Postpartum is more than 42 days

Her first child had already started primary school when she came to the clinic for the first time. The reason she gave was pain across her lower back, worse when she leaned back. When we asked more, there was much else: she sometimes leaked urine when she sneezed, her lower abdomen felt heavy and dragging now and then, and vaginal infections kept coming back. Every one of these began after that birth, and every one had already been treated separately.

She did not think any of it was connected to giving birth. Everyone had told her that once you complete the full month of the postpartum "confinement" period (ở cữ) and the 6-week check-up looks fine, you are done.

What the 42-day figure was set for

By the definition of the World Health Organization (WHO), the postpartum period lasts 42 days after birth. This cut-off was set for statistics, especially statistics on maternal deaths. It does not mean the body has finished recovering. The international classification of diseases, ICD-10, even has a separate code for late maternal death, counted from after day 42 to a full 1 year after birth.

At the end of 2023, a group of authors pooled global data for the journal Lancet Global Health and concluded that the 6-week window no longer fits, because many risks to a mother’s health last for 1 year and longer. The 2022 WHO guidelines on postnatal care also state clearly that if a problem is found, follow-up and treatment may need to go beyond 6 weeks.

The American College of Obstetricians and Gynecologists (ACOG), in its Committee Opinion No. 736 from 2018, also treats postpartum care as an ongoing process rather than a single visit. A mother should be contacted by a health care provider within the first 3 weeks, have a comprehensive check-up no later than week 12 (the stage ACOG calls "the fourth trimester", meaning the first three months after birth, following the three trimesters of pregnancy), and have further follow-up if needed.

What stays on after months, even years

One small study found that only about half of mothers had their usual energy back by the end of week 6. In Norway, when the baby was 12 months old, about 1/3 of first-time mothers (1 in every 3) still had diastasis recti, meaning the two vertical bands of muscle down the middle of the belly were still stretched apart to the sides, mostly to a mild degree. Population data from Germany show that both mothers and fathers slept less and less well than before the pregnancy, and this lasted up to 6 years after their first child.

• Leaking urine: in the UK and New Zealand, 12 years after the birth that was followed, 37.9% of women still leaked urine, and of those who were already leaking at month 3 after birth, about 3 in every 4 were still leaking in year 12;
• Mood: in one Australian study, among mothers with symptoms of depression in the first year, most first noticed their symptoms after month 6, long after the 6-week check-up;
• No one asks, and mothers do not tell: one Australian survey found that 94% of women had at least one health problem in the first 6 months after birth, but a quarter had never talked to a health care provider about their own health.

At our clinic, women who come in for problems after birth often talk about tiredness, poor concentration, forgetfulness, back pain, periods that have changed from before, and feeling cold and sensitive to wind. Quite a few come when their child is already a few years old, some when the child is already at school.

How traditional medicine sees the time after birth

Traditional medicine physicians sum up the postpartum state in a short phrase, "much deficiency, much stasis" (多虚多瘀 / 多虛多瘀, duō xū duō yū): a great deal is lacking, and a great deal is stuck. The gynecology textbook by Xia Guicheng (夏桂成) adds a third point, cold, putting it together as "much deficiency, much stasis, much cold".

• Deficiency (lacking): the mother loses blood and strength in giving birth, and her qi and blood are depleted;
• Stasis (stuck): when the lochia (postpartum vaginal discharge) and old blood have not fully come out, the lower abdomen hurts and new blood is hard to make;
• Cold: there is a saying that a woman who has just given birth is "like a block of ice", and when qi and blood are lacking for a long time, yang qi (the body’s warmth) becomes weak, so she feels cold easily and is sensitive to wind.

Xia Guicheng explains why illnesses after birth tend to linger: when "the hundred joints are empty" (百节空虚 / 百節空虛, bǎi jié kōng xū), the weakest places are exactly where pathogenic qi (邪气 / 邪氣, xié qì: outside causes of illness such as wind and cold) gets in most easily, so illnesses that start after birth are hard to clear. Body aches after birth, which people in Vietnam call "postpartum wind" (产后风 / 產後風, chǎn hòu fēng), can mostly be treated, but the earlier they are treated, the easier it is.

Why there is no one "postpartum tonic" for everyone

From this picture of lacking and stuck at the same time, the old medical texts drew a familiar piece of advice: do not be bound by the fact that it is after birth, but do not forget that it is after birth either (勿拘于产后，亦勿忘于产后 / 勿拘於產後，亦勿忘於產後, wù jū yú chǎn hòu, yì wù wàng yú chǎn hòu). In other words, do not lock into one rigid way of treating just because the mother has just given birth, but do not forget that her body is in the postpartum stage. What is lacking is replenished, what is stuck is moved, what is cold is warmed, what is hot is cooled, depending on each person and each moment.

This goes against the habit of "give birth, then load up on tonics". Fu Qingzhu (傅青主), a famous physician who valued Sheng Hua Tang (Generating and Transforming Decoction) for new mothers, advised that the first thing to ask is whether the lochia has fully cleared. If there are still clots of pooled blood and the belly still hurts, tonic herbs such as Ren shen (Panax ginseng root) and Bai zhu (Atractylodes macrocephala rhizome) should not be rushed in. Hai Thuong Lan Ong, the great Vietnamese physician, also warned: if after birth there are still clots of blood, do not put too much faith in the saying "after birth you must strongly tonify qi and blood". Tonics that are too rich and too heavy make qi and blood even more sluggish, meaning more stasis and poorer flow. Yet herbs that break up stasis (herbs that disperse pooled blood), if too strong, wear down upright qi (正气 / 正氣, zhèng qì), the body’s own strength to resist illness.

