Denise and her blog

Denise Tiran FRCM, is an international authority on midwifery complementary therapies.

Watch our video and read Denise's blog for all the latest on complementary therapies and maternity care.

Find us on Facebook

Connect on LinkedIn

World Mental Health Day

Published : 10/10/2020

Today is World Mental Health Day so here, Denise considers some of the complementary therapies and natural remedies which may – or may not be of help.

Most people know that some new mothers can experience postnatal depression, but depression during pregnancy is becoming much better recognised. Antenatal depression may occur in women with a tendency to depression, anxiety or severe stress when not pregnant, or may arise as a result of the hormonal, physical, social and occupational changes brought about by pregnancy. It can be severe, partly because is it not always diagnosed early enough, or because women do not always feel able to talk about it to their midwives or doctors. There are several ways of reducing the severity of antenatal depression, including trying to reduce stress and stressful situations, eating well and having moderate amounts of exercise. Avoiding stimulants such as caffeine, alcohol and nicotine is wise advice in pregnancy anyway, but will also reduce the impact on antenatal depression. Yoga, Pilates, swimming, tai chi and other gentle exercise can all help, especially in a designated antenatal class, in which the opportunity to talk to others can also be helpful. Relaxation therapies such as massage, reflexology, and aromatherapy can be helpful, as can mindfulness training or hypnotherapy from a qualified practitioner. Acupuncture has also been shown to reduce stress hormone levels such as cortisol and to increase feel-good factors including endorphins and encephalins. Expectant mothers, however, should be discouraged from stopping or reducing their current antidepressant medication without medical support and must be advised not to take the herbal remedy St John’s wort, which is not considered safe in pregnancy.

St John’s wort (SJW) is a herbal remedy also known as hypericum (its Latin name is Hypericum perforatum). It is often taken orally for mild to moderate depression and mood disturbance, but can also be useful for polycystic ovary syndrome, menopausal symptoms, seasonal affective disorder and other conditions. However, SJW is not a suitable alternative to antidepressants. Although the evidence is inconclusive, there is some suggestion that it may have adverse effects on the developing baby. Similarly, in breastfeeding, it should be avoided because the baby may be at greater risk of lethargy and drowsiness, as well as intestinal colic

SJW can cause a variety of adverse effects in patients, even those who are taking it appropriately. These include insomnia, restlessness, anxiety, panic attacks, irritability, dizziness, headaches and skin rashes. More serious effects include low blood sugar, high blood pressure , raised thyroid stimulating hormone and sensitivity to sunlight (this latter effect meaning that anyone also using aromatherapy oils should use citrus oils such as orange, bergamot, grapefruit and lime oils cautiously. Significantly, SJW should not be substituted for the selective serotonin reuptake inhibitor (SSRI) antidepressants such as sertraline, citalopram, seroxat or fluoxetine, because its mechanism of action is similar. Women will need to withdraw gradually from SSRIs and the same applies to SJW; they should certainly not be taken together as major adverse effects such as SSRI syndrome can develop in which the person experiences suicidal thoughts and mania.

SJW can also interact with various other medications especially when taken in excessive or prolonged amounts. In addition to SSRIs, SJW can interact with the contraceptive Pill, anticoagulants, immune system suppressants, iron supplements and many other drugs used in cancer care and transplant surgery. It should also be avoided if taking other herbal remedies, notably L-tryptophan, an essential amino acid used to increase serotonin levels in depressive conditions, and red yeast, sometimes used to lower cholesterol.

SJW cream can be used topically to treat bruising and aid wound healing but the herbal remedy should not be confused with the homeopathic version which is much safer since it does not act pharmacologically. SJW cream is however safe enough to use during pregnancy and breastfeeding in small amounts. In non-pregnant women, SJW should be avoided when having fertility treatment and should not be taken with the Pill as it may reduce its contraceptive effects.

Complementary Therapies Explained

Published : 08/10/2020

As a midwifery lecturer, I have been teaching complementary therapies for over 30 years and have long held that they must be set in the context of the culture in which they are used. Where a culture combines mainstream health care with ancient local or regional medicine systems including the use of indigenous plants and techniques, the population has a far greater appreciation of the clinical effects of treatment, both positive and negative. For example, in China, Hong Kong, Taiwan and other Far Eastern countries traditional Chinese medicine is integrated into the healthcare facilities available to the public and medical students are taught about both systems. Similarly, in India there has traditionally been cross-referral of patients between orthodox and complementary practitioners, and further legal changes to integrate the two systems more comprehensively have been made in recent years. Guidelines for the registration of traditional African medicine were published by the World Health Organisation some years ago to facilitate greater integration into the healthcare provision across the continent, particularly in sub-Saharan Africa. In South America, countries vary in respect of acceptance and regulation of traditional medicine, but some such as Brazil have introduced legislation to ensure consistency of standards and to preserve local traditions Indeed, the World Health Organisation has accepted a wide range of traditional medical modalities into its global compendium.  In the Western world, things are rather different. Complementary – or alternative – medicine does not have the respect of mainstream medicine. This may be partly due to the prevailing medical system and the status of the medical professions. The political standing of doctors is considerable in some developed countries. One only has to look at the power of the British Medical Association to appreciate the influence of doctors on healthcare policy. Scientists frequently demean complementary medicine as not being sufficiently evidence-based – largely because it is difficult to undertake randomised controlled trials when using modalities that need, by their very definition, to be individualised to the person. The pharmaceutical companies also exert immense financial pressure on governments, and there is an underlying emphasis on the benefits of drugs to treat disease. In addition, the focus of medical practice is on the suppression of symptoms rather than on finding the cause of disease; there is still poor appreciation of the impact of lifestyle factors such as diet and stress on illness. Added to this is the short-term healthcare policy-making of governments in which the controlling political party may no longer be in power to witness the impact of any long term health promotion initiatives.  Furthermore, populations differ widely between cultures in which people generally defer to authority compared to westernised democracies in which individuals can make their own decisions about whether to accept medical advice and treatment or to find their own alternatives. It could be argued that the rise in the use of complementary and alternative medicine is a rebellion against paternalistic orthodox medicine. The Internet too has added to the potential “knowledge-base” of healthcare consumers, although it must be acknowledged that information is not always accurate, comprehensive and balanced and may, on occasion, be downright dangerous. There is also a misplaced notion in the west that “more is better”. Nowhere do we see this more than amongst the pregnant population. Women in westernised countries want to take control of their childbearing experience; they search the Internet for solutions to the discomforts of pregnancy and notably take it on themselves to interfere in the normal process of going into labour, arguably the most common reason for pregnant women to resort to natural remedies and complementary therapies. Added to this is the ill-informed advice given by healthcare professionals about natural methods, in an attempt to be seen as mothers’ advocates. Only today, I saw on Facebook a proudly displayed post from a UK birth centre actively encouraging women to eat dates to promote labour onset. This is not, in itself a bad suggestion, but incomplete advice put out by an organisation deemed to be the “authority” for women using the service can risk some women experiencing negative effects which may go unrecognised by staff who are not in possession of the full facts. Also, there was no advice to restrict the use of natural remedies that may interact with other complementary practices or with conventional medical induction of labour. This, then, is the nub of the argument: in the developed countries there are so many options for dealing with various health conditions, ranging from highly sophisticated contemporary medical treatments for specific problems to well-known and popular complementary therapies to the fringe alternatives (commonly used by desperate cancer patients seeking solutions), that people are unaware of the issues that may occur when they are combined. It is well known that herbal remedies, which act pharmacologically, carry a significant risk of interaction with other pharmacological agents, including both prescribed and recreational drugs and other natural remedies (See my forthcoming book on Using Natural Remedies Safely in Pregnancy and Childbirth, due to be published March 2021).  Having spent almost my entire career practising, researching, writing about, teaching and promoting the use of complementary therapies in pregnancy and childbirth, I would be doing a disservice to everyone to suggest that their use should now be limited. However it is vital that midwives, doctors, doulas, antenatal teachers and other maternity professionals, as well as people attempting to conceive, and those in the antenatal, labour and postpartum periods, understand that these “alternatives” are powerful and may be either beneficial or hazardous. I always say, if something has the power to do good, it also has the power to do harm if not used appropriately. As with any medicinal product, natural remedies and complementary therapies MUST be adapted to the individual, used correctly, in the smallest “dose” needed to achieve a positive effect. Professionals must understand the reasons for use and those people who should not use a particular remedy or therapy; they must understand the way in which the therapy works, and be alert to side effects and adverse reactions – and know how to deal with them. Their use of alternatives must be set in the context of the culture in which they are working – and in developed countries that usually means the national healthcare services. In the UK, the NHS works for the good of the majority rather than the interests of individuals; it is focused on using evidence-based practices and dismissing those without “proof” of both effectiveness and safety. The NHS is litigation conscious and policy is largely directed towards the “just in case” scenario, utilising routine practices in an attempt to show that everything has been done correctly – just in case there is a legal case arising from possible malpractice or other factors. Whilst we may not like the culture in which NHS employees work, that is the prevailing situation and any alternative options must be used or offered with this in mind.

In honour of National Curry Week (5th to 11th October) Denise questions whether curry will bring on labour

Published : 06/10/2020

Eating curry is one of many so-called “old wives’ tales” about starting labour. To my knowledge, there is no research to prove this but it is thought to work because the hot spices stimulate the gut which may have an indirect effect on the nearby nerves and muscles of the uterus, thus triggering contractions. Diarrhoea and loose stools can be a sign of impending labour but are natural responses to the changes already occurring in the body in readiness for labour. Other popular natural ways of getting yourself into labour include pineapple (the core contains a chemical which can cause contraction of uterine muscle) and dates, which have been shown in a couple of studies to have some effect on contractions. Dates contain fatty acids that help in the production of prostaglandins, as well as other chemicals which may contribute to smooth muscle contraction. Aubergine and tomatoes with parmesan is a popular Italian recipe that is also though to contribute  to labour onset, but its success is more likely to be due to the herbs used in the recipe - basil and oregano should be used with caution during pregnancy as they are known, in large quantities to cause threatened miscarriage. So – in honour of national curry week, perhaps the best curry recipe to trigger labour would be one with aubergine, tomatoes, pineapple and dates in it! However, my advice is to take care with all natural ways of starting labour and just to let your body do its own work – after all that’s what you’re designed for.

Celebrating World Reflexology Week

Published : 24/09/2020

Did you know there are many different styles of reflexology? The word “reflexology” refers to the use of one small part of the body as a “map” of the whole. Normally reflexology is performed on the feet, with every part of the body being reflected on one of both feet, but the therapy can also be done via the hands, ears, tongue, face or even the back.

The style that Denise and her team teach for midwives and doulas is the German style of clinical reflex zone therapy (RZT) devised by the German midwife, Hanne Marquardt.

RZT fits very well with midwifery because it can be used both as a relaxation treatment but also for more specific conditions such as pregnancy sickness, backache, sciatica, carpal tunnel syndrome and to stimulate the onset of labour. It is good for pain relief in labour and can help with retained placenta. Postnatally, RZT can aid recovery from birth, stimulate lactation and boost the immune system.

Other types of reflexology range from the very gentle light touch reflexology, combining traditional reflexology with healing energy techniques, to vertical reflexology, which starts by applying pressure to the weight-bearing tops of the feet or hands, followed by a conventional treatment. Eastern styles include Chinese Five Element reflexology and Taiwanese Rwo Schur, which uses an extremely intense pressure. Most generic reflexologists use the Ingham method, which incorporates more massage-type techniques rather than just pressure point treatments

Denise’s First Course after Lockdown

Published : 21/09/2020

At long last, after lockdown, today was Denise’s first day back to face to face teaching the Expectancy Aromatherapy and Acupressure for Post Dates Pregnancy 2 day course.
She’s been teaching the midwives from Homerton hospital. It was only the second time in six months she’d been in to London but they all had a lovely day despite having to wear face masks!

Aromatherapy in Indonesia

Published : 29/08/2020

Denise gave another lecture on aromatherapy in midwifery to a group of Indonesian midwives this week. After a slight panic due to having a power cut after a storm, she was able to join the session with just a few minutes to spare. She says:

It was lovely to meet more of the midwives from Indonesia this morning and to greet some colleagues who have attended previous sessions. We had some insightful discussion and we shared experiences of women’s use of aromatherapy in both Indonesia and the UK. As there are so many different herbs and spices that grow in Indonesia, local people use them both in cooking and for medicinal purposes, so pregnant women are familiar with using oils during childbirth. Popular oils include ylang ylang and frangipani, both very fragrant oils suitable for pain relief and relaxation. However, it was interesting to hear that clove oil is very popular in Indonesia although it is generally considered unsafe for pregnancy and caution is needed if it’s used in labour, to avoid over-stimulating the contractions. 

I was also asked by one of the midwifery lecturers attending the session if I thought that aromatherapy should be included in pre-registration midwifery training. As many regular readers of my blogs know, I have been campaigning for many years for the subject of “complementary therapies” to be included in UK midwifery training so that, on qualifying, midwives have a basic understanding of the benefits and risks of natural remedies and therapies in pregnancy, birth and breastfeeding. Students need to develop an awareness of what women are using in terms of natural remedies so that they can provide advice on using them safely. However, development of more in-depth knowledge and the specific skills in order to use the therapy in their midwifery practice should be provided as a post-registration qualification. The pre-registration curriculum is already overloaded with essential content and, although I personally feel this is essential to safe practice, the nature of midwifery today precludes its inclusion during basic training.

Do we focus on the positive aspects of complementary therapies and the negative aspects of standard medical treatment? The problem of informed consent.

Published : 24/08/2020

Midwives, doulas and antenatal teachers are passionate about advocacy and promoting normal birth. They empower women to progress through their pregnancies and  labours, as far as possible without intervention. Complementary therapies are a great way of working towards achieving physiological birth, but we must not forget that they are as much of an intervention as medical treatments and other aspects of care.

Informed consent is essential – providing women with sufficient information about both the benefits AND the risks of any care that is offered so that women can make informed decisions about whether or not to accept it. This applies equally to complementary therapies as to Caesarean section. In her recent assignment, one of my students asked: “do midwives focus on the positive aspects of complementary therapies and the negatives of standard medical treatment?”. 

