Here Denise discusses the ethical and physiological issues relating to the misuse of fragrance.
There is increasing concern amongst the scientific and medical communities about the general public's progressive over-exposure to chemicals. We are bombarded by chemicals in our cleaning products and air freshers, food preservatives, fuel and industrial pollution and fragrances, including perfumes, scented candles and bath products. We smell aromas in shopping centres, restaurants and even in the workplace. Many of these aromas are pleasant, positive and beneficial, lifting our mood; others are not. Professionally, aromatic essential oils can be extremely therapeutic when selected appropriately, each oil having various therapeutic properties depending on the chemicals within them. Expectant parents frequently use aromatherapy oils to relieve the symptoms of pregnancy, and many midwives now offer aromatherapy to relieve pain and aid progress in labour.
However, increasingly, people are experiencing adverse effects from inhaling chemicals contained within the aroma vapours, from any source. Repeated exposure to a particular fragrance or even a single chemical in an oil has a "drip-feed" effect which can eventually lead to serious consequences (we can liken this to the effects of something like a seafood allergy which can eventually cause anaphylactic shock - susceptible people usually carry "Epi-pens" to counteract the effects quickly). In my 35 years of teaching aromatherapy to midwives, I have seen more adverse effects in the last ten years than in the 25 years before, suggesting either that, for some reason, people are more sensitive to aromas and chemicals, perhaps due to their individual susceptibility, or their health status, especially with the massive over-use of chemicals in general. I have observed some serious effects on midwives exposed to essential oils of orange (often occurring in those with a known allergy to citrus fruit such as oranges and grapefruit, or to grass seed), rose and geranium (which share some similar chemicals known to affect some people adversely) and clary sage (from both a direct allergy and, more often, from over-use in labour). Effects include skin irritation, even when inhaled, nausea or hay fever or asthma attacks. This latter is not necessarily through exposure to a direct respiratory allergen such as pollen (which does not occur in fragrances and essential oils), but more commonly from a psychosomatic memory effect from previous inhalation of flowers such as lavender, ylang ylang and chamomile. I have personally had some negative experiences from inhalation of aromas, both in my own work using essential oils for many years and in shops selling scented candles.
Whilst many fragrances are pleasant and uplifting, at the very least, others will be disliked by some people. It may be acceptable to brew coffee when trying to sell a house, but I have to question the ethics of increasingly using scents to promote commercial sales, whether in the travel industry or elsewhere. I am particularly concerned to read in this article that some airlines are using fragrances which contain common allergens, such as rose and citrus oils. I challenge airlines to consider the legality of exposing everyone going through the airport lounges and ask whether they have policies in place to deal with anyone who develops an allergic reaction, which could be severe, when inhaling aromas to which they have a known allergy.
The problem with aromas is that, in general, people like them and fail to understand the way in which the chemicals in the oils can affect individuals. Many years ago, when I first trained in aromatherapy, there was a trend in some American hospitals to diffuse aromas in the medical wards - for example, an uplifting, calming oil in the reception area, stimulating oils in the mornings and relaxing and sedating oils in the evenings, while Japanese factories in the 1980s pumped oils such as lemon through the ventilation system, to increase productivity. Sadly also, despite many years trying to educate midwives about the risks as well as the benefits of aromatherapy, there are many maternity units and birth centres today that injudiciously diffuse essential oils in public areas where numerous expectant and birthing parents, their babies and visitors, as well as all the staff are repeatedly exposed to their chemicals.
Within any institutional settings - such as hospitals and other areas where the general public pass through and staff work - blindly using fragrances contravenes the UK Health and Safety at Work act and the Control of Substances Hazardous to Health (COSHH) regulations. This is not ethical, nor is it safe. It is an accident waiting to happen - both in the airlines and other commercial settings and in the health services.
Recently Denise met some of her Licensed Consultancy midwives at our monthly online problem-solving networking meeting. Some were already in business, having completed Expectancy’s Diploma and business training, others had taken a break during the pandemic and were getting back on track with their business planning and some were just completing their academic studies and preparing end-of-year assignments. We discussed how to promote our private practices – and what not to do. One of the group had reported last month on how “well” she was doing, drawing pregnant clients in for complementary therapy treatments – but at a knock-down price. After some discussion and reflection she went back to the drawing board and formalised her pricing structure. This resulted in her increasing her prices to an appropriate level, which meant that prospective clients valued her services more – and she was able to value herself more too. This is an important concept to get to grips with in business – if you don’t value yourself, your clients won’t value you or your services.
Recently, Denise had a busy day teaching student midwives. The first session was for students at the University of Bournemouth. This was a general introduction to complementary therapies in midwifery practice with a focus on aromatherapy, as part of the students’ medicines management module. She then rushed to the University of Greenwich for a session with students taking the labour care module, exploring aromatherapy, reflexology, acupressure and hypnosis for birth preparation and techniques for aiding labour progress and easing discomforts and anxiety.
