Liver qi stagnation Clinical manifestations: insufficient lactation, distention, hardness and pain in the breasts, anxiety, irritability or swinging emotions, a tongue that is red on the sides and a wiry (xian) pulse. Treatment principle: pacify the Liver and eliminate stagnation. Points: Shaoze SI-1, Jianjing GB-21, Taichong LIV-3, Zulinqi GB-41, Shanzhong REN-17. Method: even method Point discussion Shaoze SI-1 Promotes lactation and benefits the breasts15. Guanyuan REN-4 Nourishes blood16. Shanzhong REN-17 Benefits the breasts and promotes lactation17. Zusanli ST-36 Tonifies qi and nourishes blood.18 Shenshu BL-23 Tonifies the Kidneys19. Jianjing GB-21 Indicated when breast milk does not flow20. Taichong LIV-3 Moves qi, eliminates stagnation and pacifies the Liver21. Zulinqi GB-41 Indicated for distension and pain of the breast22. Needling notes Shaoze SI-1 Perpendicular or oblique insertion directed proximally 0.1 to 0.2 cun. Guanyuan REN-4 Perpendicular insertion 0.5 to 1 cun or oblique insertion directed inferiorly 1 to 1.5 cun. Caution: deep insertion may penetrate a full bladder. Shanzhong REN-17 Transverse insertion directed superiorly or inferiorly along the channel 0.5 to 1 cun. Zusanli ST-36 Perpendicular insertion 1 to 1.5 cun. Shenshu BL-23 Oblique or perpendicular-oblique insertion towards the spine 1 to1.5 cun. Caution: deep perpendicular needling carries a risk of injuring the Kidney. Jianjing GB-21 Posterior oblique insertion 0.5 to 1 cun. Caution: perpendicular insertion especially in thin patients carries a substantial risk of inducing a pneumothorax. Taichong LIV-3 In the direction of Yongquan KID-1 0.5 to 1.5 cun. Clinical notes Applying moxibustion to Shaoze SI-1 bilaterally for 5 minutes daily for several days can be especially effective in cases of qi and blood deficiency, to promote  the production of  breast milk (which is often noticed as a baby that is more settled within 24 hours).  The application of acupressure or acupuncture to Shanzhong REN-17 and Jianjing GB-21 as the woman begins to breast-feed is a useful method of promoting the mothers “let down” reflex. Often the use of these points will stimulate an immediate tingling with a let down of milk. It is imperative that attention is also focused on the quality of food the mother is eating, her fluid intake and the amount of rest she is receiving. Nutritious blood building foods, an adequate amount of water (not milk), and plenty of rest are important contributing factors in any woman’s ability to produce good quality breast milk. Herbal breast milk promoting teas are sometimes used by women to increase their milk supply, but they are no replacement for good nutrition and adequate rest. It has been my experience some women may actually be “overdosing” on these teas (often taken preventively), confusing quantity with the quality of breast milk produced. The result is a baby that becomes increasingly demanding and unsettled following the introduction of these teas, despite the mother noticing an apparent increase in her milk flow. Obviously if the herbal tea is the cause, discontinuing will result in a more settled baby. b. Mastitis This is a breast infection which usually presents as an area of the breast that is sore, red, hot and possibly hard to the touch. The woman may also have an elevated temperature or alternating fever and chills. This infection may have begun with a blocked milk duct that was not promptly cleared or it may be the result of bacteria entering through the nipple. From a traditional Chinese perspective this involves heat and toxic heat affecting the Liver, Stomach and Gall-Bladder channels. According to Chinese medicine, the Liver influences the breasts and controls the nipple, the Stomach channel affects the central aspect of the breast tissue and the Gall Bladder channel affects the lateral aspect of the breast tissue. Distal acupuncture points can therefore be chosen according to the channel that flows through the affected area of the breast. Treatment principle: clear heat, resolve toxins and pacify the Liver. Points: Quchi L.I.