She may have a point. Midwives and doulas who use complementary therapies can be so enthusiastic that it is easy to forget that these therapies are very powerful – and that means powerful in a positive way but also powerful in a negative way when used inappropriately. ALL complementary therapies have risks as well as benefits. When birth workers  introduce the idea of using aromatherapy for pain relief in labour, reflexology for backache in pregnancy, hypnotherapy for smoking cessation  or acupuncture / acupressure for post-dates pregnancy, it is essential that we discuss the whole picture with the women in our care. The positive relaxation effects almost go without saying, despite the relatively poor evidence-base. But how often do we explain to women the potential for adverse reactions from the oils, the reflexology treatment, hypnotic suggestions or acupressure techniques?

Take post-dates pregnancy, for example. We know that many women turn to complementary therapies to try to avoid medical induction of labour with all its potential for a cascade of intervention. However, onset of labour is a physiological end-point to pregnancy and therefore ANY intervention is an intervention. Inappropriate use of aromatherapy oils, acupressure stimulation, reflexology treatments or other therapies can trigger that cascade of intervention. Even when the therapies are used appropriately, the dynamic nature of birth physiology means that there may come a time when the therapy is no longer appropriate. There is potential for interactions between pharmacological herbal or aromatherapy products with any medication given to the mother to expedite labour – such as clary sage and oxytocin – or for one to be inactivated by the other – for example, certain drugs will inactive homeopathic remedies the mother may be taking.

When midwives and doulas discuss with their clients the best way forward in a pregnancy that continues beyond the estimated date of delivery, they may offer several options – wait and see, have a medical induction or use other methods of encouraging labour onset. All of these have benefits and risks – but how often do birth workers paint the full picture for women wanting to try the “natural” option? It is one thing to act as the mother’s advocate to try and help her avoid medical induction, but we also need to be her advocate to help her make informed decisions about other options. However natural they may be, complementary therapies are NOT a natural way of starting labour – and we need to be sure that women understand the advantages and possible risks of using them at this time. Informed consent is key to all aspects of care and no more so than with complementary therapies.

The value of complementary therapies

Published : 23/08/2020

Denise has spent most of the week marking student assignments. As one of their assignments, midwives on our Diploma in Midwifery Complementary Therapies complete a reflective diary which usually raise some very interesting challenges. Midwives report significantly increased use of complementary therapies by women, sometimes by women who do not fully understand both the benefits and the risks of using complementary therapies in pregnancy and birth. This set of assignments has been no exception and here, Denise reflects on some of the points raised by the midwives. 

Many midwives remain sceptical about the value of complementary therapies, questioning why they should take on additional “tasks” when midwives are already busy with not enough time to do what they need to do.

I think this is about perception of why it is useful to include complementary therapies as new tools in our work. Whilst there is an argument about the time required to provide therapies such as massage or aromatherapy, this can be time well spent in chatting to the mother, answering her questions and easing her stress levels. We know that these therapies can reduce cortisol and other stress hormones and that has a knock-on effect on oxytocin and other birth hormones. Research has shown that having regular treatment with therapies such as reflexology or massage can facilitate physiological birth and women are less likely to require induction of labour for post-dates pregnancy and are more likely to labour well and achieve a normal birth.

Additionally, perhaps we should look at what the use of complementary therapies can bring to the maternity services. Of course, we want individual women to be relaxed and enable their bodies to work naturally, but there IS an impact on the maternity services too. This is not about introducing complementary therapies simply for relaxation but about reducing rates of induction, epidural, Caesarean section and other interventions that not only cost money but also increase the potential for litigation when things go wrong. Helping women to feel empowered by their pregnancy and birth experiences increases maternal satisfaction and reduces the risk of complaints. This is partly also due to the relationships that midwives using therapies can develop with the women – even a ten-minute hand massage can make a woman feel nurtured rather than ignored in the rush of mandatory paperwork.

Midwives wanting to implement therapies such as aromatherapy and acupuncture need to be able to demonstrate in their business plan to management that there is a benefit to the service, rather than niceties for individuals. That sounds cynical but the maternity services are geared up to getting as many pregnant women through “the system” as possible with the shortest of resources, both material and human. Demonstrating that using hypnotherapy or aromatherapy for pain relief in labour can reduce epidural use is an attractive proposition to budget holders. Setting up a service for women whose pregnancies are post-dates can show that aromatherapy and acupressure reduces medical induction rates and the cascade of intervention that often follows. Introducing moxibustion for women with breech presentation empowers them to facilitate cephalic version and reduces the Caesarean rate. Given that the difference in cost between a physiologically normal birth and a Caesarean is in the region of £1800 that is a significant cost saving. 

So rather than dismissing complementary therapies as a luxury the NHS can ill afford, perhaps we should turn it on its head and explore the cost savings that can be made by introducing selected aspects of therapies to solve some of the problems of the current NHS maternity services. 

Working for the NHS as a midwife and private practice explained

Published : 15/08/2020

Today I want to discuss the interface between working as a midwife in the NHS and also offering private services such as antenatal classes and complementary therapies. I recently saw a post on social media from a newly qualified midwife intending to work part-time in the NHS and part-time offering private services such as antenatal and postnatal support, “hypnobirthing” classes and acupuncture, aromatherapy, baby massage. Increasing numbers of midwives want to offer maternity-related services outside their NHS work but there are several issues to consider.

First and foremost is the issue of safety of mothers and babies. This midwife would be wise to consolidate her midwifery practice before setting up in private practice and before adding in other therapeutic modalities. It is easy to become so enthusiastic about offering services that women want that normal midwifery responsibilities get forgotten. Her first priority is to her clients’ safety and her second is to the midwifery profession. Even if the midwife is fully qualified in the therapy, she needs to be able to apply the theory and practice of that therapy to its use during pregnancy, birth and the postnatal period when the mother’s and baby’s physiology is adapting dynamically.

We must question what training the midwife has had in “acupuncture, aromatherapy and baby massage” since she admits to not being “dual qualified”. One or two days’ introduction to a therapy during midwifery training is certainly not enough to start offering that therapy privately and she is potentially jeopardising not only mothers and babies but also her midwifery registration. The complementary therapy professions are increasingly concerned that healthcare professionals are “cherry picking” one or two aspects of a therapy and adding it to their own practice. We would not expect a complementary therapist to attend a few days of midwifery training and then start offering midwifery-specific services alongside their standard practice and they should not expect us to do the same. Of course, she may be fully qualified in the therapies she wishes to offer, but I would question how much experience she has of using those therapies for pregnant and childbearing clients, since this is a post-qualifying area of professional development for most therapists.

Conversely, if the midwife has undertaken a short midwifery-specific training in a therapy, does that training provide access to indemnity insurance? There is so much more to the use of complementary therapies in maternity care than simply attending an introductory course which is what is sometimes offered in midwifery pre-registration training. In addition, many complementary therapy courses delivered for midwives on NHS premises are suitable only for NHS work, subject to managerial permission and the development of local clinical guidelines, and certainly do not prepare midwives to use them in private practice.

It may also depend on how this midwife wishes to advertise her services. The Nursing and Midwifery Council prohibits the use of the midwifery qualification to imply that being a midwife makes you somehow a “better” therapist. However, if she is advertising midwifery-related antenatal and postnatal support then she is working as an independent midwife, albeit without offering birth services. Any care given to the mother or baby must comply with normal standards and the midwife must be able to differentiate between midwifery-specific elements of her treatment and those which are not. For example, palpating the abdomen and listening in to the fetal heart constitutes midwifery care. Similarly, extra caution must be employed to distinguish between care that might be provided in a maternity unit or birth centre and that which can be provided in private practice in the community. An example here might be providing treatments for post-dates pregnancy: in the NHS many midwives include a membrane sweep, whereas this may not be appropriate when working privately. It is also vital that the midwife fully appreciates the boundaries between working in the NHS and in private practice. There is huge potential for conflicts of interest which could land her in hot water – advertising, using NHS time (even to answer a phone call from a potential private client), referral of women with complications and much more.

Next, there is the issue of insurance for both this midwife’s NHS midwifery and for her private practice. It must be noted that the Royal College of Midwives provides medical malpracticeinsurance, not personal professional indemnity insurance, and does not cover members for private practice (except “occasionally” – ie not as part of a formal business). The Royal College of Nursing provides indemnity insurance to full members which covers midwifery practice and some maternity-specific services such as complementary therapies. However, if a midwife chooses to work in private practice, s/he must maintain adequate cover for the midwifery cases that have gone before – if you relinquish your RCM insurance at the point of “going private” then you relinquish your right to legal and professional cover in the event that one of your previous cases comes to court.

Finally, although this midwife does not state whether or not she has any business experience, this is an essential part of setting up in private practice. Enthusiasm to offer services that are not generally part of NHS maternity services should not overwhelm the professional and academic need to understand business issues. I have come across many midwives keen to set up private services who make mistakes – not just financial, but often professional or legal mistakes. Examples include not complying with health and safety requirements, advertising standards, accounting and HMRC regulations and, of course, NMC regulations.

Coffee and Pregnant Ladies

Published : 13/08/2020

Coffee is said to have several benefits including increased mental alertness, aiding fat metabolism and possibly protecting against diseases such as diabetes, Alzheimer's and certain cancers. It is a good source of antioxidants and other nutrients and is even thought to prolong life. Drinking coffee may contribute to smoother skin and reducing depressive thoughts.

On the other hand, pregnant women have long been advised to reduce their coffee intake because of the adverse effects on the developing baby and increased risk of miscarriage. In fact, coffee in itself is not a bad thing - it is the caffeine that is the problem. The NHS advises women to limit caffeine intake - to no more than 1-2 cups of caffeinated coffee a day. Filter coffee contains more caffeine than instant; even decaffeinated coffee still has a small amount of caffeine in it.

However, what is not emphasised is where else caffeine is found - black and particularly green tea, cola, energy and other soft drinks - and chocolate. One bar of chocolate contains almost half of the advised daily amount of caffeine. Hot chocolate drinks and even coffee or chocolate flavoured ice cream can contain a significant amount of caffeine.

Painkillers, cold and flu remedies also often contain caffeine (although pregnant women should use these only on the advice of their midwives or doctors).

Pregnant women are bombarded by advice about what they should and should not do to keep themselves and their babies safe. Reduce coffee, minimal alcohol, quit smoking - and more. It can be equally, if not more, stressful for a woman to worry about what she has or has not done - particularly when much of this advice is given with an implication of maternal blame if the baby is not healthy at birth. Surely, our advice to women should be the golden rule that applies to everyone - moderation in all things. Or, as my grandmother used to say - " a little of what you fancy does you good - and a lot does not".

Preparing for the new academic year

Published : 06/08/2020

Denise has been extremely busy recently winding up the end of the academic year for our current students and getting ready for a new group of midwives starting their courses in September.

She says: Coronavirus has meant that most of our current students have been unable to finish their study programmes as we've had to postpone so many of the modules until the new year. They've been finishing their assignments due in August so I've been chatting to many of them on zoom, offering tutorial support.

I've also been interviewing midwives wanting to join us in September , both for the Diploma and Certificate in Midwifery Complementary Therapies and our acupuncture course. We've got a couple of new programmes as well, enabling midwives to focus on one particular therapy, either aromatherapy or reflex zone therapy (clinical reflexology).

Due to our study days needing to be delivered online until December, I'm also busy wrapping up parcels to send to all the new students including programme handbooks, sets of oils and - for those starting the Licensed Consultancy to prepare for private practice - their starter packs of goodies to help them on their way.

My dining room looks as if a bomb has hit it, with parcels all over the place. I took one lot to the local post office the other day at a time when I thought it would be quiet, but was most embarrassed to find a long queue waiting by the time I had finished.


Published : 16/07/2020

Today, Denise challenges midwives offering aromatherapy in birth centres to consider whether they are complying with the law, and poses some questions to help you review your aromatherapy service.

Many midwives have set up aromatherapy services in their birth centres to help women cope with contractions and to encourage progress in labour. However, providing aromatherapy in an institutional setting such as a birth centre or maternity unit is very different from working as an aromatherapist in a private clinic, especially since most midwives are not fully qualified aromatherapists.

Several laws and regulations govern our use of aromatherapy in midwifery practice, not least the Nursing and Midwifery Council Code, which states, amongst other points that we should “take care to protect ourselves and others”. This means that we need to consider the wider effects of the chemicals in the aromatic oils and set them in the context of medicines management and chemical regulations such as the Health and Safety at Work Act and the Control of Substances Hazardous to Health Regulations. Employers and employees have a duty of care to minimise risk and, in maternity care, and to ensure safety of mothers and babies, as well as staff and visitors.

One issue, on which I have previously written at length, is the use of vaporisers / diffusers in maternity units. It is unsafe and unethical to expose everyone in the unit to the chemicals in the air. Compare this to the risks of passive smoking and the regulations on smoking in the workplace. Similarly, a pregnant nurse would not be expected to be present whilst an X-ray is taken, or to remain in the presence of anaesthetic gases. Breathing in the vapours (smells) of aromatherapy oils can be as hazardous to some people as being exposed to passive smoking, X-rays or anaesthetic gases. If vaporisation is used, you must be able to justify it in the care of individual women and take steps to remove the vaporiser / diffuser in the event of mothers, partners or staff being adversely affected.

Here are a few questions to consider when establishing, reviewing or auditing your aromatherapy service.

  • Are your oils stored in a locked refrigerator once opened? Are those bottles not yet in use stored in a cool, dark, locked cupboard?
  • When ordering oils do you purchase using the Latin names to ensure you always buy the same oil, eg there are several different types of lavender?
  • Do you record the batch number of each oil in a central register so you can check back in the event of adverse effects?
  • If you use oil blends prepared by one midwife in advance, are gloves worn for dispensing large amounts and is this done in a well ventilated room?
  • Do you assess women for skin type and sensitivity, allergies, medical and obstetric condition before use?
  • If you use pre-prepared blends for specific purposes eg pain relief in labour, do you offer an alternative option in the case of known sensitivities to specific oils?
  • If you pre-prepare blends do you label fully with oil names, carrier oil, percentage dose, “use by” date of no more than four weeks?
  • IF you use vaporisers / diffusers in a birth centre, or if women wish to use them at home, do you ensure they are used only for 15 minutes at a time and then discontinued?
  • If you use aromatherapy in the delivery suite, do you ensure that high-risk women are not exposed to the aromas / chemical vapours?
  • If you provide oil blends for women to take home (eg for post-dates pregnancy) do you comply with EU regulations on dispensing of herbal medicines?
  • If you provide blends for women to take home do you provide written information on how to use, possible adverse effects and general safety information eg “do not take by mouth”, “do not use neat on skin”, “keep out of reach of children”, “do not use near or on your baby”, do not use near animals”, etc?
  • Are your clinical guidelines up to date and cross referenced to other guidelines for care?
  • Do your clinical guidelines identify contraindications relevant to staff eg pregnant midwives not using uterotonic oils?
  • Do your clinical guidelines alert midwives to sedating effects of some oils which may affect ability to make clinical decision or to drive?
  • Do your clinical guidelines identify the course of action to be taken in the event of adverse events (mother or staff) such as contact dermatitis or splashes of oils in the eye, as well as how to deal with spills etc?