Denise says: it was lovely to be with so many of the students, both online and face to face, and to offer them an introduction to the vast specialism that is midwifery complementary medicine. As always, many students were shocked by the issues they need to consider when advising parents on natural remedies or when midwives want to implement aromatherapy and other therapies in their practice. We particularly considered the fact that essential oils, which work in exactly the same way as drugs, must also be used along the same lines as medicines. Expectant and birthing parents wanting to use aromatherapy oils should be assessed to ensure it is safe for them to do so and observed for any side effects that may occur; blends must be individualised and confined solely to that individual – no wafting aroma vapours along the corridor and no diffusers in public areas. Aromatherapy treatment must be evaluated and recorded in the notes together with any specific aftercare advice given. In accordance with the post-Brexit Cosmetics Regulations 2020, oil blends cannot be given to parents for home use unless this first consultation and treatment has been undertaken by the same midwife.
Denise was in Norwich again this week running some self care sessions for the midwives, students and support workers.
It’s so important for maternity staff to look after themselves - as they say on the airlines - please attach your own oxygen mask before helping others.
If maternity workers are stressed and tired that’s passed on to expectant and birthing parents. Congratulations to Head of Midwifery, Stephanie Pease for thanking the hard working staff and giving them some Me Time.
Here, Denise explores issues raised at the University of Surrey's Midwifery Society conference on Friday, which focused on diversity issues in perinatal care.
This student midwife conference handled a topical, sensitive subject well and provoked much discussion. Sessions on race, LBGTQIA+, disability, asylum seekers and other groups who experience discrimination during pregnancy and birth were not always easy listening but certainly caused a degree of personal reflection. Each speaker was passionate about their topic, being representative of the group about which they were speaking and able to recount their lived experiences.
There was a lot of emphasis on midwives using the "right" language and how we may inadvertently use words which could offend or upset people who do not fit into the "normal" mould (whatever that might be). A humorous but moving account was given by Diana, a Bolivian asylum seeker who only spoke Spanish, of her time in labour.An English midwife, trying to be kind, kept giving her hot chocolate to drink. Diana, trying to be polite and not sure how to decline it, would drink the hot chocolate even though she didn't like it. The midwife, assuming that Diana had enjoyed it, kept offering here more - and Diana's overriding memory of her labour in a UK maternity unit is one of hot chocolate which she now hates.
However, it was the final speaker who summed up the nub of all the issues. Abina Brown spoke about "birthing outside guidelines" and how maternity professionals "deal" with parents who choose to go against convention. Surely our role as midwives is to guide each parent through their childbearing experience irrespective of which category they best "fit". Whether we are giving dietary advice to people from another culture, asking transgender women what pronoun they wish us to use or how to communicate compassionately with a non English speaking asylum seeker, there are two fundamental issues here: understanding and individualisation.
Guidelines are NOT in the interests of the individual parent. They are not even there to protect the midwife.Guidelines are devised to protect the institution (the NHS), save money and avoid litigation - and sometimes do more harm than good for parents. Take, for example, the guideline on induction of labour in postdates pregnancy - the attitude that refusing induction may kill a baby is a powerful form of coercion for all, except the most assertive parents (who are then viewed as "difficult patients").
It is, however, easy to act in ways which others may view as discriminatory. How many midwives make assumptions about women who don't fit the traditional mould? Many will have heard colleagues say (or said it themselves) things like "oh she's got red hair, she will be more at risk of a postpartum haemorrhage"? Our assumptions affect our behaviour - about women who are obese, requesting a home birth after previous Caesarean or who are from the traveller community. We can discriminate in ways we don't realise because midwives are part of a society that takes a negative view towards those who are not the same as us. Other examples of negativity towards our clients are parents who choose unassisted birth against our advice, those who have ten children and are pregnant again, women who want to birth in the woods with whale music playing - anyone who sits outside our own view of what is "normal"
Yes, we need more education to understand people whose culture, race, language, sexuality or identity we do not understand, but more than that, we need to return to the basic tenets of being a midwife - to learn to care for the INDIVIDUAL. This has definitely been lost from midwifery education and practice because we are too busy form filling and trying to avoid litigation. Independent midwives have never had a problem.in caring for anyone who is "different" because every parent is seen as an individual with their own set of beliefs, needs and desires for the birth of their baby. Let's get back to true midwifery, forget the guidelines and care for each pregnant and birthing parent as an individual.
One of the biggest advantages of offering complementary therapies in private practice is that clients are given the time they need.
In some respects, it almost doesn't matter which therapy is used - it is the overall experience of having someone to talk to, who can explain things and answer questions, who they can come to know and be assured that they will see again next time.
Let us embrace the value of complementary therapies in helping expectant parents to cope with pregnancy and even to enjoy it as they prepare to bring new life into the world.
Denise has been seeing a lot of posts on Social media recently from students offering their used midwifery textbooks for sale at the end of their training. Here she explores the issues around academic reading and keeping up to date.
