Tiredness that won’t go away after birth

"My family feeds me every kind of tonic, and I still feel completely drained." She said this when her baby was just over a month old. Her hands and feet were cold even when there was no wind, and at night she lay awake for a long time before she could sleep. One thing she mentioned as if it were a minor detail: after breastfeeding she did not feel hungry, and when she ate, the food took a long time to digest.

With tiredness that lasts like this, there are two things to understand well before you buy more tonics. First, is your body short of something that a blood test can measure? Second, if it really is deficiency (a lack of something), is your body able to absorb the tonics?

Tiredness in the first months, and when it is no longer normal

Nearly 1,200 mothers in Australia were asked about their health after birth. When their babies were 2 months old, 6 in 10 said they were exhausted. At 6 months, the figure was still almost half. In Canada, a research team found that tiredness eased gradually until month 6, and then some women became more tired again in the second half of the first year.

At our clinic, of 82 women whose records mention the postpartum period or breastfeeding, 44 complained of tiredness, more than any other reason.

Being tired in the first few months is not unusual. What matters is whether it gets lighter week by week. If you catch up on sleep for a few nights and are just as tired as before, or it has not eased after 6 weeks, you should see a doctor.

First, the kinds of tiredness that tests can measure

Some causes cannot be known for sure by looking at your complexion or taking your pulse. You need a blood test.

The cause most often missed is iron deficiency without anemia. The body keeps a store of iron, measured by a value called ferritin. The store can be almost empty while hemoglobin (the value used to tell whether you are anemic) is still within the normal range, so a complete blood count alone shows nothing. Blood loss during birth and breastfeeding both draw iron from the mother’s store.

In Switzerland and France, two trials were done in women with unexplained tiredness who were not anemic. The group taking iron felt less tired than the group taking a placebo, but only among those with low ferritin. For women whose iron stores were full, taking iron did no better. These two studies were not done specifically in postpartum mothers. Even so, they show that you need to know whether your iron store is low before you can know whether taking iron will help. In the UK, fewer than 1 in 10 test requests for people complaining of tiredness included ferritin, yet 1 in every 4 ferritin tests came back abnormal.

You should also have your thyroid function checked. After birth, the thyroid can become inflamed, at first making you jittery, sleepless and losing weight, and later sluggish and sensitive to cold. People around you can easily take this for simple tiredness or low mood. If you are a long-term vegetarian or eat very little meat, fish, eggs or dairy, you are at risk of vitamin B12 deficiency.

If you had gestational diabetes, you need a blood sugar test, even if you are not tired. In this group, the later risk of type 2 diabetes (the type common in adults) is nearly 10 times that of other women. The American Diabetes Association advises testing at about 4–12 weeks after birth, then repeating it every 1–3 years.

Vitamin D, on the other hand, is not among the routine tests for tiredness (tests done for everyone who is tired, without a specific reason). In 2024 the Endocrine Society (US) advised against routine testing; doctors order it only when there is a specific reason. Many "fatigue test" packages still include vitamin D, but that does not mean every mother needs it.

If you are low in iron and breastfeeding

If tests show iron deficiency and you are breastfeeding, it is all the more important to take iron the right way:

• Take iron in the morning, away from meals and well apart from coffee, because coffee cuts the amount of iron absorbed by more than half;
• Take iron with a little orange juice or something rich in vitamin C;
• Constipation is a common symptom when taking iron; talk to your doctor about it, and do not stop on your own;
• Have a follow-up blood test about 6 weeks after you start taking iron.

Do not buy iron tablets and take them on your own before being tested. If your iron store is not low, taking more will not ease your tiredness. And while you wait for the tablets to work, other causes such as the thyroid or depression get pushed aside.

Normal results, but you still feel drained

Some women hold a test report where every value is within range, yet they run out of steam every afternoon. In our clinic’s experience, some people have normal test results but their body still does not have enough strength to cope with everything it is carrying, especially while breastfeeding. In that case, besides taking the pulse and looking at the tongue, the doctor also uses Applied Kinesiology (AK), that is, manual muscle testing, to see how the parts of the body are working together and to find where the body is short of strength to cope.

Walther’s AK textbook classes lack of sleep as physical stress, alongside emotional stress, and both kinds of stress weigh on the adrenal glands (small glands sitting on top of the two kidneys that release hormones to help the body cope with stress). When the adrenal glands are overloaded, people tend to sleep poorly, get headaches and feel tired, and their blood sugar (the amount of sugar in the blood) easily drops too low when they skip a meal (Walther 2000). A mother who is up at night breastfeeding, eats in a hurry or forgets meals because she is busy with the baby fits that picture exactly. If you had gestational diabetes, you still have your blood sugar tested first, as mentioned above. So the doctor also tests the muscles that AK textbooks link to the adrenal glands, asks in detail about meal times and sleep, and then tests muscle strength while you think about whatever is weighing on you, to see how far the stress reaches. Your private worries stay your own. AK adds a layer of assessment; it does not replace tests or a medical diagnosis. The doctor reads the results together with your pulse, your tongue and the test values you already have.

