Warning signs after birth that need care right away

In the section on obstetrics written by Hai Thuong Lan Ong, there is one line: "When a woman is lying in after birth, safety and danger, life and death, can turn in the blink of an eye" (lying in: the postpartum "confinement" period, ở cữ). This 18th-century Vietnamese physician knew that there are very dangerous moments after birth. He also knew that sometimes herbal decoctions are not enough, and that the wrong medicine can do even more harm.

This article is about moments like those. Many danger signs appear after the mother is already home, and some come even after the month of confinement is over.

The old texts already recorded critical conditions after birth

Hai Thuong wrote: "Of all the critical conditions after birth, none is graver than the 3 rushing conditions and the 3 urgent conditions" (三冲三急 / 三衝三急, sān chōng sān jí). The three rushing conditions are when "bad blood rushes up" to the heart, the lungs or the stomach, with signs such as confusion, shortness of breath, chest tightness and vomiting. The three urgent conditions are vomiting, heavy sweating and diarrhea all at the same time. He also called rapid breathing after birth "the first danger".

For fainting and dizziness after birth (blood dizziness, 血晕 / 血暈, xuè yùn), the old texts make a careful distinction. Heavy bleeding with dizziness comes from blood loss. Light bleeding with dizziness may come from blood stasis (old blood pooled inside that cannot come out). If a woman who is losing blood is mistaken for one with stasis and given stasis-expelling herbs (herbs that push pooled blood out), Hai Thuong wrote, "she will die at once".

Modern traditional medicine textbooks also say: go to hospital

Modern traditional medicine textbooks put it more bluntly. On eclampsia after birth (seizures, usually with high blood pressure), the gynecology textbook by Xia Guicheng (夏桂成) states: "This condition is an emergency; traditional and Western medicine must be combined in emergency care." For postpartum infection, the old rule that "after birth, only warming medicines should be used" is set aside, and antibiotics, IV fluids and, in severe cases, blood transfusion are used. Retained placenta or retained membranes require a curettage of the uterus; one "must not rely on herbal medicine alone". Bleeding that trickles on for 2–3 months needs tests to rule out a disease of the placental cells. According to Giovanni Maciocia, author of a gynecology and obstetrics textbook in Chinese medicine widely used in the West, severe fainting after birth needs urgent treatment, usually in intensive care, and even in China herbal medicine is rarely used at that point.

Dangers that can appear late

Modern medicine has recorded many complications after birth that appear later than people expect.

Heavy bleeding does not only happen at delivery. Abnormal bleeding can appear anywhere from 24 hours to 12 weeks after birth, in about 1–2% of mothers. It is usually caused by retained placental tissue, poor contraction of the place where the placenta was attached, or inflammation of the uterine lining. These causes need an ultrasound, and sometimes a procedure.

High blood pressure, blood clots, infection

High blood pressure with organ damage can start up to 6 weeks after birth. One study following 152 women readmitted to hospital for this condition found that 63.2% of them had never been diagnosed with high blood pressure during pregnancy. Among those who had seizures (eclampsia), more than 90% had them within 7 days of going home. The most common warning sign is headache.

The risk of blood clots is highest in the first 6 weeks and stays slightly raised until week 12. A clot inside a blood vessel (thrombosis) usually comes without fever; the signs are pain, tightness and swelling in one calf, and if the clot travels to the lungs, shortness of breath and chest pain. Many infections happen after the mother is home, in the uterus, a cesarean wound, stitches, the breast or the urinary tract; mastitis is most common in weeks 2–3.

Peripartum cardiomyopathy and postpartum psychosis

Peripartum cardiomyopathy (the heart muscle weakens and pumps poorly around the time of birth) can appear from the last month of pregnancy until about 5–6 months after birth. Shortness of breath, tiredness and swollen legs are very common around birth, so this condition is easily missed, especially in women who have had preeclampsia. With early detection and the right treatment, many women recover partly, sometimes fully.

Postpartum psychosis affects about 1–2 in 1,000 mothers, usually in the first 2 weeks. The mother becomes confused, hears or sees things that are not there, talks in an unusual way, and cannot sleep at all. This is a psychiatric emergency, different from the baby blues.

In the United States, data from 2017–2019 show that 30% of pregnancy-related deaths happened from day 43 to the end of the first year, and more than 80% were judged preventable with early recognition and timely hospital care.

When not to take traditional herbal medicine

When danger signs are present, some herbs make the situation harder.

• Heavy bleeding: do not use Sheng Hua Tang (Generating and Transforming Decoction) or herbs that invigorate or break up blood (活血、破血, huó xuè, pò xuè: herbs that make blood move strongly and break up pooled blood). Traditional materia medica texts state clearly that this group easily depletes and stirs the blood, meaning more blood is lost and bleeding comes more easily.
• High blood pressure: Ma huang (Ephedra sinica stem) raises blood pressure; Gan cao (Glycyrrhiza uralensis root, licorice) in large doses over a long time can cause fluid retention and high blood pressure; Ren shen (Panax ginseng root) used for a long time can also raise blood pressure.
• Taking anticoagulants (for example after surgery, or when a blood clot has already formed): Dang gui (Angelica sinensis root), Dan shen (Salvia miltiorrhiza root), Chuan xiong (Ligusticum chuanxiong rhizome), Tao ren (Prunus persica seed), Hong hua (Carthamus tinctorius flower) and Ren shen can make the effect of the medicine unpredictable. There has been a case where Dang gui taken with an anticoagulant more than doubled the result of a blood clotting test (INR), meaning the blood clotted much less easily and bled more easily.
• Fever from infection: do not use warming tonics (tonic herbs that are warm or hot in nature); see a doctor and take antibiotics.