It’s that time of year when students are coming towards the end of their three year pre-registration midwifery programmes – and when those about to start midwifery training excitedly start preparing. Part of this preparation is thinking about which textbooks to buy. The two traditional UK midwifery texts are Myles’ Textbook for Midwifery and Mayes’ Midwifery, to both of which I have contributed chapters on complementary therapies on many occasions over the various editions. Another staple is Bailliere’s Midwives’ Dictionary, which I have edited every three years since 1997 and have just finished the 14th edition (Tiran, Redford 2022). However, there is such huge diversity within the modern midwifery profession, including obstetrics, physiology, psychology, sociology, research methods, obstetric emergencies and many contemporary issues, that there is a dizzying selection of textbooks, some of which cost up to £50 or more.
It is therefore understandable that students who have purchased their own copies may want to sell them on to incoming students. However, I am concerned that some books posted for sale on social media are extremely old and have been replaced with more recent editions. I recently saw a copy of the 11th edition of the Bailliere’s Midwives’ Dictionary (2009) for sale at £10, only marginally less than the latest edition which contains many new terms and more socially acceptable definitions. Another student was selling a 2011 copy of Obstetrics by Ten Teachers, despite it having been updated six years later. Some of the books are so old that they could be kept as historical texts - and prove very interesting to compare practice years ago with how it has evolved today.
However, whilst some books remain useful for new learners, many become out of date quickly. Remember that a newly published book is often already 18 months old or more by the time it is available for sale, since the writing of it and the publication process take considerable time. My advice to incoming student midwives (despite being an author wanting you to buy my books!) is just to buy one recent comprehensive textbook (either Myles’ or Mayes’) and the dictionary – and then wait to see what is available in the university library. You may develop an interest in a specific aspect of midwifery such as breast feeding, genital mutilation, genetics or complementary therapies, in which case you can look for the most recent academic textbooks on those specialisms. You could consider sharing books with a group of colleagues to enable you all to access both general midwifery and specialist texts. You could ask for Christmas or birthday presents for those you feel you would like to own. You may find cheaper versions of some books as digital copies. Bear in mind that many of the books you purchase for your own course will be out of date by the time you qualify and may not, therefore, be suitable for students coming along after you.
Books are wonderful, especially when you own a pristine hard copy, but it is essential to keep up to date. Not only could you lose assignment marks by referring to an old edition, it could also mean you are not up to date in your practice.
If you are lucky enough to own a previous edition, especially one that is more than 20 years old, keep it for posterity, but make sure your theory and practice are based on the most up to date editions.
The beautiful blue flowers are sometimes added to cocktails. More importantly, borage contains significantly more gamma linolenic acids, one of the primary therapeutic constituents, than evening primrose oil.
Both EPO and borage are traditional remedies to start labour although evidence for effectiveness is limited.
Care should be taken with borage as it can cause liver toxicity in some.
Z is for ZuSanLi, an acupuncture point also called Stomach 36. It is situated about four finger-widths below the bottom edge of the kneecap, between the two bones of the lower leg. In pregnancy it can relieve nausea, constipation, carpal tunnel syndrome, anxiety and aid birth preparation. It is useful for aiding progress in labour and postnatal recovery. Stomach 36 is one of the 15 points taught on Expectancy’s Certificate in Midwifery Acupuncture programme – we are now recruiting for September.
Y is for ylang ylang, (Cananga odorata), a wonderfully relaxing essential oil that is safe to use in pregnancy and birth. It can have strong sedative effects so should not be used for too long, and midwives caring for parents in labour who wish to use it should take regular breaks and keep hydrated to ensure they are alert enough to make clinical decisions (and drive).
It is very good for postnatal blues but caution is urged if there is a history of diagnosed clinical depression, as the effects can be so deep that the emotions can almost be pushed inwards, compounding the problem. The aroma is deep and floral but can be heavy and cloying for some people so use in small doses and for short periods of time.
In the home, ylang ylang should not be used near neonates, elderly relatives or animals (it is toxic to cats and dogs).
X is for X-rays – one of the sources of energy that can inactivate homeopathic remedies. Since homeopathic medicines are chemically very fragile, they can be easily inactivated by X-rays, mobile ‘phones, televisions and microwaves. Never store your homeopathic arnica and other remedies near electrical sources in the home – and take care when passing through the airport if you have homeopathic jetlag remedies with you.
W is for witch hazel, a common herbal remedy used for perineal healing after birth. However, witch hazel should not be used on an inflamed or infected wound. It can be useful for haemorrhoids after birth as it has an astringent effect, causing vasoconstriction, although the research evidence is poor. Witch hazel should not be taken orally.
V is for Vitex agnus castus - This herbal remedy, also called chaste berry, is a popular remedy for menopausal problems and is also used for infertility treatments. However, it should not be self-administered orally in the preconception period, pregnancy and when breast feeding, unless on the advice of a qualified medical herbalist. There is some suggestion that the plant hormones may compromise implantation of the embryo in early pregnancy. These also increase dopamine activity which blocks the production of prolactin, so it may affect lactation. Topical use of the cream appears safe.
