Denise and her blog


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

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Vaginal and Caesarean Births…Some Advice

Published : 21/10/2021

Denise is 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.



Aromatherapy Oils Are Not To Be Played With

Published : 19/10/2021

Here, Denise discusses an issue that arose on a recent aromatherapy course in which a midwife reacted adversely to the oils.

During our  aromatherapy course for midwives this weekend, one student had a significant reaction to the essential oils, which we finally identified as being caused by frankincense. The student had already told me she suffered with eosinophilic asthma and I had urged her to be cautious but explained that some reactions cannot be anticipated or attributed to specific oils.

As the midwives were deciding on their preferred blends for the practical massage session, this midwife began to experience tightening in her throat and the beginnings of symptoms indicative of an asthma attack. Fortunately, she was able to move to another room and the oils she and her partner had chosen did not seem to affect her so she was able to engage in the practical work.

I have had several other midwives experiencing adverse reactions to oils during courses, some of which have been quite severe. Different oils have been involved including geranium, rose, clary sage, sweet orange, lavender and now frankincense. Indeed, I have witnessed a far greater number of midwives having negative effects from oils in the last five years than in all the years of teaching aromatherapy before that. Another midwife had such a serious reaction to simply sniffing clary sage from the bottle that we thought we would have to take her to A&E (she declined the offer and eventually the effects wore off). Other symptoms have included midwives being violently sick (from geranium) or developing an acute migraine-like headache (after using chamomile). One midwife reacted so badly to the use, by another midwife, of rose hand cream that she had to go home – she later informed us that she was allergic to roses.

I know of several maternity units where midwives with allergies to citrus fruits are unable to use oils such as orange, grapefruit, neroli or other citrus oils. Another unit has not one, but two members of staff severely allergic to lavender, one having been seriously affected when a mother brought her own lavender oil into the birth centre.

I cannot stress enough that midwives must take care when using aromatherapy in their practice, offering it to birthing parents or using it around other staff. The adverse effects can be unpredictable, severe and long-lasting. It is unethical, unsafe and unprofessional to assume that all people exposed to the oils in a birth centre either like the aromas or can tolerate the chemical effects. Get to know your oils and their benefits and possible adverse effects!



Why is Complementary Medicine not Included?

Published : 12/10/2021

Denise is in Portsmouth again this week, teaching aromatherapy and acupressure for postdates pregnancy. Having had a good first day,  the course is having to decamp on Tuesday to another hospital due to lack of room availability. The group was due to use a church hall but a last minute change was required when the church rescinded its booking, claiming that aromatherapy and massage did not fit with its religious ideals. Here, Denise reflects on the attitudes towards complementary therapies.

What a shame that we were unable to use the church hall for the second day of our course due to a possible conflict between religious views and what is sometimes still seen as "new age" therapies. Complementary medicine still has to fight its cause on many fronts. Scientists accuse CTs of being poorly evidenced. Purists feel that "alternatives" have no place in conventional healthcare; obstetricians claim they can interfere with medical interventions (true to a certain extent but they may also avoid the need for medical intervention). Managers sometimes reject them because , they say, there is not enough time to use them. Others claim they are dangerous, illogical or are an element of fringe medicine (or witchcraft).

In almost 40 years of practising, teaching, researching and writing about complementary therapies, I have encountered many views and much opposition. People are, of course, entitled to their views, although it is sad that some are based on lack of knowledge and understanding of what CTs are about, how they work and how they can be used beneficially to enhance maternity care. 

We hear a lot, today, about different lifestyles, perspectives and views on everything from sexuality to religion to disability to politics. Everywhere there are pleas for greater inclusivity. Why then does complementary medicine continue to be sidelined by the conventional healthcare and scientific communities? Is it not time that complementary medicine was brought in from the cold and considered equally alongside other forms of medicine and healthcare?



What’s Happened to Midwifery?

Published : 11/10/2021

I've seen many posts on social media about the deplorable state of midwifery and the maternity services in Britain but I've also seen similar posts from French midwives where midwifery is possibly even more.medicalised.than in the UK. Midwifery is in crisis in the western world - I would say we are seeing the death of midwifery as we know it unless radical action is taken now.

Blame is heaped on the current government yet this situation has been evolving for decades. It's not the fault of one government or one political party. One government can't cure the problems of fifty year's worth of intervention, control and pathologising of childbirth. 