-11, Rugen ST-18, Taichong LIV-3, Xingjian LIV-2, Zulinqi GB-41, Neiting ST-44. Method: even or reducing method. Point discussion Quchi L.I.-11 Clears heat23. Rugen ST-18 Principal local point for disorders of the breast24. Taichong LIV-3 Indicated for breast pain.25 Xingjian LIV-2 Clears Liver heat .26 Neiting ST-44 Clears heat from the Stomach channel27. Zulinqi GB-41 Indicated for distension and pain of the breast28. Needling notes Quchi L.I.-11 Perpendicular insertion 1 to 1.5 cun. Rugen ST-18 Transverse-oblique insertion in the direction of the channel. Caution: deep or perpendicular insertion carries a substantial risk of puncturing the lung. Taichong LIV-3 In the direction of Yongquan KID-1 0.5 to 1.5 cun. Xingjian LIV-2 Perpendicular insertion 0.5 cun to 0.8 cun. Neiting ST-44 Perpendicular insertion 0.5 cun. Zulinqi GB-41 Perpendicular insertion 1 to 1.5 cun. Incorrect angle of insertion will not enable the needle to pass between the shafts of the fourth and firth metatarsal bones. Clinical notes These points can be particularly effective when used at the first signs of an infection; midwives report the redness disappearing from the affected breast tissue while the needles are still in place. Local points can also be used with superficial needling to form a ring around the affected breast tissue. It is important that mastitis is treated promptly and correctly. If a breast abscess develops, the woman will need antibiotics and possible surgical intervention. There is also the possibility of subsequent scar tissue around the infected site. Acupuncture treatment is usually given once a day over 3-4 days to ensure that the mastitis successfully resolves. Following treatment it is to be expected that women will show some clinical signs of improvement (reduced pain, swelling or redness at the site of infection), if not immediately then certainly within a few hours. If this is not the case, my recommendation is that they contact their midwife or doctor for further assessment. 7. Postnatal depression a. Minor postnatal depression Minor postpartum depression is seen in traditional Chinese medicine as being related to disruption of the seven emotions, disturbance of the spirit or fatigue following birth. Following childbirth a woman has multiple emotional and physical adjustments to make as she recovers. Pre-existing deficiency of qi and blood, or deficiency of qi and blood arising from complications during childbirth, can influence the zangfu, especially the Heart, Liver, Spleen and Kidney. This results in a variety of patterns of disharmony involving depression and anxiety. I have found the following pattern differentiations useful; they are from a translation of the French text Acupuncture En Gynecologie Et Obstertrique29. BOX: Following childbirth a woman has multiple emotional and physical adjustments to make as she recovers. Heart and Spleen yang deficiency Clinical manifestations: depression, dull complexion, shortness of breath, no desire to talk, palpitations, forgetfulness, agitated dream-disturbed sleep, lack of appetite, a tongue that is pale and swollen with teeth marks on the edge, and a weak (ruo) pulse. Treatment principle: Nourish and tonify the Heart and tonify the Spleen. Points: Shenmen HE-7, Xinshu BL-15, Pishu BL-20, Qihai REN-6, Sanyinjiao SP-6. Method: Reinforcing. Moxa is applicable at Xinshu BL-15, Pishu BL-20 and Qihai REN-6. Deficiency of Kidney and Liver Clinical manifestations: insomnia, vertigo, lower back ache, a tongue with thin coating, and a thready (xi) and wiry (xian) pulse. Treatment principle: Nourish the Liver and Kidney, nourish the Heart and calm the mind. Points: Shenmen HE-7, Neiguan P-6, Ganshu BL-18, Shenshu BL-23, Mingmen DU-4, Taixi KID-3, Sanyinjiao SP-6. Method: Reinforcing. Stagnation of Liver qi with Liver fire rising Clinical manifestations: insomnia, anxiety, agitation, dizziness, headache, impatience, easily angered, lack of appetite, nausea, belching, a red tongue and a wiry (xian) and rapid (shu) pulse. Treatment