Denise has been in Glasgow this week for various meetings. Flying from Heathrow, she reflected on the pre-flight safety briefing, including what to do in the event of reduced oxygen in the cabin, and related this to our work as midwives providing care for expectant and birthing parents. She says:
Midwives work incredibly hard in difficult circumstances, with inadequate staffing and long hours, often without time for a break, even a drink or visit to the toilet. Yet how can we expect to care for families if we are not fit, healthy and refreshed ourselves? Midwives become dehydrated, ketotic and exhausted which leaves them in no fit state to care for people. Put this in the context of the institution for which they work, with its dependence on risk avoidance and the pressures of an immensely punitive culture, and the stress on midwives and other maternity care providers is immense..It is hardly surprising that midwives are leaving the NHS in droves.
Isn't it about time we started looking after ourselves first? We need to praise and thank the midwifery workforce, not bully them into being a mechanistic corporate set of hands blindly doing the job. We.need to facilitate midwives and support workers to give mindful care that not only helps service users but also leaves service providers feeling fulfilled and valued.
One NHS trust has recently asked me to provide a series of half day relaxation events for its staff, to thank them for their efforts and to give them something back to show that they are, indeed, valued. Engaging in some rostered "me time", with relaxation to music, massage and time to chat over a cup of tea and cake can do wonders to boost morale. Offering a metaphorical "oxygen mask" goes some.way towards helping midwives and support workers feel appreciated and to revitalise them so they are in a better state to provide quality and caring support to parents and babies.
Denise recently interviewed a midwife for our Diploma who had just completed a Master's in Business Administration (MBA). Discussion turned to some of the issues plaguing the NHS and her insight into midwives’ lack of knowledge of the business of maternity care. Denise reflects on her conversation:
Midwives seem to have little concept of how the NHS works or how much everything costs.
For example, the difference in cost between a spontaneous vaginal birth and a Caesarean section is around £2000; an epidural costs at least £850; even the comparative pennies needed for a urine sample bottle or a pack of gauze swabs add up to a multibillion pound NHS.
A trial was done some years ago in a London surgical ward in which the prices of NHS equipment were listed on cupboard doors. Increased awareness of the nurses led to more mindful use, less wastage and considerable cost savings. I find it fascinating when teaching business studies to the midwives preparing to set up their own private practices via our Licensed Consultancy scheme to hear their views on money - costs, pricing and savings. One midwife recently told me she would be charging just £35 for an hour's complementary therapy treatment in her private practice. This was way below the average price of a pregnancy massage in her area. Further, she had not considered the money she had already spent to get to the point of starting her business - training and experience, NMC registration and revalidation, insurances, equipment and the costs of starting and running her business. She was, in effect, giving her services free of charge - and actually paying to provide them. It is interesting that independent midwives do not have the same reticence talking about their fees as midwives working solely in the NHS.
Asking people to pay for their services is not a problem. Indeed, it is the only way an independent midwife is paid. NHS midwives do not give their time free of charge – so why is there such a negative feeling about asking expectant parents - who have consciously chosen a private option – to pay the fees for services provided? No one would expect to go to the hairdresser or massage therapist without paying for their expert services – so why do we have a mindset that finds talking about “money” distasteful?. I believe that midwifery and all healthcare pre-registration programmes should include a mandatory module on the business of healthcare.
If NHS staff understood how much everything costs, there would be less wastage and savings would contribute to a more balanced use of NHS limited budgets. For midwives going into private practice, it would be wise to study business matters before commencing to avoid costly mistakes – professional and legal as well as financial.
A greater understanding of the business of maternity care would contribute to a more successful business.
U is for uterus. In foot reflexology the point for the uterus is on the inside of the heel. Many people think it's acceptable to massage this area to stimulate contractions, but it's not. Uterine contractions start in the pituitary gland so to aid labour requires stimulation of the reflex points for the anterior and posterior pituitary gland on the side of the big toes. Over-stimulating the uterus reflex points on the heels can disrupt labour physiology and, in extreme circumstances, may even cause placental separation and bleeding.
T is for “Therapy shopping”. Some people, when desperate to resolve a problem, try every complementary therapy they can find, in what is often called “therapy shopping”. It is not helpful to use several different therapies or natural remedies together as this can “confuse” physiology and often make things worse.
Expectant parents desperate to avoid an induction of labour may do this, trying all the herbal remedies they can think of, including clary sage, raspberry leaf, castor oil, as well as eating pineapple, dates and mangoes and consulting a reflexologist, acupuncturist and/or aromatherapist. Midwives and doulas should encourage parents to try just one thing at a time (although don’t leave raspberry leaf until term) unless under the direction of a fully qualified practitioner of complementary therapy who can balance the combination safely.
S is fo r syntocinon. If expectant parents need intravenous oxytocin they must not use oils or herbal remedies with similar effects. This includes clary sage, jasmine, rose, cinnamon and nutmeg oils, raspberry leaf, evening primrose, black and cohosh other herbal remedies.
