Thoughts, observations and the classical Chinese medicine view: The first trimester of pregnancy

Pregnant Woman Line Drawing - Hugh Lau

For most people who walk the earth, reproduction is an experience that is a given, whether by choice or by accident. Like breathing, sexuality and reproduction are two of life’s basic drives. Once pregnant, today’s women find themselves reaching for information and guidance on how to care for themselves and their unborn babies. Besides the numerous books and classes on pregnancy and birth, many seek this guidance and care from practitioners of Chinese medicine because it is known for its wisdom and safety.

The amazing physical and emotional changes during the first trimester are a unique time for most women. It is during these three months when the cellular organization of an embryo takes place within a woman’s body. These profoundly important months are those where the foundation of an embryo’s life is getting laid down, yet these changes remain invisible to the outside eye, so to that eye it is a silent time. However, for most women there is nothing silent about it, because it is during these first three months that their lives are dramatically changing at the fastest rate they have ever known, with symptoms that affect them daily to one degree or another.

I would like to share with the readers of this newsletter my notes and studies of the classics, from classes that I took with the brilliant sinologist and scholar Elisabeth Rochat de La Vallée, along with my observations and thoughts of these first three months, and focus on what the classics had to say way back when.

In studying the ancients on their thoughts regarding pregnancy, we must realize that these teachings came from the astute observations and witnessing of nature in all its glory and violence. The lessons the ancients learned originated from watching the power and influence of the moon, sun and stars, the weather, seasons, elements, the sowing, cultivating, and harvesting of crops, the language of plants and animals, and bottom line, the interdependence of all these factors as they affect everything on earth. These lessons influenced the religion, culture, philosophy, politics, and wars waged during those venerable times. In quoting from the Mawangdui Silk Texts and the Zhubing Yuanhou Lun/Treatise on the Origin and Symptoms of Diseases, texts that reflect the values of early China’s beliefs in rigorous self-cultivation and mental discipline, one sees that they contain volumes covering medicine, including the ten lunar months of pregnancy. Needless to say, there were no techniques to see into the body through ultrasonography or x-ray as there are today, nor were there labs where the assessment of the embryo and fetus could be evaluated. What was studied and advised was based upon the empiric outcomes of witnessing and working with centuries of women, pregnancies, births, babies, and mothering. Even though the thoughts in these writings can be challenged by today’s technological findings, there is nonetheless a rich and wise warp thread that is as consistent with health today as it was two thousand years ago.

The classic writings quoted below are taken from the Zhubing Yuanhuo Lun, the Mawangdui, and Sun Si Miao. They will offer you the ability to contemplate the first three of the ten lunar months of pregnancy, interpreted and practiced by the leading physicians of that time. I invite you to open your modern mind and embrace the poetry and wisdom of the following classical descriptions of the first trimester of pregnancy.

While reading these classics we must keep in mind that they date from 200 years prior to the birth and 600 years after the death of Christ respectively. Society and culture were already patriarchal, where women were subjugated to men and to their control and physical strength. Also, at these early times, there were great class distinctions, where the royalty and nobles lived a different life than those who worked in the fields, houses, and served the privileged. The advice given regarding gestation was unlikely practiced by most women, as only those of the upper classes or some degree of privilege were lucky enough to actually follow these teachings. I imagine that most women reproduced and experienced their pregnancies and births with only a small portion of this type of attention, although I am sure that the classic guidance, instruction, and superstitions of the day had their effect anyway. It is a mute point to say that these ancient thoughts reflect life long before the invention of the microscope, before understanding the double helix of the human genome, and before the world of chemicals, drugs, and modern stress. In seeing these many differences, and appreciating that these teachings date before a time we could even comprehend, they still have meaning, they definitely have wisdom, and they should be considered by the modern mindset.

Our present-day lifestyle has lost the ancient thread of living in harmony with the earth. In fact, recent generations have even lost the concept of it. One of the consequences of this loss is that infertility for both genders is on an exponential rise and for them, in order for conception to occur, assistance of hormonal therapy and/or in vitro fertilization is needed, reinforcements far removed from the act of sexual intercourse.