principle: Smooth and regulate the Liver, harmonise the Stomach and clear the head. Points: Shenmen HE-7, Neiguan P-6, Fengchi GB-20, Zusanli ST-36, Taichong LIV-3. Method: Reducing. Clinical notes In clinical practice I have also found the following points to be useful: Yintang (M-HN-3) as a local point to calm the mind. Baihui DU-20 as a point to lift the spirit. Benshen GB-13 combined with Shenting DU-24 to calm the mind and relieve anxiety from persistent worry. Toulinqi GB-15 to balance the emotions when a woman is swinging between episodes of low spirits and elation. Point discussion Shenmen HE-7 Calms the Heart and spirit. Xinshu BL-15 Tonifies and nourishes the Heart. Pishu BL-20 Tonifies Spleen qi and yang. Qihai REN-6 Tonifies qi and yang. Sanyinjiao SP-6 Regulates the Spleen and Stomach, harmonises the Heart and Kidney and thus calms the spirit. Neiguan P-6 Calms the Heart and spirit. Ganshu BL-18 Regulates and tonifies the Liver. Shenshu BL-23 Tonifies the Kidney. Mingmen DU-4 Tonifies Kidney yang. Taixi KID-3 Promotes Kidney yin. Fengchi GB-20 and Taichong LIV-3 Calms Liver yang rising and clears the head. Zusanli ST-36 Harmonises the Stomach and clears heat. Yintang (Extra) Calms the mind30. Benshen GB-13 Calms the mind31. Toulinqi GB-15 Balances the emotions32. Shenting DU-24 Calms the mind33. Needling notes Shenmen HE-7 Perpendicular insertion 0.3 to 0.5 or oblique insertion proximally, medially or distally 0.5 to 0.8 cun. Caution: the ulnar artery and ulnar nerve lie adjacent to this point. Xinshu BL-15 Oblique insertion towards the spine 0.5 to 1 cun or transverse –oblique insertion 1 to 1.5 cun. Caution: perpendicular needling or oblique needling away from the spine carries a substantial risk of causing a pneumothorax. Pishu BL-20 Oblique insertion towards the spine 0.5 to 1 cun or transverse-oblique insertion 1 to 1.5 cun. Caution: perpendicular needling or oblique needling away from the spine carries a substantial risk of causing a pneumothorax. Qihai REN-6 Perpendicular insertion 0.8 to 1.5 cun. Caution: deep needling may penetrate the peritoneal cavity. Sanyinjiao SP-6 Perpendicular or oblique proximal insertion 1 to 1.5 cun. Neiguan P-6 Perpendicular insertion 0.5 to 1 cun. Ganshu BL-18 Oblique insertion towards the spine 0.5 to 1 cun or transverse –oblique insertion 1 to 1.5 cun. Caution: perpendicular needling or oblique needling away from the spine carries a substantial risk of causing a pneumothorax. Shenshu BL-23 Oblique or perpendicular-oblique insertion towards the spine 1 to1.5 cun. Caution: deep perpendicular needling carries a risk of injuring the Kidney. Mingmen DU-4 Perpendicular insertion 0.5 to 1 cun. Caution: the spinal canal lies between 1.25 and 1.75 cun deep to the skin surface, varying according to the body build. Taixi KID-3 Perpendicular insertion 0.5 to 1 cun or join to Kunlun BL-60. Fengchi GB-20 Directed towards the tip of the nose, the contralateral eyeball or Yintang (M-HN-3), 0.5 to 1 cun. Caution: deeper needling may damage the spinal cord. Taichong LIV-3 In the direction of Yongquan KID-1 0.5 to 1.5 cun. Zusanli ST-36 Perpendicular insertion 1 to 1.5 cun. Yintang (Extra) With the fingers of one hand pinch up the skin over the point and with the other hand needle transversely in an inferior direction 0.3 to 0.5 cun. Benshen GB-13 Transverse insertion 0.5 to 1.5 cun. Toulinqi GB-15 Transverse insertion 0.5 to 1.5 cun. Shenting DU-24 Transverse insertion 0.5 to 1 cun. b. Major postnatal depression The treatment for major postnatal  depression or puerperal psychosis is mentioned in traditional Chinese medicine texts. It was seen as a condition following childbirth where blood deficiency allowed  the agitation of internal fire, which then disturbs the mind.  The clinical manifestations include sadness and depression for no reason, laughing and crying in an abnormal manner, a woman that is unable to be calmed or reasoned with, feelings of thoracic oppression, and a body that may be seized with trembling. There may also be a loss of consciousness.   