Care should also be taken when vaginal pessaries of prostin are used to start labour especially if the woman is at home.
R is for raspberry leaf tea, a popular herbal remedy to time the uterine muscle in readiness for labour. If appropriate, it can be taken during the third trimester, gradually increasing to about 3-4 cups a day, then gradually reduced in the first two weeks after the birth. Raspberry leaf is not a means of starting labour - suddenly commencing it at term may lead to excessive contractions and possibly fetal distress.
Q is for quiet. Never underestimate the value of silence during a birth or when providing complementary therapies in pregnancy or after the birth. Music can be useful sometimes but there's a lot of psychology relating to using the right type of music. Quiet allows the birthing family to go into their own zone, to tune out the extraneous noises of the world and to focus inwardly in preparation for their new arrival.
P is for the Pericardium 6 (P6) acupuncture point, which is a useful point to combat nausea in pregnancy or labour or after Caesarean. Pressure can be applied with the thumbs or fingers, or a wristband can be worn; tiny press studs can also be taped to the point, which are almost unnoticeable. To find the P6 point measure three finger widths up the inside of the arm from the wrist crease - approximately where the buckle of a wristwatch might be. The point is found as a small dip between the tendons.
An interesting study has emerged from Australia and New Zealand about the ways in which information is disseminated and practice is influenced for acupuncturists involved in women's health. Here Denise explores the wider implications of the findings.
Acupuncture is a very popular adjunct to women's health, notably in the areas of fertility and pregnancy. It is perhaps even more popular in Australasia than the UK and USA although acupuncture is one of the most well accepted of all complementary therapies. This may be due to the level of training required, which is almost exclusively at graduate and postgraduate level. It may be because acupuncture is better regarded by conventional medical practitioners than other, more supportive therapies such a massage, and indeed is used by some anaesthetists as a means of pain control. Acupuncture is also very well researched, although this study suggests that practice is defined less by the evidence and more by collaborative information-sharing from conferences and other educational opportunities.
Referrals for acupuncture prior to and during pregnancy generally come from prospective clients, with some from doctors. However, there is a need for much greater awareness amongst conventional healthcare professionals of the benefits and effectiveness of acupuncture.
Midwives and obstetricians in particular should be better informed about the potential of acupuncture to resolve issues such as subfertility, and severe pregnancy back pain, sickness or breech presentation. Dealing with these issues by offering acupuncture treatment would reduce the complications and associated cascade of intervention that they bring. This in turn would save money for the health services and improve parental satisfaction and wellbeing.
At the very least, midwives and obstetricians should receive an introduction to the concept, effectiveness and evidence base of acupuncture during their pre-registration education, to increase their awareness and understanding of the therapy. Further, for those midwives with a special interest, being able to introduce an acupuncture service into their practice or place of work would further facilitate an improvement in care for those expectant parents suffering prolonged and intractable pregnancy symptoms which can impact on the progress and enjoyment of their whole pregnancy.
Denise recently read an article in which the use of essential oils was debated as a possible adjunct to restorative clinical supervision by professional midwifery advocates (PMAs). The author, a midwifery lecturer, rightly addresses aromatherapy safety issues but concludes that NHS trusts could consider the use of diffusers to assist in boosting staff mental wellbeing, especially as part of restorative clinical supervision (RCS). Here Denise expresses some concerns about the concept.
Essential oils can be relaxing and ease the symptoms (but not the causes) of stress when used appropriately, but I have grave concerns about PMAs advocating the use of diffusers within RCS sessions. It is not the role of the PMA to address health issues of midwives, merely to recognise them and refer on to the relevant sources of help.
When midwives are trained to use essential oils for expectant and birthing parents, they learn only a minimal aspect of the vast profession of aromatherapy and do not have the knowledge or skills to help non-pregnant staff. Even using essential oils for relaxation needs to be done in accordance with a complete assessment of the intended recipient, acknowledgement of physiological allergies and psychological odour memory and preferences. Indeed, there could be an insurance issue here in the event of any untoward adverse reactions, not only of the individual midwife undergoing RCS but also any other midwife affected. Further, the use of diffusers in these RCS sessions contravenes the Health and Safety at Work Act 1974 and the Control of Substances Hazardous to Health regulations, which require employers and employees to minimise the risks of chemicals in the workplace. I find it worrying in the extreme that this message is not getting across to midwives and that the author suggests the need for research into diffuser use within RCS.
Research on effectiveness of any complementary therapy should be preceded by understanding fully the safety issues to ensure that aromatherapy in general, and specific oils in particular, are safe: no single oil is safe for everyone. Using oils in rooms which may later be used by other staff (or parents) risks exposing them to the risks of aromatherapy – in which case the NHS trust managers could be liable for any adverse effects on individuals by having permitted the oils to be used in this way.
O is for orange essential oil. Sweet orange oil and other citrus oils such as tangerine, mandarin, lime or grapefruit, are gentle oils to use in pregnancy, birth and the postnatal period. They're uplifting, good for emotional distress and effective for constipation.