In looking at how we conduct our pregnancies once conception has occurred, we see that many women continue to remain in the workforce for the duration of pregnancy, quitting jobs or taking leaves of absence only a week before the predictive due dates. Today in North America 33% of women are sectioned, 60-80% of first-time mothers agree to have an epidural at some point during their labor, and 85% use a breast pump to facilitate lactation. When looking at maternal care in the immediate weeks postpartum we find too many women are in isolation with little wisdom from elders and scant care from their community. Post-partum time is all too often cut short because the new mother is forced back to work for financial reasons, leaving the care of her newborn to another during the 40-hour workweek. This is a seriously different picture than what is presented in the classics.

Today’s culture is not only two thousand years plus or minus a few centuries removed from these classic values, beliefs, and teachings, but we are light years away from living life as the ancients lived theirs. With that in mind, I will go ahead and present what I have learned as I studied the classics under Elisabeth Rochat de la Vallée.

CHINESE CLASSICS ON PREGNANCY

According to the Chinese classics, conception--the first moments of life, begins in the depths of water, hidden in dampness, darkness, and mystery. The image describes sexual intercourse, an action that takes place in darkness. The Mawangdui manuscript describes this in the following words:

“Therefore, to generate a human being, a man has to enter into the obscure darkness and exit from the obscure darkness, and this begins the process of making a human.”

This description is not only a statement of human life, but of all life, for the origin of all life is always in dampness, darkness, and hidden in the depths. Heaven/Yang is the first mention of life and Earth/Yin is the second. Heaven uses its power to come down to earth and earth receives these powers, transforming them and giving rise to conception. In order to create any form of life we need water, as nothing is born without Yin. When these two forces unite there is an initial movement, a rhythm, leading to expansion and growth. Think of the modern images of cellular division. The cells pulse and then push apart, separating while also remaining whole.

Fetal Development from Chinese Farmer's Almanac

Within each human there is Yin and Yang or Blood and Qi. For men the prevailing substance is Qi and for women it is Blood. When the Qi from Heaven moves into the Blood of Earth, a new form of life begins. The strength and initiation of this movement is ruled by Yang, but it is the essence of Yin and its ability to receive and gather that is essential for the creation of new life. So the Yin receives the Yang, they merge with each other, and a new form of life begins. This is an example of Yang within Yin. The Yang then keeps the Yin warm while the Yin nurtures. My beloved teacher, Dr. Miriam Lee, who was a nurse midwife in China before she became an acupuncturist, and who spearheaded the legalization of our profession in the state of California, always said that in order to have life, there must be moisture and warmth, or Yin and Yang.

The ancients saw that once conception took place, at this early stage of the merging of Yang and Yin, what existed was not yet a person per se, instead they saw that it was a potential in the making. There is a wonderful Chinese character called cai 材 meaning innate potential, and it is used when referring to the potential human at this formative time. This cai relative to a stage in human conception is nowhere near a finished state nor does it have form. Instead, it speaks of the possibilities, traits, talents, and qualities that are intrinsic in this particular union. The western mind might call the concept of cai the blueprint of DNA, containing the health status for the new individual, as well as the potentials for talents, predispositions, and abilities. How these potentials eventually pan out is realized by what the mother does in her pregnancy, what happens to her, how the infant is cared for in the post partum, and the continuing circumstances inherent as the individual lives life.

Each month during gestation the classics attributed one of our body’s organs as the ruler of that month. Dr. Miriam Lee advised me to be very careful if I chose to needle that meridian/organ during that month and in fact advised me to avoid it. In my lessons with Elisabeth Rochat de la Vallée I learned that there was no rule about this, but she, too, advised caution when choosing to needle the organ ascribed to that month’s meridian. In the case of the first two months of gestation, it is common for some woman to not even realize that a pregnancy has taken place, and unless you are taking pulses, you also may not be aware of a conception, so if you have already needled the meridian governing that month, do not worry.