Poor pay is also sometimes raised - but you don't go into midwifery or nursing for the money (that argument is for another day but it's not just the UK that pays its nurses and.midwives poorly). No amount of pay increases will bring more people into midwifery training  or stop the deluge of departures from those already working in the system.

I believe the problem lies in the culture and attitudes of the system. Midwives are mainly women and although many obstetricians are now female, they too work in a male dominated, paternalistic - and I would say, sometimes misogynistic - culture and often become part of the problem. Historically women have been moulded into "bodies that have vaginas" (as the recent Lancet referred to) and childbirth has become just another medical problem.

I heard only yesterday of a midwife committing suicide, possibly partly as a result of extreme bullying at work by her colleagues and managers. Bullying is rife in the NHS and possibly worst in midwifery - contributing to midwives leaving the profession for a better work-life balance and as.a.way to protect their own mental wellbeing.

Pressures on the maternity services have risen exponentially with increased population and increased complex needs of those using the services - obesity, diabetes, mental health issues and so on. More users bring higher demands and need more resources - including staff. Yet this means that those with complex needs take priority and those whose pregnancies and births are "normal" are left to get on with it - so they feel dissatisfied. More complex needs mean more emphasis on pathology to the extent that we all begin to see childbirth as a pathological condition.

The problems of midwifery are multifactorial and not easily rectiified. My preference would be to return to a community-based profession with individualised continuity of care and carer -but it's not going to happen easily. I believe midwives should adopt the independent midwifery model but this will be difficult in the NHS which exists for the majority and not for the individual. I feel that unless we do something soon, midwives will become obstetric nurses during birth, antenatal care will focus on the biological and not the psychosocial aspects and postnatal care -well, will there be any at all? 

I don't know what the answer is because the situation is so complicated but unless we act soon as a united profession we won't have anything to fight for. Long live midwifery.



Aromatherapy in Midwifery Practice

Published : 06/10/2021

If you’re wanting to implement aromatherapy into your midwifery practice, what do you need to learn? Here Denise shares a checklist for midwives and doulas preparing to use aromatherapy for labour care. The list can also be applied to the postgraduate study by aromatherapists wanting to specialise in maternity work.

  • Anatomy and physiology of the skin, the sense of touch, olfaction, respiration
  • Pharmacology and pharmacokinetics of essential oils. mechanism of action
  • Basic chemical concepts, specific chemistry of essential and carrier oils
  • Therapeutic properties of essential oils 
  • Methods of administration appropriate to us within labour care settings 
  • Methods of blending
  • Indications, contraindications and precautions to use of aromatherapy in pregnancy, labour and postnatal period
  • Recognition of healing reactions, adverse reactions, overdose and inappropriate use
  • Health and safety at work, control of substances hazardous to health regulations
  • Evidence-base for aromatherapy 
  • Keeping up to date with contemporary changes in aromatherapy practice
  • Evaluation and audit of midwifery aromatherapy service
  • Change management and the process of implementation of aromatherapy in midwifery practice

 



A Word About Essential Oils

Published : 02/10/2021

Essential oils are not a panacea for everything! 

Denise comments on continuing concerns about the overuse of aroma therapy oils.

Can you use lavender oil to lower blood pressure if an expectant parent has developed pre-eclampsia?

Is it OK to use tea tree (known to relax.smooth muscle) to stop a threatened preterm labour?

How about treating a skin reaction to one essential oil with another to stop the irritation?

The answer is a resounding NO!

When aromatherapy is used in pregnancy and birth, it should be supportive and can be very relaxing, uplifting, wound healing or immune boosting. However once progress.deviates from the norm, aromatherapy should be DISCONTINUED.

It is neither medically appropriate not professionally expedient for midwives and doulas to attempt to rectify medical complications with aromatherapy oils - sometimes DRUGS are needed! And it is not good.practice to attempt to reverse the effects of one oil or blend with another. If a woman has a reaction to an oil or a single chemical in an oil, she may react adversely to other oils containing the same chemical. CAUTION always when using essential oils in pregnancy and birth. Enjoy them but don't abuse them!



Osteopathy and Chiropractic

Published : 27/09/2021

Osteopathy and chiropractic offer probably the most dynamic treatment options for expectant parents with lower or upper back pain, pelvic girdle pain or any other musculoskeletal problems in pregnancy such as carpal tunnel syndrome and shoulder girdle pain. 