Always check before use in case the mother or any other person present ( including the person administering it) has an allergy to citrus fruit - in which case it should be avoided.
N is for natural remedies, which should be used with extreme care in pregnancy. Just because they are natural does not mean they are always safe.
Many herbal remedies such as St John's wort, should be avoided in pregnancy and SJW should never used together with antidepressants. Homeopathic remedies don't act like drugs - they do not work chemically but work energetically (according to physics) and should also be used carefully - using the wrong remedy or using the right remedy for too long can cause an increase in symptoms rather than resolving them.
M is for massage, a simple tool for midwives and doulas to use during labour. The power of touch is enormous. Physically, massage can stimulate circulation and encourage the woman''s body to work efficiently. It can ease pain through the gate control mechanism - touch impulses reach the brain quicker than pain impulses. Emotionally, massage adds to the sense of nurturing that is so powerful during labour and birth.
Currently travelling in South Africa, Denise reflects on the power of the sun to raise the spirit and heal the body and mind.
It's been three long years since I've been able to visit South Africa and I'd almost forgotten how hot it can get, even at the end of the summer. I've noticed, however, how happy everyone is here, even in the cities, and certainly in the rural areas. I'm convinced this is due to the sunshine and warmth, the open air lifestyle and the space around us.
Getting a good dose of vitamin D positively impacts on our mental health, making us feel uplifted. The beaches and forests play their part allowing us to breathe deeply of the clean air; the sounds of birds are not overwhelmed by excessive traffic noise; the taste of fresh, locally sourced food (and the occasional glass of good South African wine!) nourishes the body - and taking time to relax over meals aids digestion.
Holidays are good for mind and spirit, healing us from within and without. They give us time to talk to loved ones, to share experiences with family and friends and to reflect on life. Taking a holiday, even for a short time, is therapeutic and re-energising - the ultimate complementary therapy!
Currently staying with her son in South Africa, Denise has been able to reconnect with a friend she hasn't seen for almost 30 years. Christine Lynne Stormer-Fryer was a health visitor in the early 1980s when Denise was a community midwife in Surrey (she actually introduced Denise to her husband!) On emigrating, Chris, who had trained in reflexology, opened the Reflexology Academy of Southern Africa and became a world-renowned presenter on her particular type of reflex therapy. Although the Academy is long gone, Chris's unique style of presentation and writing continues.
As is the way with old friends, gifts were exchanged - Denise gave a copy of her Using Natural Remedies Safely in Pregnancy book, and Chris gave her two self-published reflexology books. Chris's Hot-Footing It to Health is a fascinating read. Much more spiritual than Denise's scientific clinical approach, it is nevertheless a supportive text for practitioners and gives an insight to its approach for those receiving reflexology. Chris's way with words leads her to unlock language and give it new meaning, for example "Feet, being the platforms on which the body takes a stand, provide a remarkable understanding as to the 'ins and outs' of what it is to be human".
This is not a book about the practice of reflexology, and does not focus on any particular style, neither traditional European nor eastern meridian therapy, and certainly not clinical reflex zone therapy as taught by Expectancy. It explores the concept and philosophy of an ancient healing art and attempts to set it in the context of modern life. It contains a collection of sound bites - or, as Chris herself might say, "foot notes" to aid reflection on the purpose of reflexology in restoring and maintaining health and wellbeing.
Despite their reunion being short, Denise and Chris had a lovely morning and intend to keep in touch better. If you'd like to buy Chris's book the ISBN number is 9781986332064.
L is for laminaria, a type of seaweed has traditionally been used to open the cervix for termination of pregnancy and to aid cervical ripening in postdates pregnancy, as well as to help the insertion of radium in cancer patients. When inserted as a “tent” into the opening of the cervix, the gel within the leaves becomes wet it swells to help dilatation (it is a precursor of the intracervical rods currently in use in some maternity units. However, laminaria may cause infection or uterine bleeding and is no longer used medically. It should not be taken orally as it contains high levels of iron and arsenic, which may be toxic.
K is for Kidney, an acupressure point on the sole of the foot which is an excellent relaxation point.
It is also used for relaxation in reflexology, and is thought to correspond to the solar / coeliac plexus where people feel “butterflies” when anxious. Gentle pressure applied to this point on both feet can be very relaxing especially during labour or when a woman is waiting to have a Caesarean section.
J is for juniper berry essential oil which is contraindicated in pregnancy. It contains chemicals which be harmful to the developing baby and which may affect renal perfusion especially through the maternal kidneys. Many essential oils should be avoided in pregnancy - if in doubt, avoid using them.
Expectant parents wishing to avoid induction can be helped with an effective package of complementary therapies including acupressure, aromatherapy, massage and reflex zone therapy. Some maternity units are now using this Expectancy package to reduce significantly their induction rates. If you'd like a course for midwives in your unit, please contact email@example.com
A powerful clinical tool to help parents prepare for the birth and to overcome their fears and anxieties. It can also be effective for smoking cessation in pregnancy. Expectancy now offers midwives a programme in midwifery clinical hypnosis with the option to progress to a full hypnotherapy qualification. Contact firstname.lastname@example.org for more information.