Only then come tonics, matched to the right pattern

Once the measurable causes have been ruled out or treated, it is time to talk about tonics. Traditional medicine places most postpartum tiredness under qi and blood deficiency (a shortage of qi and of blood). The classical Vietnamese physician Hai Thuong Lan Ong has a whole section on this condition, called "postpartum exhaustion" (蓐劳 / 蓐勞, rù láo): after birth, qi and blood are weak, and if care and nourishment are irregular, the woman is worn out, her face looks drawn, she has no appetite, her mouth tastes bland, and she feels dizzy with blurred vision. He gave three causes: working too hard, worrying too much, and poor care.

Deficiency calls for tonics, but there are two times to wait. The first is when the lochia (postpartum vaginal discharge) has not cleared and the lower belly still hurts. At that point there is still stasis inside (old blood that has not fully come out), and the stasis must be cleared first.

The second time gets less attention: when the Spleen is weak, tonics do not get in. Physicians call this "too deficient to take tonics" (虚不受补 / 虛不受補, xū bù shòu bǔ): deficient, yet unable to receive tonics. The Spleen and Stomach are where food and drink are turned into qi and blood. Blood tonic herbs such as Shu di huang (prepared Rehmannia glutinosa root) and E jiao (donkey-hide gelatin, from Equus asinus) are rich and heavy. If you add them while the Spleen is weak, the belly gets more bloated and you feel more sluggish. The traditional internal medicine textbook says that for people who are deficient but cannot take tonics, the first step is to support the qi of the Spleen and Stomach, using gentle herbs that do not cause stagnation. When Hai Thuong treated postpartum exhaustion, he also made strengthening the Spleen the main approach, because only when you can eat and drink can essence and qi be produced.

Here are a few signs that your Spleen is not ready yet:

• Not feeling hungry after breastfeeding, poor appetite, feeling full and bloated after eating;
• Loose stools that do not hold their shape;
• Feeling heavy in the stomach or more tired after taking tonics, or getting a dry mouth or breakouts.

The lương y (traditional medicine practitioner) Nguyen Huu Duc taught his students that when blood deficiency comes from the Spleen, the main signs are not wanting to eat, poor digestion and poor absorption. To strengthen the Spleen, he said, choose herbs that are "mainly lightly aromatic, not sweet". He also said that qi recovers first and blood recovers later. You will usually feel less tired first; rosy skin and regular periods take more time.

A case: not hungry after feeds, and a prescription that changed with her digestion

When she came in, she still had a trickle of lochia. In the first week, the doctor gave herbs to clear the stasis, without strong tonics yet. Only after the lochia had cleared did treatment move on to tonifying qi and blood. Nearly three weeks later, she still did not feel hungry after breastfeeding, and she was also very thirsty, craved sweet and rich foods, and had plenty of milk, but it was thin. The doctor added Chen pi (Citrus reticulata peel, aged tangerine peel), an aromatic herb that helps the Spleen transform food, and took out a few herbs from the blood-tonic part. Two weeks later she said she felt stronger, was less drained in the late afternoon and evening, her hands and feet were warm, and her sweet cravings were almost gone. At that point the doctor removed Shu di huang, the heaviest blood tonic in the prescription, and added Sha ren (Amomum villosum fruit). At the next visit, she no longer felt cold.

After about two and a half months of treatment, she was no longer so tired that she had to lie down. By the time her baby was 4–6 months old, the exhaustion was almost gone. Then something else came to light: she was forgetful, would set out to do something and then forget it, found it hard to concentrate, worried a lot, and was still waking many times at night to breastfeed. The doctor shifted to nourishing the Heart and calming the mind (养心安神 / 養心安神, yǎng xīn ān shén; in traditional medicine, nourishing the Heart organ so the mind is settled), together with psychological support and guidance on helping her baby sleep more deeply.

When tiredness comes with forgetfulness and poor focus

A slow mind, forgetfulness and poor concentration can come from lack of sleep, low iron, the thyroid, depression or anxiety. Traditional medicine calls the group of tiredness, forgetfulness, palpitations and insomnia Heart–Spleen deficiency (心脾两虚 / 心脾兩虛, xīn pí liǎng xū: both the Heart and the Spleen are deficient). Xia Guicheng’s book has a line you can use to check yourself: if it is only exhaustion, enough rest brings a fairly quick recovery. If you have rested enough and your mind still does not clear, another cause needs to be found.

Feeling sad, empty or without interest in anything for more than 2 weeks is the time to see a mental health doctor, not just to take more tonics.

When to see a doctor

You should see a doctor and get tested when:

• It has been more than 6 weeks and the tiredness is not easing, or you are still tired after catching up on sleep;
• You look pale, get out of breath climbing stairs, have a fast heartbeat, or are losing a lot of hair;
• You have palpitations and weight loss, or the opposite: sluggishness, feeling cold and weight gain;
• You lost a lot of blood during the birth;
• You had gestational diabetes, even if you are not tired;
• You have lasting forgetfulness, poor concentration, sadness or anxiety.

If you feel exhausted in a way that is completely unlike your usual self, with shortness of breath, chest pain or a fast heartbeat even when lying at rest, go to the emergency department right away; other danger signs are in the article "Warning signs after birth that need care right away".

When you go, bring your earlier test results, including those from pregnancy and the birth, and tell the doctor which tonics you are taking.

References

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