Expectancy offers several aromatherapy courses for midwives, including a two day introductory information – only course delivered online (also suitable for doulas and antenatal teachers), a four-day Implementation of Aromatherapy in Midwifery Practice course and a full 10-day Certificate in Midwifery Aromatherapy. We are currently recruiting for the new academic year commencing September – contact for more information.

The Future of Technology in the NHS

Published : 10/07/2020

Denise was privileged to be invited to attend a webinar yesterday morning on the future of technology in the NHS post Covid 19. Although she attended this in her role as a local borough councillor, the event was apolitical. Denise comments:

Over 200 invited guests attended a webinar presentation with the Secretary of State for Health and Social Care, Matt Hancock, Tara Donnelly from NHSX, a government unit with responsibility for setting policy and developing best practice for NHS technology and other speakers from the commercial sector.
The presenters explored the huge impact that Covid 19 has had on the use of technology in the NHS, the increased use of telemedicine in primary care and the need to extend this across secondary care, as well as the need to continue to improve technology across all areas of the health and care sectors. Necessary cultural changes in respect of both NHS staff and patient approach to the use of technology in healthcare should be facilitated. Other issues discussed included the importance of data protection and confidentiality for all concerned and the essential change management processes to enable hard-pressed staff to embed technological changes into care. An interesting resource that is now available on:
This gives advice to people on how to have a virtual consultation with your GP. One speaker made the point that whilst Covid 19 has been the biggest challenge the NHS has seen since its inception, we face an even greater challenge in the next 20 years as we increase the use of technology in healthcare. All in all, a very interesting webinar.

What’s the point of professional language?

Published : 08/07/2020

As Denise prepares to start work on her sixth revision of the world-famous Bailliere’s Midwives’ Dictionary for the 14th edition, she has been pondering the current challenges to language, particularly in maternity care. Language constantly evolves, some words change or become obsolete and new words enter common usage. But, she asks, is the current trend a step too far? Denise says:

“Since becoming a midwife in the late 1970s, the language of midwifery has been forever changing to accommodate contemporary developments, to remove those words no longer used and to add new terminology. One term which midwives will understand being removed from the next edition of the Dictionary will be “supervisor of midwives” to be replaced with “professional midwifery advocate” – but when did you last use the word “funis” to describe the umbilical cord or “albuminuria” instead of “proteinuria”?

Some professional language has changed to reflect politically correct trends. When I was first a midwife, we talked about “home confinement” but this was deemed to be too risk-focused and implied – quite literally – restriction on the mother. The 1970s and 1980s saw a movement for change, headed by inspirational midwives such as the wonderful Professor Mavis Kirkham, to re-evaluate our language so that it was more “woman-focused” in line with the 1982/1984 Maternity Care in Action and the 1993 Changing Childbirth reports. Personally, I have never used the word “womb” to describe the uterus and hardly ever talk about “patients” with its inferred control of those receiving maternity care, especially since they are, on the whole, not ill.

The change of attitude from medical control to working in partnership with women and their families can also be seen in changes to phrases such as “expected” to “estimated” date of delivery and, indeed, from “delivery” to “birth”. Some phrases imply a negativity that can be reduced by minor alterations in wording. Example of these include “failure to progress” (in labour) or “incompetent cervix” which suggest the problems are somehow the fault of the “patient”.

However, in the current climate of equality, have we gone too far? Whilst midwives and obstetricians must move with the times and try to use socially inclusive language, professional terminology needs to be clear and unambiguous. Language is a form of communication which must enable those on the receiving end to understand the message of what is being said. This is why midwives and other health professionals are taught to modify their language from professional jargon, including abbreviations, to terms to which expectant parents can relate. 

Recently, I have been concerned to see several posts on social media advocating changes to the language of obstetrics and midwifery, including abandoning the names of medical instruments such as Sims’ vaginal speculum. I understand the reasoning behind this particular case – despite being a well-known obstetrician who contributed to medicine in several ways, there is dissent about the fact that Sims experimented on black women for the good of white. In no way mean are my comments here intended to be controversial but if we remove the names of those who have historically contributed to the evolution of the field of obstetrics and midwifery because of some other aspect of their lives and work, do we not risk history being repeated? We risk those in current practice who are influential in their field going unrecognised in the future. Further, in respect of language, we risk confusion through the use of non-specific terminology or the need to use unwieldy phrases to describe what we mean – in this case, using the Wikipedia definition of Sims’ speculum as the “double-bladed surgical instrument used for examining the vagina".

There is also the current laudable trend to unify language so that it is inclusive, to avoid giving offence. One Facebook post included a list of alternative terms which could be used instead of gender-specific terminology. Examples included changing “breastfeeding” to “chest feeding” with little acknowledgement that men actually do have breast tissue. An alternative word for “mother” is suggested as “birthing person”. This is despite the fact that almost all those giving birth are – physiologically – women. To date, less than 100 men around the world have given birth and then only through the wonders of modern science.

Fathers should now be referred to as “non-gestational parents” – but is this meant to include those men who have been pregnant? More worryingly, it is suggested that the phrase, “maternal” health should – incorrectly - be referred to as “perinatal” health, the former denoting the person who carries the pregnancy and the latter referring to the period around the time of birth. We should, according to this post, no longer be using standard medical terms but instead be referring to “internal reproductive organs” and “internal reproductive glands” – but how are we meant to differentiate between “birthing persons” and “non-gestational parents”?

The irony of this particular post is that it was on an American antenatal education page called – wait for it – “Motherboard” – surely that should be “Parent board”? 

An online aromatherapy course

Published : 05/07/2020

Today, Denise was busy running an international short course in maternity aromatherapy for a group of 24 excited midwives from Indonesia. Midwives in Indonesia are just beginning to explore the opportunity to include aromatherapy in their care of women, especially in labour, and one of them had even read Denise’s aromatherapy book (in English)!

The session went really well with no technical problems and there were lots of questions and discussion at the end from many of the midwives. one question centred around the use of aromatherapy for women with postnatal depression, which Denise explained could be treated with caution using essential oils. However, one of the popular oils which grows in Indonesia is ylang ylang, which has very sedating effects. Denise explained that ylang ylang can be helpful when used for women with normal postnatal “blues” but should be used with caution for those developing more serious depression, as the sedating effects can suppress the emotions in depression, rather than uplifting the mood.

Another question focused on whether aromatherapy could be used to turn a breech baby to head first. Denise explained that whilst aromatherapy is relaxing, which may help the mother’s muscle tone to relax, allowing more “give” for the baby to turn, it cannot in itself turn a breech baby. Denise, and her colleague Amanda Redford, who was moderating the Zoom session, did however, talk briefly about moxibustion and the midwives expressed interest in learning more about it. Moxibustion is a Chinese medicine technique which involves using heat near an acupuncture point on the feet, to balance the internal energies; it is, on average, 66-70% successful in turning a breech baby to head first. Amanda had only just, the evening before, conducted a webinar for UK midwives and maternity workers on moxibustion. The main area if discussion was that of insurance when working in private practice offering maternity complementary therapies. She explained that unless you are a qualified acupuncturist, midwives should not physically perform moxibustion for women, as it is not possible to obtain indemnity insurance. Instead, midwives and birth workers can teach the parents how to perform the treatment and carry it out at home by themselves.

Expectancy’s Diploma in Midwifery Complementary Therapies includes four days on aromatherapy and a day on moxibustion for breech as well as other options such as reflex zone therapy, a clinical form of reflexology, and hypnosis for childbirth, needle phobia and smoking cessation

The Expectancy Kit

Published : 29/06/2020

Denise is very excited today – she has received two huge parcels from Absolute Aromas with the beautiful wooden boxes of twelve essential oils that will be sent to midwives registering for our online Introduction to Aromatherapy in Midwifery Practice course. This will enable midwives on the course to smell the aromas and plan care packages for women during the group work we will be doing online.

In addition, midwives who join our full Certificate in Midwifery Aromatherapy receive a signed copy of Denise’s textbook, Aromatherapy in Midwifery Practice. Midwives wanting to work in private practice, receiving training via our Licensed Consultancy programme, receive the full “Expectancy kit” from Absolute Aromas, which contains all 16 essential oils taught on the course, as well as carrier oil, a mixing jar and stirring rod, all in a carry case for clinical practice.

We have a few places available on our next online Introduction to Aromatherapy in Midwifery is on Saturday 11th and Sunday 12th July 2020, with more to follow later in the year.

We are also taking applications for the Certificate in Midwifery Aromatherapy (part online, part face to face) commencing on 19th September.

Midwives registering for the Licensed Consultancy undertake both the professional / academic programme and the business training programme over the course of the academic year.

Contact us on for more details.

Denise has had a busy couple of weeks. Here she tells us a bit about what she has been doing:

Published : 27/06/2020

“I’m slightly sad this week, because we should have been travelling to Singapore and onwards to Indonesia for the ICM Congress in Bali, but of course it has been postponed until next year. Although British Airways was really helpful with flight refunds and vouchers, I’ve had the devil’s own job trying to claim a refund for our flights from Singapore to Bali and back with two local airlines. It’s no word of a lie when I tell you I’ve wasted hours online going between the booking site and the airline sites, both of which kept referring me back to the other. Why is there never a person to talk to? It is so frustrating!

The experience did, however, give me pause for thought about customer service. At Expectancy we don’t have online booking for our courses and programmes because we want to deal with each enquiry on an individual basis. Sometimes midwives, doulas, NHS maternity managers or overseas colleagues have very specific questions that need answering before they can make a decision about whether or not to join our courses. Midwives and doulas joining our longer programmes of study also have an interview, which we have been conducting online for about two years now. It gives us all a change to “meet” and we generally chat about the state of the maternity services and how complementary therapies can do so much towards enhancing care for women.

I’ve also been interviewing midwives for our next intake for the Diploma in Midwifery Complementary Therapies in September, as well as the Certificate in Midwifery Acupuncture. It’s so refreshing to see how enthusiastic midwives are about studying and practising complementary therapies, even though we won’t be able to start on the practical work until the new year once we are able to meet again in London.

Our online webinars are going well and we’ve had some interesting discussions around aromatherapy in a post-Covid world and how to maintain social distancing with such an up-close-and-personal therapy like massage. Our upcoming homeopathy and moxibustion webinars are also recruiting well. I’ve been preparing a lecture for 30 midwives from Indonesia in a couple of weeks. That’s the good thing about online teaching – the world is our oyster and we can be anywhere and teach for midwives from all over the world.

The team has also been working on new developments including our exciting Doula Certificate in Complementary Therapies, offering the opportunity to join with midwives and learn how to use complementary therapies for pregnant and birthing mothers. I’ve had some individual tutorials with midwives currently studying with Expectancy, who are working on their assignments, as well as sessions for midwives on our Licensed Consultancy, either preparing for or actually now working in private practice offering complementary therapies.

The worst thing about all this online work is that I have discovered the chair I use is really uncomfortable! It was OK when I was just sitting at the desk, but angling the PC screen so I can be seen on Zoom has meant the chair is now not at the right height (even though it’s adjustable). Ah well, I suppose I will have to either grin and bear it or buy another chair!”

Moxibustion Webinar

Published : 24/06/2020

Moxibustion is a traditional Chinese Medicine technique used to increase heat along internal energy lines to stimulate deficient energy. It is used for many conditions but has become a popular treatment for breech presentation, with almost two thirds of pregnant women now prepared to try it. In Chinese medicine, it is believed that the fetus settles into an abnormal position when the energy near the uterus is low, effecting the baby’s muscle tone and preventing them from settling into a favourable position for birth. Research shows that moxibustion is around 66% successful in turning a breech baby to head first, which is considerably better than the success rate of external cephalic version (ECV), the procedure performed by an obstetrician to try to make the baby turn. Treatment involves several sessions over a period of about a week, in the third trimester of pregnancy; women and their partners can be taught how to do this at home. A specific point on the little toes is used, which transmits energy to encourage a slight change in muscle tone of the uterus, allowing a little more “give” and encouraging the baby to turn. However, there are some women who should not have moxibustion, including anyone who has been told that she cannot have ECV and those who require a Caesarean for a medical or pregnancy complication. 

If you’re a midwife, doula or birth worker, find out more about moxibustion by joining our 2-hour webinar on Tuesday 30th June at 1900 hours – contact to book (£12). 

The next Expectancy online webinar!

Published : 16/06/2020

25th June at 19.00 hours
£12 including VAT
Please book via

This 2-hour session introduces the concepts of homeopathy, an energy-based medicine often used by women or general family health. We will consider the principles of correct use, including self-prescribing, doses, antidotes to homeopathy and healing reactions. We will then explore some of the remedies for pregnancy, labour and postnatal care, including the ever-popular arnica for perineal bruising and others. Suitable for midwives, doulas, students, health visitors, antenatal teachers
The session will be facilitated by Denise Tiran, international authority on maternity complementary therapies and author of Complementary Therapies in Maternity Care, an evidence-based approach.

Hand in Glove

Published : 07/06/2020

Denise has recently had a question about the use of gloves when providing aromatherapy in labour during the current Covid 19 situation. The midwife was asking whether wearing non-latex gloves would affect the essential oils. She says:

“ALL chemicals that come into contact with essential oils will have some impact on the chemicals in the oils, although not usually immediately. Any type of glove (latex, nitrile etc) canpotentially affect the chemicals when used for massage with essential oils, although in fairness, the risk is probably minimal. Whilst gloves can protect the midwife’s hands from the oils, gloves do interfere with the psychological effects of aromatherapy treatment in terms of touch sensations. Some cancer patients have reported feeling “dirty” when gloves are used in massage, since gloves are associated with specific clinical procedures (CV19 notwithstanding).

However, midwives providing aromatherapy for women in labour must always consider their own wellbeing and that of other people in the room.  Many people have intolerances and allergies to specific chemicals in certain essential oils. If someone has a tendency to develop allergic reactions, for example, to latex gloves, it is highly likely she will also be sensitive to some of the chemicals in essential oils. Allergic reactions can occur not only from coming into contact with the oils during massage but also from inhaling the vapours. Therefore any midwife who is wearing gloves for self-protection against the oils may still be at risk of  allergic reactions caused through inhalation.