In a modern clinical setting treatment for postnatal psychosis would not be attempted without the involvement of specialised psychiatric care. As such it is outside the scope of this text. Postnatal advice There are several observations that traditional Chinese medicine has to offer on promoting health in the postnatal period. Recovery time The idea that it will take women at least a month to fully recover from childbirth is not a widespread one in Western society. Usually partners or relatives will endeavour to be around to help out after the birth for a week (two weeks if a woman is really lucky), but then for most women it is back to “normal”. It may be an appealing idea that “super mums” will be fit and ready for action within a week or two following birth, but this is not the reality for most women. While most will certainly cope (and be rewarded by plenty of verbal feedback on how well they are doing), several months later it is often hard to shake off the tiredness and exhaustion. BOX: It may be an appealing idea that “super mums” will be fit and ready for action within a week or two following birth, but this is not the reality for most women. While 30 days (or even 100 days in certain texts) of recovery time may sound extreme to some women, it is in reality a reasonable time period if it is considered that this is needed to compensate not only for the birth but also for the experience of being pregnant for nine months. This is not a time for absolute bed rest but rather a time when physical rest should be taken at every opportunity. Exercise is appropriate (although not an exhausting attempt to get back into shape), and attention should be placed on a diet that is suited to the woman’s constitution, with the emphasis on building blood and qi. In my opinion it is most helpful for women to realise that they are not expected to bounce back from childbirth within a few weeks, instead recognising that it may take a lengthier timeframe to recover their energy completely. BOX: In my opinion it is most helpful for women to realise that they are not expected to bounce back from childbirth within a few weeks, instead recognising that it may take a lengthier timeframe to recover their energy completely. Avoiding pathogenic wind and cold Most women now have access to hot showers and hairdryers, in contrast to the culture that gave rise to traditional warnings about exposure to cold. However, it is still important to avoid exposure to cold and wind, for example avoiding sleeping/breast-feeding by open windows or fans, or leaving the swimming pool feeling chilled or with wet damp hair. Pathogenic cold also has relevance when considering diet, as cold raw foods (sandwiches, green salads, iced water, juices and yoghurts) are often consumed frequently post birth, not always by choice but because they are quick and easy to grab in the chaos of life with a new baby or because women see these as ideal foods for weight loss. Dietary treatment Dietary advice is, an extremely important part of promoting postnatal recovery. In general it is important for all new mothers to consider the foods they are consuming. There should be an emphasis on qi and blood building foods, for example: • Foods to tonify qi include oats, rice, potato, sweet potato, mushroom (button and shitake), yam, basil, cinnamon, clove, dill, fennel, fenugreek, ginger, nutmeg, rosemary, thyme and jasmine tea. • Foods to build blood include, corn, sweet rice, beetroot, all dark leafy greens, apricot, avocado, date, kidney bean, sesame seeds, egg and soya milk as well as the obvious iron rich foods such as red meat and spinach. Emphasis also needs to be placed on cooking methods. Foods that are cooked slowly or lightly are seen in traditional Chinese medicine as more nourishing and kinder to the digestive system. For example there is a vital difference between using raw oats in muesli and cooking them into porridge. Warm soups are considered particularly nourishing in the initial postnatal weeks, especially chicken soup. It is also important