Commonly used to combat sickness in pregnancy. Ginger biscuits are not the answer as there's too much sugar (which can make sickness worse) and not enough ginger to be effective. Ginger tea made from grated root ginger is best, sipped throughout the day. Ginger essential oil should not be used in pregnancy as it may trigger uterine contractions.
Teaching a group of midwives recently, Denise was disappointed to see, during the practical work, one of the midwives flicking through her mobile 'phone whilst receiving foot massage from another midwife. When asked to put her 'phone to one side, she said it helped her relax. She challenged Denise, stating that young women like to use their 'phones all the time and might want to do so during a massage, without any understanding of why this is inappropriate.
First, being on her 'phone whilst having the massage was disrespectful and certainly did not enable her to appreciate the power of relaxation from her own experience. Her attitude was that her partner had access to her feet to practise but she could not relate this to what she could apply to her midwifery practice. She did not recognise the opportunity for social interaction that comes from an expectant parent being face to face with a midwife whilst enjoying some "me" time. It's amazing what women talk about during foot massage (or reflexology) that they don't discuss during a normal antenatal appointment - this has been shown in research.
More importantly, a mobile 'phone is a source of energy (heat) that interferes with hormonal energy. It's been proven that men who carry mobile 'phones in their trouser pockets may have reduced fertility because the constant heat near the scrotum interferes with sperm production. Similarly, this heat exacerbates the stress hormone, cortisol, and adds to, rather than reduces, internal stress levels. Given that stress contributes to disturbances in the pregnancy and may cause either preterm or delayed onset of labour, it stands to reason that expectant parents should be encouraged to use them less, and at the very least, to enter into the spirit of relaxation that comes from having a massage.
When expectant parents are offered complementary therapies, they must understand that it requires them to work in partnership with the practitioner. This includes agreeing to comply with the aftercare advice such as increasing fluid intake and avoiding toxins eg coffee and alcohol. It also means that those who refuse to put down their mobile 'phones should be informed that they cannot receive masage, reflexology or other therapies (homeopathy, for example, is inactivated by the heat from mobiles, TVs and microwaves). And for midwives, it requires a commitment to what they are learning and how the experience of receiving massage can contribute to that learning.
Or perhaps fear of the maternity services, fear of being left alone during labour or fear of being coerced into accepting something expectant parents don't want.
Clinical hypnosis can be very effective at helping women face their fears and is individualized to each woman to help her overcome them.
A remedy used in some African countries to prepare for and ease the birth process.
Any type of dancing can boost the feel-good endorphins and reduce stress hormones.
Belly dancing is particularly popular and helps to allow some give in the pelvic brim in preparation for birth, and encourages the baby to settle into an optimum position for birth.
C is for chiropractic, a statutorily regulated profession supplementary to hea!thcare.
One of the most used medical therapies in the world, chiropractic is similar to osteopathy but uses different techniques to realign deviations in the musculoskeletal system caused by injury, disease or genetics. In pregnancy, it is effective not only for backache, sciatica and other bone and muscle issues but can also help to turn a breech baby to head first and relieve heartburn and indigestion.
B is for backache in pregnancy, caused by the effects of progesterone and relaxin on the musculoskeletal system. It's often accompanied by sciatica and pelvic and groin pain.
Osteopathy or chiropractic are probably the most effective therapies, but massage, aromatherapy or reflexology may bring some temporary relief. Acupuncture can also help.
A is for Acupuncture - a credible, well researched therapy that is effective in treating many pregnancy issues including sub-fertility, sickness, backache, headache, constipation and carpal tunnel syndrome.
It can be used for postdates pregnancy, slow latent phase, pain relief in labour and retained placenta.
Denise says: Valerian tea can be helpful for insomnia but there is conflicting advice about whether it is safe in pregnancy and a few studies suggest it may reduce the level of zinc in the fetal brain. It is generally felt that expectant parents should avoid taking valerian. It can cause drowsiness and interact with sedative and antidepressant drugs and certain herbs such as Sr Johns' wort (another herb that should be avoided in pregnancy). In non-pregnant people, valerian should not be taken regularly for more than six weeks as it can lead to liver toxicity; suddenly stopping it after a prolonged period of time can cause palpitations and hallucinations.
For the third year running Denise has had to teach aromatherapy to midwives and therapists in Japan as an online course.
Having been teaching in Japan for over 20 years she misses visiting - but is hoping next year will be different. This last weekend she was up all night teaching because of the 9 hour time difference!
The pandemic has affected maternity care badly in Japan with women still having to wear masks in labour and are unable to have their partners with them.
There is also a notably increased rate of suicide amongst expectant and new mothers.
The public is however is far more compliant with wearing masks, self-isolating and accepting vaccinations.