In respect of Covid 19, midwives should question whether or not essential oils should continue to be applied via massage at this time unless it is provided by the birth companion. Aromatherapy used in labour should always be considered as a clinical intervention not merely a relaxation strategy and, in accordance with the NMC Code, midwives must be able to justify their use of any intervention. Where it is deemed appropriate to use aromatherapy, there are various other ways of administering EOs which do not require direct contact, such as compresses, in water (bath, but not the birthing pool) and by individualised inhalation (not vaporisers).”

Denise’s live online webinar on Maternity Aromatherapy in a Socially distanced World explores some of these issues. The next session is on Monday 13th July at 10:00 Hours and costs just £12 including VAT. Book via


Ask your pregnant mums!

Published : 04/06/2020

If you’re a midwife, doula or obstetrician, be sure to ask pregnant mums if they’re using complementary therapies or natural remedies. This is particularly important if a woman is admitted with suspected preterm labour for which no medical cause can be found.

Check whether she’s been taking raspberry leaf tea or other herbal remedies that may trigger contractions, or if she has used aromatherapy oils in the bath. She may even have been applying pressure to acupuncture points.

These are all good natural ways of preparing for and aiding progress in labour, but need to be used appropriately. Raspberry leaf is a birth preparation herb and is not a way of starting labour. Conversely, clary sage and jasmine aromatherapy oils, as well as many herbs, are known to aid contractions so should be avoided until at least 37 weeks of pregnancy.

Certain acupuncture points have been shown in many research studies to be effective in stimulating labour, but are generally considered to be “forbidden points” in pregnancy. Ask your clients about their use of natural therapies and remedies – in early pregnancy, in the last trimester and in early labour..... and if you’re pregnant, be sure to let your midwife or doctor know what you’re using, any remedies you’re taking by mouth and if you are seeing an independent therapist.

Working for yourself

Published : 01/06/2020

Many midwives decide to branch out from their NHS work to offer private services such as antenatal classes, complementary therapies or lactation support. But did you know that you are required to inform your NHS manager and sign a “possible conflict of interest” form? Conflicts of interest may arise between the clinical and business aspects of working privately, between the services you provide in the NHS and your private services, or between working as an NHS employee and working as a self-employed practitioner. There does, however, seem to be some confusion, even for managers. A friend of mine was told by her midwifery manager that she must inform the Nursing and Midwifery Council of her intention to offer private complementary therapy services for pregnant women, but this is not true. You do need to be careful what services you provide and are wise not to offer the same as those already available through the NHS: for example, promoting private services for women who are overdue when the maternity unit where you work offers a post-dates pregnancy clinic could lead to difficulties which would be seen as a conflict of interest. If you’re considering moving into private practice, don’t be caught out by all the potential pitfalls. Denise offers specialist business training for midwives, including a Licensed Consultancy scheme to support you in setting up, establishing and growing your business. 


Published : 31/05/2020

Reflexology works on the principle that a small part of the body represents a map of the whole. Pressure applied to on specific points, usually on the feet or hands, send impulses to other parts of the body. Whilst reflexology is relaxing it is not simply a foot massage. And did you know that there are many different types of reflexology? General styles of reflexology do incorporate more massage techniques, whereas Chinese and other Eastern forms of the therapy are similar in principle to acupuncture (without the needles). Denise teaches a very clinical form called reflex zone therapy (RZT), devised by a German midwife, Hanne Marquardt. RZT can treat many of the symptoms of pregnancy, help to start labour, aid progress and relieve pain and even help if the placenta is slow to deliver. After the birth RZT can be used to stimulate lactation, enhance the immune system and aid recovery. All being well, our next course commences in September in London  – or  Denise and her team can come to you to teach the therapy. Contact

Some Advice About Aloe Vera

Published : 27/05/2020

Denise has recently had an enquiry from a midwife about a lady wanting to use aloe vera in early labour. Here’s what she says about it:

“Aloe vera" (Latin name, aloe vera or aloe barbadensis) is a very popular remedy, usually used in gel or extract form to condition the skin and treat various skin conditions, for wound healing and sunburn, and to prevent stretch marks, treat haemorrhoids and sore gums. Aloe juice can be consumed as a juice for constipation, to aid hydration, improve liver health and as a general health tonic. However, is it safe in pregnancy?

Taking aloe vera by mouth, in any form including products from aloe latex or aloe extract, is not safe in pregnancy because it contains chemicals called anthraquinones which may affect the development of the baby and cause miscarriage or premature labour. These chemicals also cause diarrhoea, which can be severe and may lead to dehydration, abdominal pain and loss of essential nutrients such as potassium. It’s OK to use aloe gel on the skin in pregnancy and it may help to prevent or reduce the severity of stretch marks – but in some people it can cause skin irritation. It’s important to ask any woman who reports skin itching whether she has used any herbal remedies or essential oils on her skin, as many can cause contact dermatitis and this may be confused with normal skin itching of pregnancy or with the more serious liver-related condition of cholestasis.

Some women want to drink aloe vera juice to trigger labour contractions, but there is no evidence to suggest it works, despite it being a regular question asked on expectant mums’ online chat groups. Although it is probably safe enough in small doses at the end of pregnancy, I would not encourage women to drink large quantities of it to get labour going. It’s particularly important to avoid it if a woman is taking any oral medications, including pain relieving drugs and laxatives or those aimed at preventing pregnancy complications such as diclofenac, ibuprofen, aspirin. Aloe taken by mouth can interfere with the absorption of drugs taken orally because of its sticky viscous consistency. It will also interact with anticoagulant and anti-platelet drugs  given by injection including enoxaparin and heparin.

It's also wise to use aloe vera cautiously on the skin during pregnancy, labour and after the birth. There is plenty of evidence to show that it is antibacterial, antiviral and anti-inflammatory but it should not be used near the vagina during labour (for example, as a wash-down fluid) where the baby is going to emerge. Although oral aloe may cause contractions, this is not the same when the gel is applied to the skin, as the absorption is different, and there is no evidence of any benefits in labour. ALL interventions in labour can interfere with the normal progress of labour, sometimes causing excessive or irregular contractions and leading to fetal distress.

Aloe is sometimes advocated for perineal healing after the birth and has been shown to be effective in combination with  calendula. However, it should not be applied near the vaginal opening or directly on the wound as it can cause burning and itching.

Remember - ALL herbal remedies work like drugs and are mostly discouraged in pregnancy and labour. Other remedies which should also be used with caution include raspberry leaf, evening primrose oil, castor oil and aromatherapy oils such as clary sage oil.

FREE downloadable leaflets are available on this website for expectant mums.

Introduction to Complementary Therapies in Pregnancy and Birth

Published : 23/05/2020

£12 including VAT

Book via

For midwives, doulas, students, health visitors, antenatal teachers, GPs and obstetricians.

This 2-hour session explores the popular complementary therapies used by women during pregnancy, labour and after birth, including aromatherapy, reflexology, acupuncture, as well as some of the self-help strategies used by expectant mums – ginger for nausea, raspberry leaf for birth preparation and different remedies to trigger labour.

The session will be facilitated by Denise Tiran, international authority on maternity complementary therapies and author of Complementary Therapies in Maternity Care, an evidence-based approach

Denise finishes her latest book

Published : 22/05/2020

At long last, Denise has finished writing her latest book! The manuscript is set to go to the publishers, Jesica Kingsley Publishing, tonight. Denise says: 

“I'm so grateful to have had these last few weeks to finish the writing. I'd already had a two month extension to the submission date and I don't think I would have finished it on time if we had not had lockdown - every cloud has a silver lining. 

I've enjoyed writing this latest, on the Safe Use of Natural Remedies in Pregnancy - a guide for maternity professionals. It's rather like a dictionary, with alphabetical entries on different herbs, homeopathic remedies, aromatherapy oils and traditional medicines from around the world, exploring the safety aspects during pregnancy and birth. 

I started writing professional textbooks on complementary therapies in midwifery in the early 1990s, being given an opportunity quite by chance to contribute to Mayes' Midwifery, one of the world's primary midwifery textbooks. I'd already started a book on complementary therapies,which I intended to be for expectant mums, but I had no idea how to go about finding a publisher. The editor at what was then Bailiere Tindall (now Elsevier) persuaded me to change the manuscript so it was more suited to midwives  - and the rest, as they say, is history.

I've written three aromatherapy books, three reflexology books, four general texts on complementary therapies in midwifery, one on nausea and vomiting in pregnancy, and three books for pregnant mums. My last book was  on The Business of Maternity Care, a guide for midwives and doulas setting up in private practice. I've also contributed chapters to several editions of various midwifery textbooks and have revised the last five editions of the world famous Bailliere's
Midwives' Dictionary - and I'm about to start on the next edition. 

Previously, when I finished a manuscript - and that's exactly what it was, a precious pile of typed pages - I would carefully package up the papers and send them by registered post to the editor - it was far too valuable to risk being lost in the post. Nowadays, of course, it's just the click of a button to send it by email - but there isn't quite that same sense of ceremony. However I'll be celebrating with my partner and best friends by having a virtual dinner party tonight.

I always say, when I finish writing, that's the very last time I'm ever writing another book. My previous editor, Claire Wilson, who was my editor for many years, both at Elsevier and then at Jessica Kingsley, always laughed when I said that because almost invariably, a couple of weeks later I'd be on the phone saying "I've got this idea for a new book"

However this time, I'm definitely not doing any more. There's just that little matter of the next edition of Bailiere's Midwives' Dictionary to be done and that's it.  But, wait - I've got this idea for a new book on .....!“

Denise's book will be published in early 2021. You can find many of her other books on Amazon. 

We're also offering the first five people to contact us the opportunity to receive a free signed copy of Denise's book on The Business of Maternity Care. Contact us on stating your full name, the name you would like inside the book and your full address and postcode. If you miss the opportunity, we also have fifty copies of Denise's Aromatherapy manual for midwifery practice available to give away - email us with your details as above.


Exiting New Online Courses

Published : 18/05/2020

Denise and her team have, like many others, been looking at new ways of working and adapting since lockdown began.
Many of the team offer private services for pregnant women and they have been getting quite innovative with their clinical appointments.
And of course Denise has been planning new courses to be delivered online via ‘Zoom’.
Her first course ‘Maternity Aromatherapy in a Socially Distanced World’
Thursday 21st May at 19.00 UK time
£12 including VAT
Book via
For midwives, doulas, students, health visitors, antenatal teachers

This 2-hour session introduces aromatherapy and its benefits for expectant, labouring and newly birthed mothers. We will consider how maternity and birth workers can use or advise on the safe use of essential oils at this time. As we are socially distanced, the popular means of administering aromatherapy in massage is less suitable, although we will discuss how partners could use massage. We will also explore how other ways of administering essential oils could be used to good effect for our clients.
The session will be facilitated by Denise Tiran, international authority on maternity complementary therapies and author of ‘Aromatherapy in Midwifery Practice’.



Published : 11/05/2020

Research has shown that many expectant mums use herbal remedies to maintain health and ease pregnancy discomforts, but occasionally to treat more serious conditions. Several herbal remedies are thought to help urinary infections, including cranberry, dandelion, garlic and uva ursi. However, urinary infections should be treated promptly in pregnancy, sometimes triggering premature labour or spreading to the kidneys and causing serious problems. So how effective and safe are these remedies?


Cranberry is a very popular remedy to prevent and treat urinary infections and there is some evidence that it can be effective. However, cranberry juice must be sugar-free to avoid the sugar sticking to the urinary tubes and bladder wall, causing further bacterial growth. In excessive or prolonged doses, cranberry can cause thrush, allergic reactions or kidney stones and should be avoided in women with diabetes.


Dandelion tea can be helpful for urinary conditions and is known to reduce oedema (swelling). It is full of iron so may boost iron in women with anaemia. However, dandelion also contains high levels of vitamin K so it can interfere with blood clotting, causing bruising and delay in stopping bleeding. Women taking anticoagulant drugs or other medication with similar effects (eg aspirin, clexane, ibuprofen) should avoid dandelion tea. Some people can develop allergic reactions, especially those sensitive to daisies, chrysanthemums and marigolds. 


Garlic has been shown to fight bacterial infections and can be added to foods in cooking. However, care should be taken with commercially produced garlic capsules, especially in the first three months as excessive amounts of garlic may cause threatened miscarriage (although this has not been proven in research). In the last weeks of pregnancy excessive consumption can cause the amniotic fluid surrounding the baby to have a garlicy aroma, and if the mum takes a lot of garlic capsules while breastfeeding, it can make the milk smell of garlic.  


Uva ursi is sometimes used by medical herbalists to treat urinary infections and kidney disease. However, it should be avoided during pregnancy as it is through to cause miscarriage and premature labour and may affect development of the baby. In the postnatal period it seems safe enough but should not be taken by women with inflammatory bowel disease (Crohn’s, irritable bowel syndrome etc), high blood pressure or kidney or liver disease.


NB All herbal remedies should be used with caution in pregnancy and labour and should not replace conventional medical treatment – urinary infections may require a course of antibiotics to prevent complications.


Raspberry leaf – preparation for birth, NOT a way to start labour

Published : 06/05/2020

Raspberry leaf is a popular herbal remedy to aid birth, but it’s meant to be used to prepare the body for labour and not as a means of triggering contractions if you’re overdue. A chemical in the leaves of the raspberry bush is thought to tone the muscle of the uterus, aid cervical ripening, shorten duration of pregnancy and first stage of labour. Many mums (and some maternity professionals) incorrectly believe it should only be taken at the end of the pregnancy, but it should really be started around 32 weeks and built up gradually over several weeks. Leaving it until the end of pregnancy is more likely to cause excessive contractions and even fetal distress. It’s not appropriate for expectant mums with a history of previous Caesarean section as it can cause tension on the original scar tissue. It’s contraindicated with a history of preterm labour, high blood pressure, irritable bowel syndrome or if the baby is in any position other than head-first, if the placenta is lying low in the uterus or if there is any bleeding in the pregnancy. Raspberry leaf should not be taken at the same time as using other herbal remedies to try to trigger labour, such as clary sage oil, evening primrose, castor oil, black cohosh or blue cohosh and should be avoided if the mum is receiving induction of labour (oxytocin) or if she is taking anticoagulants.