that a woman’s underlying constitution be considered. This means that a woman with an underlying yin deficiency can be given advice on avoiding food that is stimulating, for example coffee, alcohol, sugar and strong pungent spices, as well as on foods to nourish yin such as aduki, black and kidney beans, tofu, coconut milk, fish, beef, pork, egg and fruits such as apple, apricot, avocado and pear. A woman with an underlying yang deficiency can be advised to avoid cold drinks such as cold filtered water and cold juices, and raw foods such as green salads, replacing them with alternatives that are warmer or have been precooked, for example rice or potato salads. Foods to tonify yang include radish, leek, squash, chestnut, sweet rice, fennel seed, basil, bay leaf, black pepper, cayenne, coriander, garlic, marjoram, onion, ginger, anchovy, mussel, trout, mutton, peach and vinegar. While there is a long documented history in traditional Chinese medicine of women taking dietary remedies to encourage lactation and to promote qi and blood following childbirth, I have not found the ingredients of these soups and porridges automatically transferable to a western diet. Soups consisting of black-bone chicken, pig trotters or astragalus root and pork liver are usually off-putting through description alone. Dietary advice also needs to take into account the taste factor, as the herbs frequently used in these remedies are distinctly different from western foods and may be rather difficult for some women to take. I have found it useful to provide women with a pamphlet listing qi and blood-building foods as outlined above. This information also covers general dietary principles such as avoiding cold foods and using warming cooking methods. Case Histories Sina Schimmel-Schmidt (midwife) Postnatal visit. At 6 weeks Julie was crying. She was tired, depressed, felt lonely and unsupported by her partner. Apart from taking the time to listen to her, I used: Yintang (M-HN-3), Taichong LIV-3 bilaterally, Toulinqi GB-15 bilaterally. The needles were retained for 20 minutes. The change in her facial expression, especially when I needled Yintang (M-HN-3) was remarkable. She appeared brighter and more peaceful. She was instantly lighter and more cheerful and stated, “its wonderful, my head is not so heavy any more”. Liz Brunton (midwife) Sharon was having her 4th baby. She had always had night sweats following childbirth and was used to them. I needled Yinxi HE-6, Fuliu KID-7 for two days in succession following birth and her night sweats reduced so dramatically that no further treatment was necessary. Debra Betts Jody came to see me with her partner at 37 weeks to learn about using acupressure points during labour. She was carrying twins and wanted to be active in promoting a natural birth. During the session it also transpired she was anxious about the prospect of experiencing postnatal depression as this had occurred with the birth of her first child, now two years old. Although arrangements had been made for her mother to come and stay (as her husband would be returning to work shortly after the birth) she was concerned about being able to cope with twins and the demands of her little girl. A prebirth treatment appointment was made but she was unable to keep this, going spontaneously into natural labour. On phone follow up it appeared all had gone well during the labour but she was now concerned about her postnatal recovery. I offered her the option of a home visit four days post-birth and then once a week for several weeks if she felt this would be useful. On the first visit at four days post birth Jody was tired but felt she was coping well. Although there were no obvious presenting symptoms of an underlying pattern of disharmony, a pale pink tongue with slight toothmarks on the sides and a pulse that was weak (ruo), suggested the potential for a Heart and Spleen yang deficiency to develop. ‘Mother roasting’ was used, combined with acupuncture to Yintang (M-HN-3) and Baihui DU-20, with even method. At a visit on day