A follow-up study of 115 women who received chiropractic for back pain in pregnancy indicated a 52% improvement after one treatment, with steadily increasing rates of improvement with longer courses of treatment, particularly when continued postnatally for up to a year (PetersonMühlemannHumphreys 2014). 

In countries such as Canada, where chiropractic is accepted as being complementary to conventional healthcare, expectant parents with musculoskeletal symptoms can receive care which is genuinely shared between the obstetrician and the chiropractor.

In the UK, osteopathy and chiropractic are highly regarded allied health professions, with all practitioners statutorily registered under the General Osteopaths Council or General Chiropractic Council. Hensel, Buchanan, Brown et al (2015) set up the Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects (PROMOTE) study to evaluate the efficacy of osteopathic techniques for musculoskeletal pain in late pregnancy.

400 expectant parents were randomly allocated to receive standard care, osteopathy with standard care or placebo ultrasound treatment with standard care. Both osteopathy and the placebo treatment achieved some improvement in symptoms reported by participants although osteopathy was significantly more effective.

This was one of the largest trials ever conducted on the effectiveness of osteopathic manipulations in pregnancy, although it was interesting to note a high attrition rate, stated as being due to missed appointments and the onset of labour before 40 weeks’ gestation in some women.

As with much other complementary medicine research, the need to use a standardised treatment regime rather than individually-tailored clinically-relevant programmes of treatment may have affected the ultimate efficacy of treatment.



Black and Blue Cohosh Explained

Published : 25/09/2021

Some women take herbal remedies to trigger labour, including either black cohosh or blue cohosh.

Black cohosh is thought to have hormonal effects, menstrual and uterine-stimulating effects, but there is little reliable information available on the safety or effectiveness. When taken orally, it can cause gastrointestinal disturbance headache, dizziness, breast tenderness and skin irritation.Women with a history of hepatic or renal disease, epilepsy or vaginal bleeding in pregnancy should be advised to avoid black cohosh.

Blue cohosh is now known to cause significant adverse effects including reports of severe poisoning and life-threatening toxicity in the baby, including stroke, acute myocardial infarction, congestive heart failure, multiple organ injury and neonatal shock and should not be used in pregnancy or for birth.

NB It is essential to differentiate between black cohosh (Cimicifuga racemosa) and blue cohosh (Caulophyllum thalictroides) to avoid confusion and inappropriate administration. It is also important to differentiate between the herbal (pharmacological) and homeopathic (energetic) use of these plants





The Science of Aromatherapy Oils

Published : 24/09/2021

Aromatherapy oils are like Victoria sponge cakes! Whether you buy your cake from one supermarket chain or another, or from a local artisan bakery, the basic ingredients are much the same. Some cakes may contain more sugar, extra cream, fewer eggs or different flavoured jam than others, so the taste of the end product is affected by the proportion of these primary ingredients.

Essential oils, in principle, are much the same. They all contain the same groups and sub-groups of chemical ingredients, but in widely different proportions. When you examine a list of the "top ten" chemicals in each oil, it's these that give the oil its distinctive aroma and its primary effects  - such as being relaxing or stimulating, analgesic or anti-infective and so on. With almost 300 chemicals in each oil, some are found in such minute traces that their physiological effects are negligible. 

In pregnancy, we're concerned with avoiding those oils with high levels of specific chemicals particularly, ketones, which may be toxic to the fetus or cause uterine contractions or other maternal complications. Essential oils with only a trace of these chemicals will be much safer than those with significantly higher levels. Conversely, oils with high proportions of ketones should be avoided in pregnancy until term - oils such as jasmine, clary sage, rose or cinnamon.



Why are Good Midwives Being Driven Away?

Published : 16/09/2021

Have midwives lost the ability to use their common sense because they're caught up in a system that requires ticks in boxes and a "just in case" approach? Why can't the system enable midwives to watch and wait instead of intervening prematurely in what is, after all, a physiological process for both mother and baby?