Sheng Hua Tang is the clearest example. It is a famous postpartum formula, but it is right only when the mother has all three: stasis, blood deficiency and cold, for example when the lochia does not flow freely and the lower abdomen is cold and painful. It is not used for someone who is bleeding heavily, has a fever, has foul-smelling lochia or has internal heat. In the 19th century, taking Sheng Hua Tang after birth became almost a custom, and many people prescribed it for themselves and their families, so much so that the famous physician Wang Shixiong (王士雄) criticized the practice sharply. This formula, like other tonic formulas, does not yet have clear safety data for use while breastfeeding. So please do not buy it yourself based on word of mouth. Let a physician examine you and choose the medicine, taking into account that you are breastfeeding.

"After birth, keep warm" (产后宜温 / 產後宜溫, chǎn hòu yí wēn) is the same. Keeping the body warm and avoiding raw and cold foods is right. But keeping warm does not mean giving up all vegetables, fish and fruit, or lying still in one place without bathing. When there is fever or infection, the traditional medicine texts themselves say to drop the "warming tonics only" approach (only building up with warm and hot foods and herbs) and see a doctor right away.

Back to the woman at the start of this article

On her first visit, the doctor showed her exercises for her abdominal muscles and asked her to have a gynecological examination first, before thinking about any mobilization of the spine and pelvis. A few months later she came back for the gynecological examination. Only then did more come to light: she had had vaginal discharge and itching for about five years, and at night she had trouble falling asleep and did not sleep deeply. On examination, the doctor found that the skin of her lower abdomen was cold. The traditional medicine diagnosis was qi deficiency (here meaning a lack of qi, that is, a lack of strength), blood deficiency (a lack of blood), together with cold. So the doctor did not treat the infection or the sleep separately, but chose the herbs to address all three together.

After about two weeks, the discharge was much lighter, only about a quarter of what it had been. She slept more deeply and woke up feeling well. The back pain and leaking urine needed to be followed for longer. At that point she was hoping for a second baby the following year, so this was also a good time for her body to recover first.

For women who plan to have more children, WHO advises waiting at least 24 months after a birth before getting pregnant again. Those two years are also time for the mother’s body to recover.

Seven questions you can ask yourself

The seven questions below do not replace a diagnosis. They are only a way to take a fresh look at your own body, whether your child is 3 months or already 5 years old.

1. When you wake up in the morning, are you still tired even though you slept reasonably well, and is the tiredness easing month by month?
2. Do you still leak urine when you cough, sneeze, run or jump, or feel a heavy, dragging sensation in your lower abdomen?
3. Are your back and joints more painful than before you gave birth?
4. If your periods have come back, are they different from before: heavier, more painful, with clots, or trickling on for a long time?
5. Are you more forgetful, less able to concentrate than before, or more easily irritated?
6. Do you often feel cold, more sensitive to wind than before, or run out of energy quickly toward the end of the day?
7. Has it been more than two weeks that you still feel sad or low, or cannot sleep even when you have the chance?

If you answer "yes" to any one question, take it as a reason to get checked, rather than thinking "everyone is like this after birth". If you have a dull tiredness that keeps going, it is worth testing for anemia and thyroid problems before talking about tonics, because postpartum thyroiditis affects about 5–10% of women and is very easily mistaken for tiredness or depression.

Some women have every test done, with every result within normal limits, yet they still feel tired and forgetful. At our clinic, besides taking the pulse and looking at the tongue, the doctor also examines with Applied Kinesiology (AK), that is, testing the strength of individual muscles by hand to see which muscles are weak and why. In AK, when a few muscles are working below their capacity, other muscles have to take over the load, so the place that hurts or feels tired is often not where the problem started. You place your own hand on an area such as the lower abdomen, a pelvic joint, or an old cesarean scar if you had a cesarean, and the doctor tests the muscle again to see whether that area is contributing to the pain or tiredness (Walther 2000).

The doctor also tests your muscles while you think about what is weighing on you, because according to AK texts, muscles often weaken when a person focuses on something that makes them sad or worried (Walther 1981). The doctor then rests the fingertips lightly on the two bumps of your forehead; you only need to think about it, not talk about it (Walther 2000). The results are placed alongside your pulse, your tongue and any tests you have already had, and do not replace a medical diagnosis (ICAK-USA).

About question 7 in particular: if you have also lost interest in everything, feel empty, or have thoughts of harming yourself or your baby, you need to see a mental health doctor soon. Physical recovery cannot replace that treatment.

The "Postpartum Recovery" series

This article opens a series that follows the milestones after birth, from the confinement days to the time you are ready to try for another baby. The next articles will cover lochia, the confinement period, breast milk, feeling cold and sensitive to wind, and much more.

Give yourself more time, and ask for an examination when you feel you need one.

References

Sources in Vietnamese

• Hạ Quế Thành. Sổ tay chẩn đoán điều trị phụ khoa (bản dịch tiếng Việt).
• Hạ Quế Thành. Thực dụng Trung y phụ khoa học (bản dịch tiếng Việt của BS. Tâm).
• Hải Thượng Lãn Ông. Hải Thượng y tông tâm lĩnh. Hà Nội: NXB Y học.
• Phó Thanh Chủ. Phó Thanh Chủ nữ khoa (bản dịch tiếng Việt).

Sources in English

• American College of Obstetricians and Gynecologists (ACOG). 2018. ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstet Gynecol. 131(5):e140-e150. doi:10.1097/AOG.0000000000002633. PMID: 29683911.
• American Thyroid Association. Postpartum Thyroiditis [Internet; patient information]. Available from: https://www.thyroid.org/postpartum-thyroiditis/.
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• Walther DS. 1981. Applied Kinesiology. Vol. I: Basic Procedures and Muscle Testing. Pueblo (CO): Systems DC. p. 26.
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