ten, Jody was feeling more confident that she was recovering well, she had enjoyed the mother roasting treatment and the twins were feeding well. Treatment: Tonification to Zusanli ST-36, Zhongwan REN-12 and Guanyuan REN-4 with needles followed by moxa. Even method at Yintang (M-HN-3) and Baihui DU-20. The body points were marked so that her partner could moxa these if she felt like another treatment before the next visit. On day fifteen Jody reported that she had managed to persuade her partner to use the moxa treatment at least once. Gaohuangshu BL-43, Shenshu BL-23 and Mingmen DU-4 were used by tonification method, with moxa to Shenshu BL-23 and Mingmen DU-4 and even method to Yintang (M-HN-3) and Baihui DU-20. Advice was given on taking qi and blood building foods (she was reluctant to take herbs while breastfeeding) and it was agreed that she would ring in for further appointments if she began to feel anything that indicated postnatal depression was beginning to occur. On follow up a month later she felt she was coping well and very pleased to report that at six weeks she felt she had sailed through the early postnatal period. Kass Stone – Midwife Sue had a history of anaemia. She gave birth at home at 41weeks to a healthy baby girl weighing 3750g. I needled Kunlun BL-60 and Hegu L.I.-4 during the third stage of labour, and also used pressure on Jianjing GB-21, as I wanted to minimise her blood loss, given her low haemoglobin level. The placenta came away smoothly and her blood loss was only 10ml. Within the first two hours after birth Sue had a clotted loss of 100ml. Later in the day I needled Baihui DU-20 as Sue had noted another clotted loss as before. Lochia settled after this. Postpartum period was uneventful. She continued to take Ferrograd-Folic and I did a 'mother-roasting' treatment on her at 5 days postpartum. At 5 weeks Sue reported that she was still bleeding a little. I recommended that she moxa the mother-roasting points again. At 6 weeks the lochia had ceased. References 1 Maciocia, G. Obstetrics & Gynecology in Chinese Medicine. Churchill Livingstone 1998, page 582. 2 Ibid, p604. 3 Ibid, p604. 4 Deadman P, Al-Khafaji M, Baker K 2001 A Manual of Acupuncture. Journal of Chinese Medicine Publications, p190. 5 Ibid, p319. 6 Auteroche B and Navailh R 1986 Acupuncture En Gynecologie Et Obstetrique. Maloine, Paris, chapter 11. 7 Deadman P, Al-Khafaji M, Baker K 2001 A Manual of Acupuncture. Journal of Chinese Medicine Publications, p501. 8 Ibid, p196. 9 Maciocia, G. Obstetrics & Gynecology in Chinese Medicine. Churchill Livingstone 1998, p607. 10 Deadman P, Al-Khafaji M, Baker K 2001 A Manual of Acupuncture. Journal of Chinese Medicine Publications, p113. 11 Auteroche B and Navailh R 1986 Acupuncture En Gynecologie Et Obstetrique. Maloine, Paris, chapter 11. 12 Ibid, chapter 11. 13 Deadman P, Al-Khafaji M, Baker K 2001 A Manual of Acupuncture. Journal of Chinese Medicine Publications, p217. 14 Ibid, p346. 15 Ibid, p231. 16 Maciocia, G. Obstetrics & Gynecology in Chinese Medicine. Churchill Livingstone 1998, p661. 17 Deadman P, Al-Khafaji M, Baker K 2001 A Manual of Acupuncture. Journal of Chinese Medicine Publications, p518. 18 Ibid, p158. 19 Ibid, p283. 20 Ibid, p438. 21 Maciocia, G. Obstetrics & Gynecology in Chinese Medicine. Churchill Livingstone 1998, p663. 22 Deadman P, Al-Khafaji M, Baker K 2001 A Manual of Acupuncture. Journal of Chinese Medicine Publications, p460. 23 Ibid, p112. 24 Ibid, p143. 25 Ibid, p477. 26 Giovanni M 1998 Obstetrics &Gynecology. Churchill Livingstone, Edinburgh, p669. 27 Maciocia, G. Obstetrics & Gynecology in Chinese Medicine. Churchill Livingstone 1998,p391. 28 Deadman P, Al-Khafaji M, Baker K 2001 A Manual of Acupuncture. Journal of Chinese Medicine Publications, p477. 29 Auteroche B and Navailh R 1986 Acupuncture En Gynecologie Et Obstetrique. Maloine, Paris. 30 Maciocia, G. 1989 The Foundations of Chinese Medicine. Churchill Livingstone, Edinburgh,p473. 31 Ibid,p446. 32 Ibid,p446. 33 Ibid,p472.

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