A friend recently had a lovely son but the pregnancy, birth and first few days were not all.plain sailing. Nothing was wrong medically although the system pathologised.every small.deviation from "normal" and caused extreme anxiety for the parents. The baby was breech at 35 weeks - but ECV was performed instead of waiting to see if he turned - or discussing the option of a breech birth if he didn't. Labour started spontaneously with a very long latent phase - but, surprise, surprise, duration of "established" labour was measured from hospital admission, with mutterings (threats) to intervene if "nothing happened" within a set timeframe. As it happened labour did (of course) progress to the extent that the mum started requesting an epidural - which was arranged immediately instead of spending time supporting her through each contraction and building up her confidence in her body's ability to birth naturally. It was only because the unit was busy that saved her from the possible cascade that goes with epidural - the anaesthetist was unavailable so she laboured, largely on her own with just her partner present, and eventually gave birth to a healthy son. In the postnatal ward, someone saw fit to tell the mum that - on day 1 - she didn't have enough milk and gave her a bottle of milk for the baby. What?!! And then someone decided the baby had not passed urine and mum and baby were kept in hospital until he did - 48 hours later. I can almost guarantee that he will have passed urine in the early hours and that it was missed -but the parents were subjected to.more anxiety (with no explanations) instead of "allowing" them home and having the community midwife visit to check everything was OK.

These are minor incidents in clinical terms but accumulatively worrying for the parents and marred their overall enjoyment of having their first baby. This is also not an isolated case. Midwives are so fearful of losing their registration that they comply with requirements to fit every individual into a system that favours the institution and not each parent. They are so fixated on ticking charts designed to reduce the risk of omission that they forget to think outside the box - and end up missing important cues anyway (this has been proven in research). Lack of understanding of anatomy and physiology and the paternalistic desire of the system to see pathological problems before normality causes more anxiety for parents who are naturally already in need of a confidence boost.

Midwives have lost the ability to be intuitive about pregnancy, birth and the early days of parenthood. This is the fault of pre-registration education which now has so.much content there is hardly any time to learn - and understand - the basics before going on to complications (which, let's face it, are almost more commonly seen than so-called normality these days). It's the fault of a medicalised, paternalistic, risk-averse, litigation-conscious system that exists for the majority and not for the individual. It's the fault of a midwifery profession that has such a culture of bullying - of both staff and parents - that.compassionate midwives are leaving the profession, adding to staff shortages and compounding the whole sitiation. It's the fault of managers who are trying to balance the rotas and budgets whilst also thinking about CQC inspections and national.ratings.And it's the fault of all of us for being complicit in letting it happen. 



Pineapple Fritters Anyone?

Published : 13/09/2021

Expectant parents often start eating pineapple as a way of avoiding induction of labour. Pineapple (and to a lesser extent, mango and papaya) contains bromelain, a chemical that affects smooth muscle which is thought to aid uterine contractions. The bromelain is in the central core of the pineapple so it's no good eating tinned pineapple rings. In fact, cooking destroys the bromelain, so pineapple fritters are no good either, nor is drinking pineapple juice. It needs to be fresh, raw pineapple. However, some people are allergic to pineapple and eating large quantities can even lead to anaphylactic shock.



The Caring Role of a Midwife

Published : 05/09/2021

What an incredibly moving and brave article in this month's @MIDIRS by Iris Snowdon on her personal experience of such severe burnout that she walked out of the job she loved - being a midwife. It is a harrowing - but ultimately uplifting - acount of her gradual slide into the deepest depths of despair to her healing journey to a new life. How sad that such a caring and devoted midwife should suffer as a result of complete overload and lack of sympathy from many of her colleagues. 

However, Iris is not alone. Many of the midwives who study with Expectancy report similar experiences and some of those have taken the brave step to leave the NHS and do something different. I have met midwives at all levels, from Heads of Midwifery to newly qualified midwives, who have felt unable to continue working in a culture that is unsupportive, ungrateful, bullying and blame-throwing.

A desire to continue caring for expectant parents seems common to all, but often those midwives who have to pay the bills are forced either to stay where they are and put up with the situation or to find another job outside midwifery. Increasingly, midwives are working for themselves, offering maternity- related services such as antenatal classes, complementary therapies, lactation support, birth trauma resolution or tongue-tie division, even though this may mean less income. 

It is disturbing, when the NHS is so short of midwives, that it  actually isn't really about the money, but about wanting a better work-life balance and about wanting to with families in a caring compassionate way - the way that midwifery care should be. 



Previous articles

Vaginal and Caesarean Births…Some Advice

Aromatherapy Oils Are Not To Be Played With

Why is Complementary Medicine not Included?

What’s Happened to Midwifery?

Aromatherapy in Midwifery Practice

A Word About Essential Oils

Osteopathy and Chiropractic

Black and Blue Cohosh Explained

The Science of Aromatherapy Oils

Why are Good Midwives Being Driven Away?