To download a FREE leaflet on raspberry leaf for expectant mums, see

If you’d like to learn more about the safety of herbal remedies in pregnancy or about natural ways to trigger labour and how to set up a post-dates pregnancy clinic, contact us for information about our courses on  

Denise’s journey continued 

Published : 04/05/2020

After working as a community midwife for a while I decided to go into teaching and I’ve been in midwifery education for the rest of my career. In 1980 I moved to the Middlesex Hospital, just off London’s Tottenham Court Road and was involved in teaching student nurses who were taking a four week obstetric secondment (compulsory in those days). it was a good start to learning how to teach before commencing the Postgraduate Certificate in Education of Adults (PGCEA) at Surrey University. By this time I had moved to Greenwich and Bexley School of Midwifery, initially as an unqualified tutor, with secondment to the PGCEA and the promise of a full-time post once I qualified.

My teaching practice was at St George’s Hospital in Tooting which was fairly near to where I lived, and I thoroughly enjoyed it. On several occasions we had assessments of our teaching - one of the lecturers would come from Guildford to observe us, quite a nerve wracking experience.

On one particular occasion, I had to teach “the structure of the NHS” which was deemed necessary in order to understand how the system worked. It was the most boring subject to teach but I spent many hours preparing the session, making home-made models to represent the different roles within the organisation.

The big day loomed and the students were all very supportive. Unfortunately, about halfway through, an irritable doctor interrupted us, saying that he had booked the room for his medical students. He turned out to be wrong so we eventually got rid of him and I carried on. Ten minutes later the fire alarm went off and we all had to evacuate the building for half an hour.

By the time we managed to get back into the classroom there was only about quarter of an hour of the session time left so I could not possibly complete the work I had prepared. Surprisingly,

I passed the assessment with flying colours – probably not to do with the content and depth of my knowledge, but for the way in which I managed the interruptions. I’ve never had to teach “the NHS” again and my carefully prepared models were consigned to the bin.

Denise gives advice about the Coronavirus pandemic

Published : 03/05/2020

As we all learn to live our days in different ways, we would love to know what you are doing to stay positive. Denise has been busy (as usual) and here she gives an up date on what she has been doing, as well as some tips for using complementary therapies and natural remedies to ward of the evil bug. She says:
"Last week, nothing seemed to have changed much, except for the cancellation of a two-day course in London. Then I decided to cancel all face to face teaching for the next three months. It seemed easy at the time but does raise some serious financial and practical issues for the business. Ever the optimist, I've used the time very productively. I am still working on the natural remedies book but as I said to my publisher, this now means it will be submitted on time. I try to write in the mornings and go out for a walk in the afternoons - and we have been blessed with some stunningly sunny spring weather, even though it is rather chilly. The book, which is similar to a dictionary, is coming along well and I am now up to "S" in the alphabetical listings. Still quite a lot to do, but getting there.

I should have been going off to Tokyo today but - surprise, surprise - my flight has been cancelled and even if I could get there, I would have had to self-isolate for 14 days - not much good when I was only due to be there for three days! Apparently, things are getting back to normal in Japan and the course is going ahead so, for the first time in 35 years, I am doing a "night shift", teaching the course by video link. It's a nine-hour time difference so I will start teaching at 1am. My colleague and I are having a practice session on Thursday because it has to be translated live. Should be interesting.

Like many of you, I have been worried about family and friends, especially those over 70. This last two days, I've been communicating with my son, Adam Tiran, and his Dad, trying to sort out if he can get home from South Africa. All being well, he has finally found a flight leaving on Saturday night so he should be able to go into self-isolation in a London flat of a friend who is away. I will feel much happier having him home than knowing he is in his small apartment in Johannesburg.

I do think, when this is all over, we will come out of it perhaps in a better situation - hopefully more tolerant and kind towards each other, happy to enjoy the small things in life like fresh air and the chance to go out where and when we want. I think it will produce new ways of working, and we are already thinking of ways to offer our courses online so that more midwives can learn about complementary therapies. However, in the meantime, it's a case of staying well and safe and looking after ourselves and our loved ones.

  • Here are some ideas for beating the CV19 blues:
  • Eat well - fresh fruit and veg when you can get it, a small amount of protein with each meal, plenty of water

  • use your spare time to catch up on sleep when you can 

  • spend ten minutes every day doing something you want to do, rather than something you have to do:
               a lovely aromatic bath with some gentle essential oils
               a couple of squares of chocolate, a glass of wine
               start reading that book you've been wanting to read 
               paint your nails 
                ...... or whatever takes your fancy

  • if you can get them, top up on your vitamin and mineral levels - vitamins C, D and E in particular as well as zinc, calcium and magnesium - a good quality multivitamin and mineral supplement should do it

  • give your partner a massage and ask him or her to reciprocate - just a ten minute shoulder or foot massage can work wonders 

  • try some mindfulness and relaxation, with deep breathing, focusing on a pleasant picture such as your favourite place, a beautiful beach or the clean sharp air of the mountains, and consciously relaxing each muscle group within your body

  • use diluted essential oils as cleansing sprays - mix half a litre of water with good quality lemon, tea tree or even common lavender to spray over household surfaces. This mix will last 24 hours in the fridge. You can also use eucalyptus but avoid this if you have animals as some react badly to it. 

  • if you develop flu-like symptoms, you could use homeopathic Gelsemium 30c and Bryonia 30c, which are commonly used for flu-like symptoms, although the precise remedy will depend on your precise symptoms. Homeopathy is not a substitute for medical care, especially if your symptoms worsen

and remember - STAY AT HOME and WASH YOUR HANDS 

Thinking of you all in these unprecedented times - stay safe and stay well."

    In praise of independent midwifery

    Published : 25/04/2020

    I was chatting to an independent midwife this week, who told me that, despite CV19 – or rather, because of it – many self-employed midwives are experiencing a welcome increase in workload because pregnant women who’ve booked NHS home births are being told they’re not currently available. They’ve consciously chosen to pay for independent midwives so they can achieve the home birth they want. Even without CV19, we know that women’s childbirth choices are slowly but surely being whittled away, with a very real risk that when “normal service resumes” home birth will be removed from NHS options altogether

    As a 1980s community midwife we were busy but made time for women and their families and many babies were still born at home. We visited new mothers and babies twice a day for the first three days, daily up to day ten and then, if necessary, weekly up to 28 days, a system that was viewed with envy by midwives in other countries where little or no postnatal care existed. Community midwives came to know the families in their care, were sensitive to bio-psycho-social & variations and were often able to minimise or resolve problems simply by “being there”."

    Our contemporary postnatal services are virtually non-existent. It is no wonderthatfamilies experience severe anxiety and uncertainty about how to parent, breastfeeding rates are low, and women experiencing mental health issues are not identified early enough. Our maternity services are institution-focused, not family-focused. Of course there are many reasons why this is the case – high birth rates with many women having complex needs and an over-worked dwindling midwifery workforce being just two. However, the heavy reliance on saving money, avoiding litigation and equitable service provision means that having a baby in Britain is a battle-field between the state, the professionals and the clientele. – one that women and their families are never going to win.

    I’ve been around through many periods of dissatisfaction with the maternity services, from the 1980s "Maternity Care in Action" reports, "Changing Childbirth in the 1990s" to "21st Century Maternity Matters and Better births". Working parties and the production of reports are not going to solve the problem, even though they make positive suggestions for change. Nothing is going to change fundamentally and in another ten years we will still be battling for improved maternity services. We need to get back to the humanity of childbirth, individualising care and supporting midwives to provide the best possible care for women and their families.

    In the meantime, let’s applaud those midwives who have chosen to work independently and who provide a valuable, sensitive, family-focused service for those who elect to use it.

    Ginger may not be safe in pregnancy

    Published : 23/04/2020

    Midwives, doctors and other maternity professionals almost universally seem to advise women to try ginger for pregnancy sickness. However, whilst ginger has been proven to have good antiemetic properties, there is growing evidence that it may not be safe in pregnancy.

    Ginger contains chemicals which cause blood thinning and should not be taken by women on any medication with similar effects, including those on aspirin or other preventative medication. Prolonged use can actually thin the blood and cause bruising or bleeding and heartburn, and can actually worsen the sickness in some women. There is some suggestion that taking ginger in early pregnancy may adversely affect sex hormones in the baby, and may cause stillbirth.

    There is no international consensus on safe maximum daily doses of ginger in pregnancy. – in the UK we advocate no more than 1gm, where as the USA advises that 2gm is safe. Other countries, notably in Scandinavia, advise women to avoid all commercially produced ginger supplements which often contain up to 20gm ginger. It is also worth noting that ginger biscuits do not contain enough ginger to have any therapeutic effect and the high sugar levels can often exacerbate the nausea by causing peaks and troughs of blood sugar. Ginger essential oil should not be used at all in pregnancy as it may stimulate the uterine muscle, triggering miscarriage or preterm labour.

    Although this latest advice is based on recent animal research, the body of research has been growing for some years, suggesting that ginger is not always the most appropriate remedy for pregnant women with sickness – and maternity professionals should be cautious about routinely advocating its use without checking for contraindications and precautions.

    Part 7 of Denise’s Journey

    Published : 22/04/2020

    Our training consisted of occasional study blocks and months spent on the wards gaining experience of surgical and medical nursing, intensive care, maternity and paediatrics, casualty, geriatrics and more. We had exams at the end of the study blocks, case studies to write and practical exams. We also had "finals" - both national exams to enable us to register with the, then, General Nursing Council, and hospital finals so we could gain the coveted Barts certificate and badge.

    At the time of our hospital finals I had just completed a ten day stretch on the wards and then had one day off before the big day. I was supposed to be studying on that day off but my father was coming to London to meet a business client from Pakistan for lunch - and he invited me to join him. We had a lovely lunch and a few glasses of wine - when I got back that evening I was in no fit state to start studying and I just went to bed. Fortunately I was fine the next day and everything went well.

    Practical exams were another thing. We had four throughout our training - dressings, drug administration, total patient care and ward management. If we failed, we were given one chance to redo it, then we were out.

    I failed my total patient care exam twice. I don't think I was ever cut out to be a nurse, and I'd always wanted to be a midwife anyway. The first time, I was looking after a man with breathing difficulties who also needed a dressing done. As I started i contaminated the dressing trolley which meant returning to the clinical room to start again. Unfortunately, I forgot to sit the patient upright whilst I went to sort things out and Sister had to intervene to help him breathe normally by sitting him up.

    I can't remember why I failed the second time but unusually, I was given a third and final chance.The day of the exam loomed and I was incredibly nervous. I’d informed the patient about it and he was almost as nervous as me. I had two examiners - a tutor and the Chief Nursing Officer in the school - very scary!

    The main part of the assessment was being observed doing a bed bath. I struggled through until I got to the bit where I was supposed to ask the patient if he would prefer to wash his "private parts" himself. He said he would do this and I went to hand him the soap. Unfortunately in my nervousness the soap slipped out of my hand and dropped onto the floor. I scrabbled to retrieve it but the soap slipped further under the bed. Every time I reached for it it moved further away until I was literally crawling under the bed on my hands and knees.

    Eventually I managed to get it and, in somewhat of a flap, I continued with the bed bath. The two examiners were very kind and left shortly afterwards. They didn't reappear and I assumed they were going to fail me again. Miraculously I passed, and I can only assume the examiners didn't return because they were sitting in their office laughing helplessly over the sight of a student nurse scrabbling around on the floor looking for a piece of soap.

    Part 6 of Denise’s Journey

    Published : 21/04/2020

    Despite moving to London at the tender age of 19 we were, in the 1970s, incredibly safe especially in the City of London. Barts lies between Smithfield, the original meat market, and St Paul's Cathedral, and in those days there was also a main post office depot right next door. The market traders and porters would all look out for us and always treated us with respect. They seemed to know we were nurses even when not in uniform but I suppose the hospital was the only place where gaggles of young women came from. Sometimes, on our way to Farringdon tube station, they would see us lugging our suitcases (no wheeled ones in those days) and they would compete amongst themselves to offer to carry them through the meat market for us.

    One of the main sources of entertainment in the quiet post-work-hours City was College Hall in Charterhouse Square, where the medical students lived. There was a bar and we spent many an evening there having fun, especially as several of us started dating medical students. It was quite normal to see single girls making their way back to the nurses' home in the hospital at 3am through the deserted streets - quite safely. Getting in to the nurses home was another matter however as the doors were locked at 11pm. I think it involved entering via the underground tunnels from the main hospital and warning our friends to look out for us in case we needed a door unlocking.

    The 1970s was a time when there were many extremely wealthy visitors from the Middle East who came to shop in Harrod's and Selfridge's. One of the girls in the set above us excitedly told us one day that she had met a man from Saudi Arabia in Oxford Street and that he was taking her out to dinner that night. We implored her not to go as she didn't know this man, but she was so excited - and off she went. We waited anxiously for her return - dead on the stroke of 11pm.

    We crowded into her room to hear about the evening; she was positively glowing. She said that her companion had taken her to an extremely upmarket restaurant in the West End. With bated breath, we waited to hear what he had expected in return. "Nothing" she said, "he just wanted company". He had returned her to the hospital and as she stepped out of the taxi, he had given her a wrapped parcel. She proudly produced said parcel and started to unwrap it. Inside was the most luxurious leather briefcase. We all gasped, it was beautiful. She opened it up and we all screamed - inside lay £1000 in crisp fivers!! A fortune in those days, especially for an impoverished student nurse. His gift restored our faith in overseas visitors. She never saw or heard from him again. Sadly, we didn't ever get the same offer from anyone else.

    Part 5 of Denise’s Journey

    Published : 20/04/2020

    Barts nurses were very proud of their caps. We were given squares of stiff white material and had a whole afternoon in class learning how to make up our caps. The student cap required you to fold one edge of the square of material several times over to make the band that went round your head. This was then pinned to the size of your head. Someone later found out that this was roughly equivalent to the circumference of a catering size tin of Nescafe so a few of us kept these for the purpose.

    The top of the cap was then pleated and pinned again, leaving a "tail" . Technically this was supposed to stick up at the back of your head but those in the know folded them down on to the top so the cap looked like a pillbox style hat. Of course the fact that we were newbies was proclaimed to the world by the fact that the tail of our caps stuck up. Some people (those with the coffee tins) were much better at making up new caps than the rest of us so we paid them to make up new ones when needed.

    When we qualified the style of our caps changed and the same square of material was used to make one that rose up from the front and then down the back to the base of your neck. When I later returned to Barts as a newly qualified midwife I very proudly wore my new style cap. The problem was, the necessary position we had to assume when helping a woman to give birth meant that the the back of the cap would fall forwards into the "delivery field" where the baby was about to be born! We needed a lot of new caps - but these were at least easier to make than the student caps.