THE FIRST MONTH

The Zhubing Yuanhou Lun says of the first month of pregnancy:

“The first month of pregnancy is called the beginning of the form. (The woman) must nourish herself with essences and cooked foods, and choose sour tastes. It is therefore appropriate to eat barley, but she must not eat acrid and pungent foods. This is called the gestation of the innate material. The Jue Yin of the Foot supports it. The Jue Yin of Foot is the Liver circulation/meridian and the Liver governs the Blood. During the first month the Blood flows with difficulty and no longer comes out, this is why the Jue Yin of the Foot supports it.”

The first month of pregnancy is ruled by the Liver, the organ that governs the Blood. When gestation occurs the menses stop, and the circulation of the Liver Blood that normally flows out as a menses month after month, ceases to be released. Instead that Blood is stored for use as nourishment to the lush bed of the uterus for the implantation and growth of the embryo. This first month is called the “beginning of the form”.

In the Huainanzi/The Writings of the Huainan Masters, Chapter 7, the beginning form of the first month of life is described as a “fertile paste/gao” 膏. Gao is translated as fatty and often refers to flesh, fat, or paste, all of which indicate precious and vital essence. So it is in this most primitive time that a fertile paste is forming, but it is not yet seen as having form.

It is also said that the first month is one where the mother’s blood moves with difficulty. This is because the creation of a form and the gathering of essence is a pulling in of sorts, a gathering of the Blood from both the Liver and the Kidney. This is not a time for release as is done cyclically during menstruation, but is instead a time for consolidation and coagulation. For this reason, the ancients advised the woman to not physically exert herself causing her Blood to move, because this movement could prevent the gathering and coagulating. It is the Liver that stores and gathers the Blood in this first month, treasuring its nourishing aspects. This is why a quietude and stillness of the mother’s circulation is preferred over activity or movement. It is during this first month that the essences quietly begin to form new life. Sun Simiao, a physician from the Sui Dynasty (581-618 AD) advises that it is better to sleep and be calm and quiet. He says of the first month:

“the Jue Yin of the Foot internally is related to the Liver and the Liver masters the muscular movement and the Blood”.

Raven Birth Book Front Cover

He warns the mother not to move with a lot of strength because the Blood would go to the muscles instead of the uterus where it must enrich the womb/endometrium. If there is too much muscular movement, the function of storing and beginning to make the form would be reduced, and the nourishment of uterine Blood might not be rich enough for the fertilized egg to implant. When the uterus is not full with essence and nourishment, miscarriage is a possibility. Excess movement is also warned against because it has the potential of creating a Yin/Yang imbalance or awakening wind.

As we modern practitioners know from paying attention to women at the start of a pregnancy, the first month is most often one where the woman wants to remain still, away from the hustle and bustle of ordinary life and the fast pace of activities and responsibilities. She instead wants to lie around on the couch, nap, read that novel she’s been waiting to read, or just take time and be off-duty. Modern women might chastise themselves for such behavior because our present culture recognizes and praises work and activity as important. However, if and when a pregnant woman learns that these ancient concepts are exactly what she desires, she will see that she is in fact doing something vitally important for the life of her developing embryo. This knowledge gives a woman insight to not judge herself as lazy or non-productive, but instead assures her that her instincts reflect the laws of nature. We live in a Yang society with Yang values, so as a practitioner, teach your patients that this is a Yin time of stillness, consolidation, and gathering.

While a woman is in these first formative weeks of gestation, her sources of uterine nourishment are derived from two places: the stored Liver Blood from the previous month of the last reproductive cycle, and the quality of the food she chooses. When a woman desires a child it is important to eat well with foods of high quality so that the Blood stored in the Liver is adequate. This ensures that the Blood and Qi of the mother maintain the strength within her body and that the embryo receives this nourishment. It is best, the writings say, if the woman eats cooked foods. This is because cooked foods do not require endogenous fires to break them down and are therefore easier to digest. Cold and raw foods require the Qi or Fire to ferment them and therefore reduce Yang’s ability to warm and to hold. Cold foods, especially if in excess, produce stagnation, cold, and phlegm, each of which could cause a disharmony leading to physical problems, some of which end in miscarriage.