Most of this evidence comes from case reports and drug interactions; no study has shown that a single herb on its own causes heavy bleeding. Even so, when danger signs are present, let a doctor handle them first, and ask about traditional herbal medicine afterwards.

When to go to the emergency room, and when to be seen the same day

According to current guidelines, all the signs below need to be checked right away. The time windows above are when the risk is highest, not a deadline. Throughout the first year after birth, if you notice any of the signs below, get checked right away.

If you need emergency care, call 115 (the ambulance number in Vietnam) or have a family member take you; do not drive yourself. When you arrive, say right away, "I gave birth … weeks ago".

Go to the emergency room right away if you have:

• Heavy bleeding, dizziness, fainting, pale skin, cold sweats, a racing heart;
• A headache that will not go away or keeps getting worse, blurred vision, pain above the navel or under the right ribs, seizures;
• A home blood pressure reading with the top number at 160 or higher, or the bottom number at 110 or higher (either one is enough);
• Shortness of breath, chest pain, coughing up blood, or new shortness of breath when lying down, swelling that increases quickly;
• A headache with weakness or numbness on one side of the body, a drooping mouth, difficulty speaking;
• Fever with shaking chills, drowsiness, rapid breathing, cold hands and feet;
• Swelling of the face or hands that increases quickly; dizziness, fainting or a racing heart even without heavy bleeding; severe abdominal pain; repeated vomiting; exhaustion very different from your usual tiredness;
• Confusion, hearing or seeing things that are not there, not being able to sleep at all;
• Thoughts of harming yourself or your baby. If this happens, do not stay alone.

See an obstetrician the same day, within a few hours, rather than watching it at home or waiting for your next appointment, if you have:

• A fever of 38°C or higher, even if measured only once; foul-smelling lochia (postpartum vaginal discharge); lower abdominal pain that keeps getting worse;
• A breast that is swollen, hot, red and painful, with fever (while waiting to be seen, keep breastfeeding or expressing milk);
• A cesarean wound or stitches that are red, swollen or leaking fluid; burning or urgent urination with fever;
• Pain, tightness, swelling and redness in one calf or thigh, even without fever. Go somewhere that can do an ultrasound of the blood vessels. If you also have shortness of breath or chest pain, go to the emergency room;
• Bleeding that becomes heavy again like the first days, or keeps trickling without getting lighter after 2–3 weeks;
• A home blood pressure reading with the top number at 140 or higher, or the bottom number at 90 or higher, even if you feel fine. Go somewhere with an obstetrics department to have it measured again and be assessed.

Call your obstetrician or the hospital where you gave birth first if you can; if you cannot reach them, go straight to the emergency room.

In Vietnam, we still often see mothers bundled up tightly, or lying over a charcoal brazier in hot weather (a traditional way of keeping a new mother warm), who then develop fever, dizziness or drowsiness. If this happens, do not add more layers. The gynecology textbook by Xia Guicheng states that heatstroke after birth can be life-threatening. Take off some clothes and get her to a doctor.

What our clinic does in these moments

When we see any of the signs above, our job is to recognize them and send you to hospital, not to prescribe more medicine. If you call the clinic about these signs, our reception will advise you to go to an obstetrician or the emergency room right away, and will not book a traditional medicine appointment. If you are taking anticoagulants or blood pressure medicine, we ask in detail before prescribing any herb. Once you are past the emergency stage and under the care of an obstetrician, cardiologist or psychiatrist, traditional medicine can support your recovery, such as sleep, appetite and strength. We only do this when your main treating doctor agrees, and we always check against the medicines you are taking and whether you are breastfeeding.

The previous article in this series, "Postpartum is more than 42 days", has seven questions to help you take a fresh look at your own body. For today, save 115 and the number of the hospital where you gave birth in your phone, and tell your family where to find them.

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. Phụ đạo xán nhiên; Tọa thảo lương mô.

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• Centers for Disease Control and Prevention (CDC). Hear Her: Urgent Maternal Warning Signs [Internet]. Available from: https://www.cdc.gov/hearher/maternal-warning-signs/index.html.
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• Chen JK, Chen TT. 2004. Chinese Medical Herbology and Pharmacology. City of Industry (CA): Art of Medicine Press.
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• Maciocia G. Obstetrics and Gynecology in Chinese Medicine. Chapters 55–56.
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• Royal College of Psychiatrists. Postpartum psychosis [Internet]. Available from: https://www.rcpsych.ac.uk/mental-health/mental-illnesses-and-mental-health-problems/postpartum-psychosis.
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Sources in Chinese

• 钟赣生, 主编. 中药学.