    Part 4 of Denise’s Journey

    Published : 19/04/2020

    Life as a student nurse was busy but nothing like it is now. Ward sisters were very strict and everyone was called "nurse" and their surname. We weren't even allowed to call each other by our first names in class! My first ward placement was a surgical ward with a very fierce sister - we were all scared of her. On one occasion I had been asked by one of the patients what my first name was (surreptitiously, because the patients were all scared of Sister too). I was blanket bathing him but needed to leave the cubicle to fetch something. Whilst I was away, Sister came past the man's curtained bed and he called out, thinking it was me returning - but he used my Christian name. Sister was really angry, both with him and especially with me for having told the patient my name. A definite black mark.

    On nights on the neurosurgical ward, I was sent to my supper break. To get to the canteen at night we had to take the underground passageway which went under the road to the main building. It was very spooky especially as everyone said there was a ghost, called the White Lady, at the end of the corridor by the lifts.

    One night I was returning from my break and decided to take the stairs to avoid the White Lady. As I got to the ground floor I saw someone outside in the churchyard, who I could just recognise as one of our patients in his pyjamas. The poor man had a very aggressive brain tumour which made him very confused and he had "escaped" from the ward and had no idea where he was.

    I went outside to try to guide him back to the ward (on the fourth floor) but he became quite aggressive and wandered further into the graveyard. It was starting to rain and I still couldn't persuade him to come with me. Suddenly Night Sister appeared, breathlessly running up to me, having not yet seen the patient. "Nurse what are you doing out here in the graveyard in the rain?" she said. I think she thought I was the one who was confused. I think I thought she was the White Lady come to get me!

    Finally we managed to entice the poor patient back indoors. By this time he was dreadfully confused, aggressive and uncontrollable and eventually the doctors arrived and he had to be sedated to take him back to the ward. He was given paraldehyde, so strong it had to be administered in a glass syringe - anyone remember that?

    Part 3 of Denise’s Journey

    Published : 18/04/2020

    I went into nurse training because, in order to become a midwife, it was a better career option, although it was possible to train as a midwife direct even then. Having qualified in 1978, I gained three month's experience of nursing, working on the Observation ward (casualty take ward) on night duty for three months. I seem to remember this basically involved looking after drunk tramps with fleas, but it was good fun and filled in the time before starting midwifery training.
    I went to Northwick Park in Harrow, North London and was in the very last group to do the one year post-nursing midwifery course before it was extended to 18 months. Northwick Park was very different from Barts. The uniform was a ghastly white dress with nude tights and white shoes that made us look four times bigger than we were. However, it gave us a very good training with lots of experience.

    Our senior tutor was Maureen Hickman whose midwifery textbook had just been published. We were in awe of being taught by someone who was clever enough to have published a textbook.

    I'm not sure my own students feel the same, even when given reading lists for their complementary therapy courses with a predominance of books by Tiran!

    Nothing particularly stands out from my midwifery training - except that I loved it! I'd found my niche.

    On qualifying, I returned to Barts and worked on night duty on the Labour ward for a few months before achieving a coveted post as a community midwife in Surrey at the incredibly young age of 24. I remember the father of one of the pregnant mums I was visiting saying that I didn't look like a "district midwife" because I wasn't old enough, wearing a cap (I usually threw it in the boot) and riding a bike! My area was very rural and it would have been very difficult riding a bike as I sometimes had ten miles between home visits.

    It was also a very affluent area where all the houses had names, not numbers. When handing over to a colleague we would need to give directions such as "turn left by the farm gate and right at the third tree" - but I always seemed to take the scenic route or spend ages going up and down a country lane looking for the right house (of course we had no mobile phones or satnavs in those days).

    Home birth was still not uncommon in 1980. One lady ‘phoned me early one morning saying she thought she was in very early labour (second baby). I visited to assess her and found nothing much was happening so I said I would return at lunch time. Still nothing was happening so I went back after my afternoon clinic. Rather fed up, we decided I would rupture her membranes. I then said I would go home, get something to eat and come back.

    I drove home, fed the cat and started to cook supper when the 'phone rang. It was the lady's husband breathlessly saying "the baby's coming and we've had to ‘phone the doctor". I drove the fifteen miles along country lanes in little over fifteen minutes. I arrived to find the GP, a kindly gentleman fast approaching retirement, literally holding the baby's head in; he proudly told me he was "saving the delivery" for me!
    Although I had always wanted to be a community midwife, I decided to move into midwifery teaching after just over a year - and I've been in teaching for the rest of my career. More of that next time ......

    Part 2 of Denise’s Journey

    Published : 17/04/2020

    We used to have such fun when we were students. These days there's no time and most students just want to get off home after a busy shift. We had blocks of study and blocks of clinical practice. When we were on the wards we worked early or late day shifts and one week in four on nights - so much easier than the rotas now.

    Nights were the best for me. We were usually on nights with several others from our set and we used to play tricks on each other. One time, somebody rang round all our wards and asked us to take a pint bottle of milk down to Night Sister's office, but we were told not to knock on the door because she was busy. One by one we took the bottles down - and by the morning there was a long line of milk bottles down the corridor! Goodness knows what Night Sister thought.

    Another time, when we were in our third year and in charge of the ward on nights, one of our friends was in charge of Coronary Care (unthinkable now). When we had patients with very high temperatures we had to call the porters to bring buckets of ice to cool the patients down. Someone phoned the porters and said there was a patient in coronary care with a very high temperature and could they please take two buckets of ice. When the porters arrived our friend said, of course, there was no one needing the ice.

    The porter was very grumpy and refused to take it back so he dumped the whole lot in the sink in the ward kitchen. Unfortunately, the sink was stainless steel and the ice made such a racket that it woke up all the patients with a start. This was not good, being in coronary care, and our friend spent the rest of the night doing ECGs on everyone. Not one of our most sensible tricks!”

    Part 1 of Denise’s Journey

    Published : 16/04/2020

    Since the 45th anniversary of starting nursing, Denise has been reflecting on little memoirs from her years in nursing and midwifery. Denise decided she wanted to be a midwife when she was 15, not that anyone in her family was in the medical profession. She gained a place at the prestigious St Bartholomew's Hospital and started training in February 1975.

    Her parents left her at the nurse's home after a tearful farewell. All students had to "live in" in those days and rent was taken out of the salary. Denise remembers her first payslip as being a heady £90 after deductions - an absolute fortune to a 19 year old who had just left home for the first time.

    The tutors were very strict and it was really like still being at school. They had 28 in their group (set 14) and almost all of them were 18 and 19 year old school leavers. They did have one girl who was ancient at 24 and - scanadalously - divorced!
    Denise reminisces:
    “ Nurses started in PTS for eight weeks - preliminary training school - in which we learned basics such as bed making and blanket bathing. We also had lectures on looking after ourselves. I remember the session on "family planning" - the Chief Nursing Officer came to talk to us and her basic message was: "the best form contraception is NO"!

    We were not allowed to have boyfriends in our rooms - we had to meet them in the common room downstairs. The only men allowed upstairs were dads and brothers - but some students did seem to have quite a few different "brothers"! The nurses' home was locked ?at 11pm? - but the medical student residences and the bar were open till the early morning. Many a time we would party all night and turn up in duty at 7.30am, bleary eyed, to look after a ward full of patients.”
    To be continued!

    Keeping cool in pregnancy during a hot summer

    Published : 15/04/2020

    Best tips for keeping cool in pregnancy during a hot summer.

    Denise’s best advice – rest in a cool sheltered place, use a hat, keep hydrated, wear cotton clothing.

    Sit with your legs raised if possible – and do not wear the same pair of shoes every day – heat will increase any swelling and this can stretch the shoes, especially if they are leather.

    Cool baths / showers, get into bed wet after a shower to maintain cool skin. Peppermint oil during pregnancy?

    It is not advisable to use any oil to cope with symptoms of pregnancy on a regular basis – we should still think of them as medicines.

    If someone uses peppermint, it must be the correct peppermint as there are several types, some of which are not suitable in pregnancy – the one that is OK has the Latin name Mentha Piperata. It should not be put on the skin neat as it can cause skin irritation and should be avoided by women with any heart problems as peppermint is a mild cardiac stimulant (the same applies to peppermint tea in large amounts). Whilst it can cool the skin it does not cool the core temperature well - a woman’s body temperature rises by 1 degree Celsius in pregnancy normally.

    Ten reasons why midwives must stop using aromatherapy diffusers in maternity units

    Published : 14/04/2020

    Here’s some wise advice from Denise about aromatherapy diffusers.

    1. Mothers, midwives, visitors and other staff might not like the particular aroma chosen.
    2. Some people may react adversely to certain oils, for example orange or mandarin if they are allergic to citrus fruit.
    3. Diffusing aromas in a public place is like passive smoking - if you can smell the are inhaling the chemicals, which may be harmful.
    4. The Nursing and Midwifery Council Code requires you to protect yourself and others (13.4).
    5. Control of Substances Hazardous to Health regulations require you to minimise risk of chemicals in the workplace.
    6. Any women exposed to aromatherapy oil vapours must have this recorded in their medical notes.
    7. Aromatherapy can be discussed in antenatal classes but should not be diffused or offered to everyone to smell as they may react adversely.
    8. Midwives exposed for long periods to large amount of sedating aromas such as lavender or clary sage may be unable to make clinical decisions quickly in an emergency.
    9. Staff and visitors who are pregnant, or who have asthma, epilepsy or liver disease may be adversely affected by inhaling the chemicals of the oil aromas.
    10. Neonates should not be exposed to aromatherapy oils due to their immature liver, skin and immune systems.


    Published : 13/04/2020

    Denise is currently writing her next book on the Safe Use of Natural Remedies in Pregnancy. Here she expresses concern over the current state of homeopathy.

    ‘Homeopathy is going through a very bad time, worldwide. In Japan, a law was passed a couple of years ago prohibiting any health professional from prescribing or advising on homeopathic remedies. France, one of the most fervent advocates of homeopathy, is due to abolish state funding for it. USA and Australian medical organisations have taken steps to regulate and restrict it. Recent events in the UK have led NHS England to disparage homeopathy and to warn the Professional Standards Authority that continuing to recognise the Society of Homeopaths would imply to the general public that the modality has a scientific basis. Unfortunately, the individualised nature of homeopathic prescribing means that the remedies cannot be tested in the same way as conventional medicines and do not fit into the “gold standard” randomised controlled trial system of research so lauded by the medical scientific community.

    There is however, a fundamental flaw in the argument posed by all these regulators of conventional healthcare. They cannot claim that homeopathy is “dangerous” and then state that “there is nothing in it” – the latter implying that it is harmless. The preparation of homeopathic remedies includes dilution so that the original chemical substance is no longer present in any meaningful amount. However, preparation also involves a process of vigorous shaking (called “succussing”) – which agitates the molecules in the substance to release energetic power. So – doctors are right when they state that there is nothing chemical in the homeopathic remedies – but they are wrong when they claim that it “does nothing” because the physical power has been increased by the sucussing. Homeopathy is based on quantum physics. The theory that the water in which the substance is dissolved has the ability to retain the memory of that substance was proven by Jean Benveniste, a French immunologist, in the late 20th century, a study that was published in the prestigious scientific journal, Nature. Further work has been done by Brian Josephson, a physicist, and Luc Montagnier, a virologist.

    Homeopathy is NOT worthless and it is NOT dangerous when prescribed by appropriately qualified practitioners. What makes homeopathy dangerous – and other therapies such as aromatherapy, AND conventional medicines – is the injudicious way in which the general public self-administers the various remedies. Aspirin and paracetamol are drugs freely available on the high street and are proven effective pain killers but if taken in excess can cause intestinal bleeding or liver damage respectively – and in some cases can be fatal. Aromatherapy can have a relaxing effect, ease muscle pain and even help with labour contractions – but is being shockingly abused by an ill-informed general public and even some health professionals including midwives. Many, many herbal medicines can have a blood-thinning effect or cause liver damage when taken for prolonged periods but people believe that because they are “natural” this also means they are “safe”. An additional problem for natural remedies such as herbal medicine (which acts like drugs) or homeopathy (which does not) is that they should not normally be combined with conventional medicines as this can either inactivate the remedies or increase the risk of adverse effects.’

    Interactions between herbal remedies and prescribed medications in pregnancy

    Published : 12/04/2020

    Here, Denise talks about herbal remedies in pregnancy and draws our attention to the interactions between herbal remedies and prescribed medications

    There is considerable evidence for the anticoagulant (blood thinning) effects of many herbal remedies - especially ginger, garlic and gingko biloba. This is especially relevant to expectant mums because prolonged use of therapeutic amounts of these remedies can cause vaginal bleeding or general bruising.

    This means that some mums-to-be should avoid taking large amounts of these plant remedies, although the small amounts used in cooking are generally safe. For example, ginger, a common remedy for pregnancy sickness should not be used by women taking blood thinning drugs, aspirin or other drugs aiming to prevent pre eclampsia such as clexane.

    Using ginger to treat sickness over a prolonged period of time (more than three weeks) may mean the blood has thinned and blood samples should be taken to check clotting factors.

    Expectant mums should be asked by midwives or doctors if they are taking any herbal remedies and this should be documented. And please, if you're pregnant use ALL herbal remedies, including aromatherapy oils carefully and ALWAYS tell your midwife or doctor. So many herbal remedies and oils can interact with prescribed drugs, either inactivating them or making them work for longer than is needed (which increases the risks of side effects).

    We all want some Figgy Pudding - but is it safe when you’re pregnant?

    Published : 11/04/2020

    If you have a craving for brandy-laden Christmas pud every day of your pregnancy, that’s not going to be too good for you, what with all the sugar and alcohol in it. But let’s get things in perspective. If you want to enjoy some Christmas pudding on 25th – have some! A normal portion, even with the alcohol, is going to do you no harm whatsoever (unless you are allergic to alcohol, have a major liver condition or have been dependent on it).

    Yes, we know that expectant mums are advised not to drink alcohol but we aren’t talking getting absolutely blotto here – we’re talking about a miniscule amount mixed in with other ingredients. Pregnant mums spend enough time feeling guilty about what they should and should not do, but – as my mother used to say – all things in moderation. It might do you a lot more good than being miserable thinking you can’t have it. Obviously, it isn’t wise to drink alcohol in pregnancy at all, but again, a single glass of wine on a single day of your pregnancy will not harm you, your baby or the progress of your pregnancy.