Sour food is the taste that is recommended because sour is the taste for the Liver, and sour’s function is to gather. In so doing, sour nourishes the Liver. The first month, therefore, is the time to pull in one’s energy. Gathering, storing, and warming are the basic needs for the growing embryo. It is interesting that at the beginning of a pregnancy a woman might find herself craving unusual foods that are sour in nature. When I was a child I remember my European grandmother telling my older cousins that she thought they were pregnant because they suddenly craved sour foods at our Sunday family meals. Pungent and acrid foods are to be avoided because they have the opposite effect of sour’s gathering and storing. Instead, hot, spicy and stimulating foods scatter and diffuse. Acrid foods that are sharp, bitter and smell unpleasant are not advised, nor do women crave them. Barley is the grain recommended during the first month. Nutritionally speaking, it is a whole grain high in B vitamins and minerals and is a great source of dietary fiber. In the first month when some women experience problems in digestion and elimination, barley weaves well into present day intelligence.

THE SECOND MONTH

The Zhubing Yuanhou Lun says of the second month of pregnancy:

“the second month of pregnancy is called the beginning of the rich paste. The woman must not eat acrid and pungent foods. She must stay quiet and avoid sexual relations, because that could cause pains in the one hundred joints. It is also called the beginning of storing or treasuring. The Shao Yang of the Foot supports it. The Shao Yang of the Foot is the circulation of the Gallbladder and it is governed by the essences. In the second month, the essences of the child are perfectly formed in the uterus…”

In the second month the essences of conception have consolidated and a form has begun to emerge. In the Su Wen, chapter 4, it tells us “the essences are the foundation of a living body”. This form now has all the necessities and possibilities of creating an embryo.

Sun Simiao writes that the embryo becomes “knotted” in the second month. This is a kind of coagulation where the essences have consolidated and merged together. Here the embryo is no longer a formless paste as it was in the first month. Now it forms a dot, or a bulge, called die 胅. It has a Qi of its own. It has made itself into more than just an intangible form like water. Now it has its own form. It has become itself. In the first month we begin in Yin/Liver, in the second month we follow with Yang/Gall Bladder. This is the normal sequence of life on earth, Yin to Yang.

Matisse Woman

The woman is still urged to remain calm and still, as the need to store energy is very much still in effect. In the first month, the Liver is quiet and still, but in the second month, we have the Gall Bladder, a Yang organ, that comes into play. Through the second month much storage has taken place, but we are still told to remain “quiet” as we must continue to store and protect the essences.

Even though the Gall Bladder is a hollow (Fu) organ and therefore Yang, it is also one of the Extraordinary Fu (hollow organs), and unlike all other Fu the Gall Bladder is full of an essence which we call bile, describing its capacity to be both solid and empty, or Zang and Fu. This bile comes from the digested foods and fluids of nutrition that are stored as essence to produce harmony in the body’s physiology. No other Fu/hollow organ does this; all the others receive and eliminate. This is why the texts say that the second month of pregnancy is the Shao Yang of the Foot. Here the Yang arrives, but it has to be a quiet Yang because it must continue to store essence and thus remain in a stage of stillness rather than of movement or agitation.

Since the Gall Bladder is a Yang organ associated with movement--sometimes with strong movement, it is also associated with the male principle that includes action. Sperm and its actions represent the male principle, and it is during the second month that this principle becomes more fully integrated into the forming embryo.

“This is also perhaps the reason why some authors have said that in the second month the essences of the father, the sperm, are completely assimilated and integrated into the blood of the mother in the uterus, forming the basis for the essences of the child itself”.
- Elisabeth Rochat de la Vallée

As well as being advised to remain still and to avoid sex, women are told not to eat pungent or acrid foods. The advice for the first month is quite similar to the second, and in observing pregnant women, we see that during the second month the desire for time out of normal life is even stronger than it was the previous month, and sexual appetite is also quiet. This stillness refers not only to the physical body but it also refers to the spiritual or emotional body, as a disturbance of either can produce internal wind, stimulating the Shao Yang of the Foot to disturb the serenity and quietude necessary at this time.

The Gall Bladder is also associated with the Ministerial Fire of the Ming Men, which is also the Fire of the Pericardium and Triple Heater, the two organs that rule gestational life in the third and fourth months.