    ....and if someone is cooking a meal with alcohol in it, Danish advice is to leave the lid slightly loose to allow the alcohol to evaporate more easily.

    Scented Candles at Christmas time

    Published : 10/04/2020

    Here, Denise is asking:

    "How safe are scented candles and oil diffusers if you’re pregnant at Christmas time?"

    The aromas of mince pies baking, pine cones on the fire and the spices in mulled wine are all part of the Christmas tradition. Many people also like to use scented candles, aromatherapy oil diffusers and room sprays to fragrance the atmosphere. But do you know what’s in these candles, oils and sprays and whether they are safe for everyone in your family? It’s even more important to consider the safety when you’re pregnant.

    When you smell aromas you are inhaling vapours containing chemicals. The reason that fragrances smell different is because the candle / oil contains varying levels of hundreds of chemicals. These chemicals pass via your smell receptors in your nose to your lungs and around your entire body to all your major organs, and some cross your placenta to your baby. They also pass from your olfactory (smell) system to the limbic system in your brain, which controls your mood – this is why some aromas (chemicals) make you feel good and others may make you feel down or depressed.

    Many commercial candles, especially those made from paraffin wax, contain high levels of organic compounds that may be harmful to health. Two common chemicals used in candles are benzene and toluene which have been reported possibly to cause cancer in large amounts. When these chemicals burn, harmful hydrocarbons are released into the air, which may cause asthma, skin complaints and other allergic reactions in susceptible people. To help avoid these problems, choose beeswax top quality candles that burn with a slow, even flame from a thin wick. Candles that contain organic oils are better than those with synthetic aromas.
    If you use a diffuser (vaporiser) for aromatherapy oils, take care only to use good quality oils from a supplier who produces them for clinical use, such as Absolute Aromas

    NEVER leave a diffuser on for more than 15-20 minutes. Avoid essential oils that are unsafe to use in pregnancy, especially clary sage, jasmine, rose, nutmeg and cinnamon. If you have asthma or are prone to hay fever, either avoid diffusers or use only small amounts of oils that do not cause your symptoms. Two or three drops is all that is needed to fragrance the room – but ensure there is good ventilation too. NEVER use a diffuser in your baby’s room and don’t take your baby into the bathroom with you if you choose to use essential oils in the bath or light a candle. Use oils considered safe in pregnancy, such as lavender, sweet orange or grapefruit. Frankincense is also good, as it is calming and soothing – well, what else would you want at Christmas?

    Consider who else is in your home with you. Only use aromas that everyone likes – dislike of an aroma can cause headaches and nausea. If you have elderly relatives or small children, use fewer drops of oil for a very short time. If anyone has a major medical problem it may be wise to avoid aromatherapy diffusers altogether. Even your pets can be affected by oil aromas so keep an eye on them for lethargy or irritability. If anyone develops a headache or feels sick, it’s probably best to stop using the oils or candles (although these symptoms may be due to too much noise and too much Christmas pudding of course!)
    My advice is to use as little as possible of any candles, aromatherapy diffusers or room sprays, for the shortest possible time. If you can still smell the aromas when you turn off the diffuser or blow out the candle flame, there are still chemicals in the air. Enjoy them, rejoice in the wonderful aromas of Christmas but use them wisely.

    St John’s Wort

    Published : 09/04/2020

    Here, Denise is focusing one of the herbal remedies - St John's Wort, a popular remedy for mild depression. While there is plenty of good research to show that St John’s Wort is effective in treating mild to moderate depression, you may not know that it works in the same way as anti-depressants and can cause similar side effects.
    This means that St John’s Wort should not be taken in combination with prescribed anti-depressants. In pregnancy, it is not an alternative to anti-depressants if an expectant mother is advised by her doctor to reduce, discontinue or change her existing drugs.
    Like anti-depressants, women taking St John’s Wort should not suddenly stop taking it as this may cause serious withdrawal problems but should reduce the dose slowly over a period of time.

    Denise’s advice on Senna

    Published : 08/04/2020

    Denise has been writing about Senna (Alexandrina, Cassia Acutifolia) and it’s uses as a herbal remedy in pregnancy and also as a general remedy.

    Senna is indicated orally for the following conditions 

    • constipation,
    • irritable bowel syndrome,
    • haemorrhoids.
    • Also, for anorectal surgery, anal fissures and weight loss.

    In pregnancy, senna appears safe but in small doses and for the short term. If taken during breastfeeding it does not appear to have adverse effects on neonatal bowel movements.

    There are, however, contraindications and precautions. It is advisable to avoid senna if there is a history of threatened or repeated miscarriages and it is deemed too purgative if used as an enematic preparation prior to labour.
    It must be avoided with dehydration, diarrhoea, Crohn disease, ulcerative colitis, appendicitis, stomach inflammation, anal prolapse, haemorrhoids, undiagnosed abdominal pain. Senna can also interfere with tests for electrolyte imbalance.

    Here’s a list of adverse affects if taken orally - abdominal pain, bloating, flatulence, nausea, bowel urgency, diarrhoea. Excessive use can cause depletion of potassium and other electrolytes, cardiovascular disorders, muscular weakness, liver damage, coma, neuropathy, asthma and allergy symptoms.
    There are lots of interactions, so use with caution! Prolonged, excessive or inappropriate use may interact with the contraceptive Pill, oestrogens and diuretics. Senna can interact with anticoagulants - heparin, warfarin, aspirin. Also with some herbs such as horsetail, liquorice, stimulant herbs including aloe vera, buckthorn, black root, blue flag, butternut bark, greater bindweed, manna, rhubarb and yellow dock.

    What’s the best venue for a post-dates pregnancy clinic?

    Published : 07/04/2020

    Here, Denise is asking...’What’s the best venue for a post-dates pregnancy clinic?’

    ‘I’m often asked about introducing a complementary therapies clinic for expectant mums who are overdue. The “package” of care I’ve used in my own practice includes specific acupressure points known to stimulate contractions, together with aromatherapy oils and massage. In 2015 I was involved in research investigating acupressure to encourage labour and there is plenty of research evidence that shows it works. Personally, I also include the reflex zone therapy (reflexology) foot points for the anterior and posterior pituitary glands (contractions actually start in the brain, not in the uterus), although not all the midwives I teach incorporate this technique. Using a range of therapies does offer mums-to-be choices about their treatment and enables midwives to tap into the therapies they are trained to use in their practice.

    But what’s the most appropriate place to hold a post-dates pregnancy clinic if you’re using aromatherapy oils such as clary sage? Remember that if you can smell the aromas of the oils you’re inhaling the chemicals. Think in terms of passive smoking and the effects this has on other people. Inhaling aromatherapy vapours can be pleasant but will also affect different people in different ways, not always beneficially. It’s especially important when using oils intended to stimulate contractions to ensure that other women will not be affected. It would not be safe to be offering uterine-stimulating oils in a clinic where women who are not yet due are attending for antenatal appointments. Nor should midwives who are pregnant be involved in providing treatments designed to encourage the onset of labour. Even midwives who are menstruating may experience problems from excessive exposure to clary sage oil.

    Holding a post-dates pregnancy clinic in the evening may be an answer as the aromas (and therefore the chemicals) will disperse overnight and won’t affect women in early pregnancy attending the next day. Maybe a Saturday morning is better when there are no regular antenatal clinics until Monday morning? On the other hand, some women may not want to make yet another trip to the maternity unit or birth centre for a treatment unless it is combined with a normal antenatal appointment, however desperate they may be to get into labour.
    Perhaps it’s better to offer these treatments to women in their own homes at a time that suits them? If you’re working in private practice, this could be an option, but brings with it some logistical issues for NHS midwives. It won’t be possible to see as many women if time is taken up travelling between appointments, so a strict selection process will be necessary to ensure an equitable service – for example, offering the post-dates pregnancy complementary therapy service only to women expecting their first baby.

    I’d love to hear what you’re doing for the women in your area who are overdue. Are you offering complementary therapies – and if so, which ones are most effective? Do you have audit statistics to support what you are doing? Have you had any difficulties in implementing or maintaining your post-dates pregnancy service?’
    Don’t forget, Expectancy offers in-house training courses for midwives wanting to develop complementary therapy post-dates pregnancy services.

    Denise’s talks about Bach Flower Remedies

    Published : 06/04/2020

    Bach flower remedies are popular and easily available in health shops. Dr Edward Bach was a Welsh immunologist in the early 20th century who became interested in how the emotions can affect health and wellbeing.he developed a series of 38 remedies to aid emotional wellbeing.
    Rescue Remedy is by far the most well known remedy. It's good for acute stress, panic, hysteria - but it's not a panacea for everything. People often take it for exam stress or driving tests although the research is fairly inconclusive on whether or not it works.

    In maternity care rescue remedy could be useful for the transition stage of labour, immediately before the birth, or for a woman who is panicking about having blood taken, or for someone who is really distressed after being given bad news.
    However, the liquid flower remedies are usually preserved in aqueous grape juice (brandy) so should not be taken by anyone with a liver problem or alcohol dependency issue. It is possible to buy rescue remedy in other forms such as creams to run on the skin which would be better for some.

    Denise’s thoughts on Rooibos tea

    Published : 01/04/2020

    Rooibos (Latin name Aspalathus linearis) is a type of tea from South Africa, sometimes called red bush, which has become increasingly popular around the world. It has a distinctive taste and aroma, (which my brother calls “elephant dung”) and is rather an acquired taste. My son, Adam who lives in South Africa, found this article about the 5.6 billion cups of rooibos consumed around the world annually, and speculated that I probably account for 2.5 billion of those cups!

    On a more serious note, rooibos is a completely different plant from black and green tea, which both come from the Camellia Sinensis genus. Rooibos tea contains no caffeine, unlike black and green teas, and has much less tannin also. As we know, caffeine should be avoided in pregnancy and most expectant mums are aware of this in relation to coffee and black tea. However, they may not be aware that tannin in tea (the stuff that stains the pot or cup brown) can interfere with the absorption of essential nutrients from food, including folate and iron – and this also applies to iron medication for anaemia. Rooibos contains antioxidants, potentially protecting people from stroke, heart attacks and certain cancers.

    Expectant mothers should be advised to limit their consumption of black or green tea to no more than about 5-6 cups a day, to avoid excess transfer across the placenta to the fetus, which may lead to miscarriage, preterm labour, low birth weight, diarrhoea and neonatal caffeine withdrawal. When consumed in excessive amounts, green and black tea may also cause alterations in maternal blood pressure, changes in electrolytes and other chemicals and even anaphylaxis. Importantly, green tea can interact with certain drugs, especially amphetamines and to a lesser extent, with anticoagulants and antiplatelet drugs, as well as with some herbal remedies. However, rooibos appears to have no such risks and is safe enough to enjoy in pregnancy whenever desired.

    Why are midwives so enthusiastic about complementary therapies?

    Published : 31/03/2020

    Since Denise pioneered the midwifery specialism of complementary therapies (CTs) in the early 1980s, the use of aromatherapy, reflexology, acupuncture and hypnosis has risen to an all-time high. But are midwives using CTs for the right reasons? Here Denise discusses some of the contemporary issues around midwives' use of CTs.

    She says ‘I was fortunate to be in the right place at the right time. My interest in complementary therapies (CTs) and the start of my 40 year career journey specialising in the subject coincided with an upsurge in interest amongst the general public. The 1980s and 1990s saw increasing involvement of medical, scientific and regulatory organisations in the UK and USA. I became very active in national and international fora and met some of the main advocates in the field including HRH Prince Charles.

    Over the 1990s and 2000s I've seen tremendous changes in the uses, acceptance and evidence-base of CTs and a huge increase in the use of specific therapies amongst midwives in particular.

    In fact, midwifery is now in a situation where almost all midwives are aware of women's interest in CTs and many midwives want to use therapies in their own practice. This may be because there is so much intervention in pregnancy and childbirth that mothers and midwives want to get back to "natural birth". Perhaps it's a means of being "with woman" in the true sense of the word "midwife".

    Midwives using CTs have shown that introducing gentle relaxation therapies into care reduces intervention, including transfers from home or birth centre to delivery suite and lowers Caesarean, epidural induction rates. This saves money, another incentive to incorporating CTs into midwifery practice.

    But is there perhaps also a desire to retain our political place in the childbirth arena? Does the use of aromatherapy or acupuncture give us just that little extra kudos to our diminishing role as the lead professionals in maternity care? Is there now a new power battle in which midwives are attempting to hold on to something that was lost in the 1970s - total care of women from conception to postpartum, in line with the WHO definition of a midwife? Do those midwives (or those maternity units) offering CTs imply a seniority in "status" because they do use them, compared to those who do not?

    Midwives have used natural therapies, manual techniques, plant remedies and fragrant oils since the human race began to enhance and aid the process and progress of pregnancy and birth, but in the 21st century, much of this empirical knowledge has been lost. Midwives are not therapists - they are midwives. Contemporary midwifery education and practice, whether we like it or not, does not normally include CTs, even though many midwives are attempting to dabble in them. Where the subject is included in universities, training usually includes an enjoyable day of massage and playing about with nice smelling oils, but this does not teach midwives the things they need to know in order to use them in practice.

    If we are going to incorporate CTs into our care of women, we need comprehensive, evidence-based education to be commenced in pre-registration training. I do not think that, at the point of qualifying, midwives need to be able to practise different therapies but they do need an understanding of the complex issues of women using natural remedies and midwives offering therapies in their practice. Indeed, CTs education for midwives should be a post-registration area which interested midwives can develop into a specialism. It is not appropriate for all midwives to be experts in CTs in the same way as we are not all experts in care of women with complex pregnancies, or in safeguarding or in FGM - that's the reason we have experts, knowledgeable authorities who have studied, practised, researched and published on the area in question.

    I would further question whether CTs really fit into the debacle that is the modern NHS. Introducing CTs into maternity care does not solve the problems of the NHS but may even compound them. We all know that CTs can be wonderful for an individual mother, relaxing her and enhancing her overall experience of pregnancy and childbirth (and improving those maternal satisfaction scores). However, unfortunately we have to look at the greater picture. Introducing new initiatives into NHS care must be effective, safe and cost effective. Services must be equitable and offered to as many women as possible, barring those who are not medically eligible to receive them. Our use of CTS must be evidence based where possible and midwives must use them within the NMC Code and within the culture of the NHS.The NHS is not person-focused, it is institution-focused and we either learn to work within that culture or get out.

    So - if you're a midwife wanting to use CTs or already using them, perhaps it's time to challenge your justification for doing so. Be honest with yourself; look beyond the "niceness" of CTs and question WHY you are doing this.