In agreement with the manuscript of the Zhubing Yuanhou Lun, the Mawangdui says of the second month:

“the dwelling place must be still”.

THE THIRD MONTH

The Zhubin Yuanhou Lun says of the third month:

“…the third month of pregnancy is called the beginning of the fetus (shi tai 始胎). At this time, the blood no longer flows, the image of the body (xing xiang 形 象) begins to develop through transformations (shi hua 實化), but the determining principle (yi) is not yet fixed. It changes according to the people the mother is exposed to. She must therefore seek out the presence of those who are noble and accomplished, eminent and royal, people who are beyond reproach and serious, but she must also avoid dwarves, the deformed and midgets, all people of ugly and horrible appearance who look like monkeys. She must eat ginger or hare and she must not carry a knife or a rope”…“The heart master is the vital spirits present in the vital circulation. Internally it is dependent on the heart and can mingle indistinctly with the spirits. This is why the heart master maintains it.”

The third month of pregnancy is called the Jue Yin of the Hand, the Heart Protector/Heart Master, or Pericardium.

The third month of pregnancy has more literature about this time than any other month and is referred to as the beginning of the fetus/tai 胎. Here we really have the potential of a child. In the first and second months we had two distinct presences, but they did not resemble a human form. Now, in the third month, we have what is referred to as an embryo or a fetus, which is the beginning of a distinct individual. At this time the circulation of blood has two systems, one for the mother and another for the fetus. The growth of life is now transformed from Blood and essence into the image of a body, but the fundamental foundation or conscience of the individual, called yi 意, is not yet fixed. Instead the yi is affected by the influences present in the woman’s life. This circulation of maternal blood affects everything that is forming in the fetus, including the brain. It is at this time that we have the beginning of what is known as the heart/mind/xin 心.

Raven Birth Book Front Cover

Maternal influences at this time are seen as profound because they affect the development of the fetus’ mental state as well as physiology. Therefore, this is the month that begins what is called “fetal education”. It is during this time that women are encouraged to stay away from looking or thinking about ugliness or negative influences, as these can all affect the growing fetus within her. Here the body and mind begins its development as a human being, and what the mother does, eats, desires, thinks, drinks, fears or worries about has an effect. It is this time in particular that the mother must watch her behavior, emotions, and inner thoughts, as well as her food, lifestyle, and habits. It is said that it is this third month where influences are made that can never be undone. This is said to be the most important month of maternal impact, as anything that is disturbing can and will affect the growing child. As a practitioner looking after women’s health during gestation, it is best to advise them to not listen to the many stories that everyone seems to want to share that are ones of difficulty in labor and delivery. In the decades of my practice I remember a button that was given to the participants of a midwifery conference that said “Shh, my baby is listening” and underneath those words was an image of a finger in front of a mouth making the sound of Shh. When I was pregnant with my first baby, I remember walking away from anyone wanting to tell me a story that led my mind into a state of fear or sorrow, and it was surprising just how many times I had to do that. In today’s world, it is advised that mothers do not spend too much time looking at the internet and learning about all the possibilities of bizarre human growth, as this creates fear and worry, both emotions leading to negativity relative to fetal education. Instead, it is best to concentrate on beauty and peace, nourishment and joy.

It is at the end of the third month that we know the finalization of the human blueprint is done. If a chromosomal anomaly exists, it will have taken place by this time. What has thus far occurred in these formative three months is the genesis of the embryo/fetus. At the end of the third month these influences are set and cannot be changed. We know in today’s world that first trimester insults are often those that interfere with normal or healthy growth for the forming individual, and that a woman’s illnesses and exposures must be avoided to properly insure ongoing normal fetal development. Do these ancient words of the first trimester ring a bell to the almost unavoidable symptoms of women wanting to stay quiet and home and away from people or foods prepared by others? Does this advice not caution a woman to isolate herself in order to avoid pernicious and unwanted influences? For many women the third month is one where women still feel sick, nauseous, and extremely tired, and remaining at home and eating in one’s own kitchen is often desired. Is this not Nature’s way of protecting the growing life within?

The text of the Education of the Embryo from Zhubing Yuanhou Lun continues:

“if the woman wants a child full of kindness and accomplished in virtue, she should regulate her heart and behave correctly. Be pure and empty in harmonious unity. She should not sit askew on the mat nor stand leaning to one side, and when she walks, she should not take roundabout paths. They eye should not look askew, the ear should not hear depraved things, the mouth should not utter a bad word, the heart should not have any bad thoughts, she should not let herself be distracted by joy or anger, she should not let herself be taken over by worries and preoccupations, she should eat chopped up meat, she should not lie down askew, and she should not put her feet at an angle. She desires fruits and foods from the cucumber family, she is nourished by preserves of sour-tasting vegetables. She likes good odors and dislikes bad ones.”

This advice about positive thinking does not change after the third month, but it definitely begins here. Zhubing Yuanhou Lun says that the Jue Yin of the Hand, the Pericardium AKA the Heart Protector or Heart Master, supports this time. Here the Pericardium is carrying out the orders of the Heart. In chapter 25 of the Nan Jing it is said that at one time the Heart and Pericardium/Heart Protector were seen as one channel with two separate vessels. Because of their anatomical connection this is easy to see. Blood carries not only the nourishing essences that we speak about in the first two months, but in the third month it also carries all the Qi of the mind as well, influencing the growing individual. This then speaks of the power of Spirit/Shen 神. Just think about when one is moved by a deep emotion or alerted by fear or danger. In situations like these the quality and rate of a pulse can change in an instant, and that emotional alarm is carried in the Blood’s circulation. Of course, it is not only the Heart and Heart Protector that is involved with the mix of emotions, other organs can also be involved. The Kidney is affected with the release of adrenalin and noradrenalin in the reactions of fight and flight, the Spleen with emotions of worry and overthinking, or the Liver with emotions of anger or depression. With these considerations, information from the Heart or Pericardium by way of the Spirit is instantly carried to the growing child.

“The heart master is the vital spirits present in the vital circulation. Internally it is dependent on the heart and can mingle indistinctly with the spirits. This is why the heart master maintains it.”

Sexuality is not advised at this time because it could create an agitation of the Ministerial Fire and therefore the Heart and Pericardium. These disturbances could lead to a blockage of the Blood with the Qi resulting in problems later in the pregnancy, or they could lead to an accumulation of heat that could dry or burn the precious essences. Physiologically, sexual orgasm causes contractions of the uterus and the maternal blood vessels, thus reducing the lush surface of the endometrium where the placenta has implanted. These contractions if protracted or too frequent can lead to unwanted cramps and can result in spotting. For women with weak Lung, Spleen or Kidney Qi, these contractions could lead to miscarriage. All of these reasons are why abstinence is recommended in the third month so women can continue to remain calm and quiet. This emotional state of calmness and careful living ensures enough Blood for both the mother and the fetus, allowing the transformation from embryo to fetus to take place with no adversity.

These thoughts and notes regarding the first three months may give the practitioner fuel to advise women to take it easy at this time. Becoming familiar with this ancient advice will help you support a woman’s instinctual need to reduce the fast pace of today’s lifestyle and instead take this influential and relevant time for herself and her growing fetus.

Bio: Raven Lang, L.Ac., O.M.D.

Raven Lang, L.Ac., O.M.D. Raven is a popular and well-respected instructor, having specialized in TCM treatment of women and pediatric patients for over 30 years. She has been teaching about natural childbirth for nearly 50 years and wrote the first book on home birth as well as opening the first birth center in North America in 1972. She worked as a midwife, founding the first non-medical midwifery school and in 1982 began to study TCM. a year later was blessed with a three-year apprenticeship with Dr. Miriam Lee, a nurse midwife from China and one of the first licensed acupuncturists in California. Raven incorporates her knowledge of midwifery, mothering, and traditional medicine (both American and Asian) in her work and brings a wealth of experience to those she serves. Now retired, Raven practiced midwifery for 20 years and traditional Chinese medicine for over 30 years in Santa Cruz, California.
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