    Of course, my questions are rhetorical - I would not still be teaching midwives about CTs nearly 40 years on if I didn't think there was benefit in them - but let's hear your views.

    Home Births and Covid19

    Published : 30/03/2020

    It’s understandable from a staff availability perspective that NHS trusts are stopping women from having their planned home births. However, continuing to enable women to birth at home could be one way of containing the virus and protecting mothers and babies from the virus-soaked hospital environment. In previous years there has been research to show that infection rates, generally, are far lower when women birth at home and this is one situation when we truly need to protect the next generation.

    Preventing women from achieving a home birth may in fact increase the number of unassisted births in which women choose to stay at home without professional help, a fact that could increase the work of the NHS if complications occur. Usually women who consciously choose to "freebirth" have researched It and prepared thoroughly but in the current situation some who had planned a home birth may now simply stay at home without calling the midwife. It’s ironic that we are all being told to "stay at home" but pregnant women wanting a home birth are now being told to "come to hospital".

    It concerns me also that when all this is over and we are back to normal NHS trusts may simply not return to offering home birth, which is a woman's right.

    Coronavirus effects on sense of smell -implications for aromatherapy

    Published : 27/03/2020

    Here, Denise explores issues related to one of the more unusual symptoms of coronavirus and questions whether it has implications for aromatherapy.

    Reports from China and other Far Eastern countries suggest that a symptom of coronavirus (CV19) is loss of the sense of smell (olfaction) and a corresponding perception of loss of the sense of taste. Although the linings of our nostrils are constantly bombarded by viruses, bacteria and other pathogens, we are usually able to fight them off to prevent them from penetrating deeper layers. However, some specific pathogens penetrate the olfactory nerve, in some cases reaching the olfactory bulb situated at the end of the olfactory nerve in the brain, killing off olfactory nerve cells along the way. Anosmia (loss of the sense of smell) can occur within 24 hours of exposure to the virus. This means that the person cannot detect enough odour molecules to activate the nerve pathways and will not therefore smell the aroma, at least by breathing normally.

    As we know, aromatherapy relies partly on the aromatic molecules of essential plant oils enabling us to inhale pleasant aromas to enhance the overall treatment experience. However, loss of the sense of smell does not mean that an individual will not benefit (or be at risk from) essential oil treatments. Chemicals in the essential oils can be absorbed via the skin and mucus membranes as well as via the nose, eventually entering the circulatory system and passing to all the organs of the body. Research exposing people with anosmia to essential oils, by inhalation or topical application, has shown physiological and emotional effects of the chemical constituents. So it may be possible to diffuse essential oils for people with mild CV19 symptoms. Not only will this aid breathing and clear the sinuses, but the antiviral effects of oils such as lemon, eucalyptus and tea tree may help to combat the virus, or at least reduce its effects. Obviously, it is not currently advisable to administer the oils via massage, the commonest and most popular method of administering aromatherapy in the UK, but the person will still gain benefit from exposure to the aromas, even though they may not realise it at the time.

    Just a couple of words of warning though – using essential oils is not a replacement for other methods of prevention, especially staying at home and frequent hand washing, nor is it a treatment for those with more than mild CV19 symptoms. If a diffuser is used to fragrance the room, it should be left on for no longer than 15-20 minutes – after this time the nostrils become saturated with the aromatic molecules and may cause side effects such as nausea or headache, potentially masking the true symptom picture of the person. Eucalyptus oil should not be used in a diffuser if you have pets as it can have adverse effects on some, notably cats. Lemon should not be used if anyone in the vicinity has a citrus fruit allergy. Avoid getting tea tree oil neat on the skin. If symptoms persist, consult a doctor.

    Denise discusses relexology

    Published : 26/03/2020

    The term “reflexology” encompasses a range of therapies that involve using one small part of the body as a “map” of the whole. Most reflexologists use the feet and/or hands, with each part of the body reflected on one or both feet / hands. Reflexology is not simply foot “massage”, it enables the practitioner to treat a wide range of conditions.

    Denise is the only lecturer in the UK who teaches the specific clinical style of reflex zone therapy (RZT) specifically applied to midwifery practice. RZT was originally adapted from generic reflexology by the German midwife, Hanne Marquardt. The charts (maps) used in RZT are different from those used in other styles of reflexology and several different manual techniques are used too. RZT can be used to treat backache, sickness and other discomforts in pregnancy, to stimulate contractions when a woman is overdue, to encourage the latent phase of labour and to deal with retained placenta, amongst many other things.

    When Denise worked at the University of Greenwich, she did some research on using RZT points on the feet to diagnose stages of the menstrual cycle. From the feet, it is possible to identify which ovary is active, to work out how far in the current cycle a woman is and then to predict when the next menstrual period will occur. Denise is about 85% successful and can normally work it out to within one day. She has also adapted this technique to predict the onset of labour, which helps when women are faced with medical induction of labour. How cool is that?!!

    Is it time to stop talking about "aromatherapy" in midwifery?

    Published : 23/03/2020

    I've recently been contacted by a midwife working in a unit where aromatherapy has been available for some years after I provided initial training for the trust. As with many units, many of the midwives who originally trained to use aromatherapy have left the trust or moved on to other clinical areas or other projects. The unit is considering sending several midwives to train fully as aromatherapists, a somewhat unnecessary expenditure, given that pregnancy and childbirth are rarely covered in pre-registration courses.

    However, tutors at the local aromatherapy school that the midwives were considering expressed concern about midwives introducing aromatherapy into their care, since aromatherapy is a completely separate profession from midwifery. This is a growing concern amongst complementary therapy educators and regulators and not without some justification. It is particularly relevant when midwives are not fully qualified in the therapy and who presume to use limited elements of another professional discipline within their own area of practice. Nowhere is this more apparent than with the use of aromatherapy, although it also applies to a lesser extent to other therapies such as acupuncture, reflexology and hypnosis.

    Midwives would be the first to object if therapists started introducing aspects of midwifery practice into their aromatherapy treatment of pregnant clients - although that, of course, would be breaking the law since the title of "midwife" is protected in statute. So are midwives actually practising "aromatherapy"? Does the use of a limited number of essential oils and a few basic massage techniques constitute "aromatherapy" in the holistic sense of the word? Aromatherapy practice is so much more than this, incorporating holistic assessment and careful prescription of appropriate essential oil blends based on physiological, chemical, botanical and energetic principles, administered by a variety of methods.

    Training to become an aromatherapist includes considerable theory and many hours of practice, in addition to anatomy and physiology, chemistry, pharmacology and pharmacokinetics, students must cover the history and development of the aromatherapy profession, business management, professional ethics and law and more in order to register. What midwives are doing is not "aromatherapy". Midwives use essential oils as additional chemical enhancements to their standard care of women in pregnancy and labour. They use massage and touch as aids to relieving pain and easing stress. The added bonus of pleasant aromas can enhance the relaxing environment in the birth centre. But there's the rub. The aromas complicate the picture because they are supposed to be "nice". Aromatherapy in the UK has always had a reputation as beauty therapy first and clinical therapy second and has spent many years attempting to be seen as more credible. Adhering to the "spa" aspect of aromatherapy detracts from its clinical potential - and its possible risks in unskilled and ill-informed hands. This is compounded by the plethora of cheap, poor quality aromatherapy oils available to the general public on the high street, with marketing strategies focusing merely on relaxation and fragrancing the environment.

    Companies producing clinical-grade esential oils do not need to do this and take steps to ensure the quality of their oils and restrictions on who is permitted to purchase some of the more powerful oils. Perhaps it is time for midwives to consider the real reasons they use "aromatherapy". Should we not, as a profession, be honest and acknowledge that what we are doing is simply using touch - as midwives have always done - and that we occasionally incorporate alternative pharmacological options which just happen to smell pleasant? Let's stop pretending and be clear that we are not providing "aromatherapy" in the widest sense of the word. That way lies more credibility in using essential oils, less scepticism from other maternity colleagues, less stepping on the professional turf of our aromatherapist colleagues and more safety for mothers and babies. 

    Are complementary therapies safe for women wanting a vaginal birth after a previous Caesarean?

    Published : 13/02/2020

    I am often asked by midwives about whether women wanting a vaginal birth after a previous Caesarean section (VBAC) can use complementary therapies and natural remedies to start labour.

    Obviously these women are desperate to avoid another Caesarean and often try everything they can find to help. Of course, having a nice relaxing massage or reflexology treatment can be good - it reduces the stress hormone, cortisol, and encourages an increase in oxytocin so labour is more likely to start naturally.

    Hypnotherapy can also help, by encouraging the expectant mum to focus on the positives of the impending birth rather than on the negative feelings about the past Caesarean.

    However just because they're natural doesn't necessarily make self-administered natural remedies safe. This applied to all pregnant women but it's a particular risk when those wanting a VBAC start trying every remedy they've heard of - and often all together.

    More is definitely not better - indeed, using lots of remedies may confuse physiology so much that it actually increases the risk of complications, leading to the need for another Caesarean.
    Maternity professionals - midwives, doulas, doctors - and therapists treating pregnant women should advise those trying for a VBAC to:

    • have regular relaxation treatments from a suitably qualified therapist who is insured for maternity work
    • avoid self-administering castor oil, raspberry leaf tea, clary sage oil, evening primrose oil and other herbal remedies - and NEVER EVER to take them all at the same time
    • inform their midwife or doctor about any complementary therapies they've had, and especially any herbal remedies they've taken or aromatherapy oils they've used.

    "Hypnobirthing" precautions

    Published : 12/02/2020

    It’s great that “hypnobirthing” is providing much-needed support for women in pregnancy and labour, including Royalty. It is particularly helpful when women find the stresses of modern pregnancy difficult to cope with.

    Any form of relaxation method that enables expectant and labouring women to focus on the positives reduces the stress hormone, cortisol, causing a corresponding rise in the oxytocic birth hormones and helping their bodies to work effectively for the birth process.

    However, unlike hypnotherapy, “hypnobirthing” is not classified or regulated as a specific complementary therapy even though it incorporates some hypnotic suggestions. “Hypnobirthing” is a structured tool used within maternity care, often delivered in group settings, which was adapted from the original 1960s work of Grantly Dick Read on preparation for birth. Clinical hypnosis – or hypnotherapy - is derived from the 18th century work of Anton Mesmer and is a form of clinical psychotherapy, individually prescribed and delivered.

    Even though “hypnobirthing” is not a discrete therapeutic modality and only includes brief elements of hypnosis, midwives, doulas and those teaching classes should take care to assess each individual (including companions present in the class) prior to starting the relaxation component.

    People respond to different cues, visual, auditory or kinetic, and group sessions do not tap into this individualised approach. “Hypnobirthing” may not be appropriate for people with a history of mental ill health and some people may react adversely to specific ideas.

    Examples that can cause difficulties include imagining themselves descending a flight of stairs if they have a fear of stairs, perhaps following a previous fall, or visualising walking by a stream if they have a fear of water or have previously fallen into a river. Class facilitators also need to be able to recognise and deal with an individual who is so responsive that they fall into a deep trance-like state.

    Castor oil - is it safe for starting labour?

    Published : 11/02/2020

    Last Sunday's “Call the Midwife” featured a woman who took castor oil to try to get into labour so that her baby would be born on her late father's birthday.
    Castor oil has long been tried as a way to start contractions, the theory being that, like enemas, excessive intestinal movement may have a knock-on effect on the uterine muscles. It's come back into fashion in recent years although it's not the most pleasant thing to drink.
    Castor oil is commercially produced from castor beans, and one recent study suggests that a single 60ml dose can trigger labour contractions. It may work for some, but the success rate is not much better than chance.
    However, castor beans contain ricin, a chemical used in germ warfare, and which can be toxic. Women should be advised not to take it repeatedly, and as with all other self-help methods, not to take it in combination with other natural remedies or techniques.
    Like many other midwives, I'm concerned that women feel so pressurised by the obstetric system that they feel they need to take matters into their own hands.

    The message to women must be that ANY intervention in the natural physiological process of starting labour is as much an intervention as medical induction.

    Turmeric and other herbal remedies in pregnancy

    Published : 10/02/2020

    I recently had a friend tell me that she was taking homeopathic remedies for her blood pressure. On questioning her, it transpired that she was actually taking a herbal remedy. Turmeric, on the advice of another friend. Turmeric may in fact reduce blood pressure but should not be taken with drugs prescribed for the same reason - this risks reducing the blood pressure too much with the possible risks of fainting or that the doctor will reduce the blood pressure medication inappropriately.

    There are several issues here that can be applied to maternity care. First, there is a significant difference between herbal and homeopathic remedies. Homeopathy does not work in the same way as herbal medicines. It is an energy-based system which uses very chemically dilute substances which have been vigorously shaken to release their energetic potential. Whilst care should be taken to ensure the correct remedies are taken, homeopathy is not dangerous - but herbal remedies certainly can be harmful. Herbal remedies, including herbal teas and essential oils used in aromatherapy, work in the same way as drugs. They are metabolised, utilised and excreted, usually via the liver. It is possible to overdose with herbal remedies, and for side effects to occur.

    Many herbal remedies interact with specific drugs and many should be not be taken at the same time as drugs. Some, including turmeric, as used by my friend, reduce blood pressure, affect blood glucose and a considerable number have strong anticoagulant effects, thinning the blood. The issues for midwives and other maternity professionals are:

    1. to advise all women requiring medication for a medical or pregnancy problem to avoid all herbal remedies unless they are prescribed by a qualified medical herbalist.
    2. to advise all women having planned surgery including Caesarean section to discontinue all herbal remedies at least two weeks before.
    3. to advise women to inform their midwife or doctor if they are taking any herbal remedies for what ever reason.
    4. to clarify whether a woman is taking herbal ( ie pharmacological ) or homeopathic (energy-based) remedies - there is a lot of public misconception, that because they are natural they are safe and also confusion between herbs and homeopathy.
    5. to record in the mother's notes if she is taking any natural remedies including herbal teas or using aromatherapy oils ( not all are safe in pregnancy).

    Previous articles

    World Mental Health Day

    Complementary Therapies Explained

    In honour of National Curry Week (5th to 11th October) Denise questions whether curry will bring on labour

    Celebrating World Reflexology Week

    Denise’s First Course after Lockdown

    Aromatherapy in Indonesia

    Do we focus on the positive aspects of complementary therapies and the negative aspects of standard medical treatment? The problem of informed consent.

    The value of complementary therapies

    Working for the NHS as a midwife and private practice explained

    Coffee and Pregnant Ladies