Homeopathic arnica is a useful remedy to relieve bruising and trauma after birth, but did you know it should not be taken preventatively before any bruising has occurred?
Arnica tablets can be commenced immediately after the birth, the dose depending on the severity of the trauma - so a higher dose would be needed after a Caesarean than after a spontaneous vaginal birth.
Taking too high a dose, or taking it for more than four days can lead to a "reverse proving" in which it may actually cause further bruising.
The Midwives’ journal of the RCM reported on a recent OpenDemocracy survey of 7000 members of the public and 500 NHS staff, which found around 40% of patients (all clinical specialisms) feeling dissatisfied with their NHS options, notably long waiting times for appointments and surgery.
Around half of these had been advised to consider private treatment by NHS staff who were concerned about the adverse effects of waiting on people’s health.
Whilst there are huge concerns about the state of the NHS, we must remember that people do have choices. In maternity care, this includes the option to consult private midwives or obstetricians, and to seek supportive services such as complementary therapies and birth preparation classes in the private sector.
Indeed, an increasing number of midwives are working part-time in the NHS and part-time offering private services to support expectant parents – enhanced postnatal care, tongue-tie division, lactation support and much more. In some countries, such as Iceland, it is standard for midwives to be paid by the state for essential services including antenatal and birth care, but for expectant parents to pay for supporting services such as antenatal education, acupuncture and some aspects of postnatal care, which are provided by the same midwives they see for their pregnancy and birth care. In a profession that advocates choice for parents, it seems contrary to the philosophy not to accept the fact that some parents may wish to pay for additional support.
Nausea and vomiting is pregnancy is usually attributed to hormonal upheaval but there is also a correlation with back or neck problems. Misalignment of the spine and musculoskeletal system can put tension on various organs, making hormonal sickness much worse.
A history of whiplash injury is particularly significant as it puts strain on the vomiting centre in the brain, increasing symptoms. Osteopathy or chiropractic can help correct the neck problem.
Denise also uses a dynamic technique adapted from reflex zone therapy (the type of reflexology taught by Expectancy) to release the neck tension - like osteopathy via the feet.
Call the Midwife's use of Leeches - the ultimate alternative medicine.
Watching Call the Midwife on Christmas Day, Denise was reminded of her student nurse days at St Bartholomew's Hospital, London, in the mid-1970s when leeches were used to remove excess blood from bruises. She says:
I was a student nurse on Casualty when leeches were re-introduced. Of course,.we.thought it was a bit gross but once both the patients and the staff had overcome their qualms about having live animals attached to the body, we realised how successful a treatment they were for large haematomas (bruises). They were initially used on the medical students who had sustained black eyes and "cauliflower ears" playing rugby - and they were the most squeamish of all. I seem to remember there was a small trial being conducted (research studies were not as common as they are today) - so everyone was fascinated. Leeches are still in use in many parts of the world as an alternative to more invasive medical procedures. I'm not sure how I feel about using them for bruising of the buttocks after birth though - that might be a step too far to have leeches attached to your bottom whilst trying to feed the baby!
Clary sage (Salvia sclarea) contains certain chemicals that make it unsafe for expectant parents prior to term (37 weeks of pregnancy). It is often used to start labour although caution should be used as it can cause excessively strong contractions leading to fetal distress. It is also used by many midwives for pain relief in labour although it should not be seen as a panacea for everything in labour. Prolonged or excessive use in established labour can also cause contractions that are initially too strong but if the clary sage is continued beyond this point it will eventually have the opposite effect, causing the contractions to peter out. Care should also be taken in the postnatal period and clary sage should not be used is there are any retained products of conception or heavy bleeding with large clots as it could precipitate a major haemorrhage. Clary sage is a useful oil in maternity care but should always be used with caution.
Denise has recently discovered that the Royal College of Midwives will no longer be accrediting courses from external organisations from 2022. She says:
This news is disappointing because Expectancy’s courses have been accredited for midwives’ continuing professional development (CPD) by the RCM for over a decade. However, this information has caused me to reflect on the purpose of having courses accredited by a professional or academic organisation. We also discussed it on one of our online problem-solving sessions with our Licensed Consultants, to debate what midwives want in terms of CPD, a requirement of maintaining up to date and contemporary midwifery practice.
Accreditation aspires to provide a kitemark of quality so that prospective participants can be assured that the course is appropriate for their needs. Pre-registration midwifery programmes undergo rigorous examination by both a higher education institution (university) and the Nursing and Midwifery Council (NMC) and must demonstrate an appropriate professional and academic standard that complies with national and international requirements for midwifery registration. In terms of postgraduate education, courses must be fully applicable to the role of the midwife but do not necessarily have to be of a particular academic standard. They may be one-day introductory courses or long academic programmes that complement the role of the midwife. They should always strive to help midwives keep up to date and enhance their skills, and knowledge so they can provide safe, effective, evidence-based care. Many courses have hitherto been accredited by the RCM or RCN, and occasionally also by universities. Expectancy’s Diploma was originally accredited by the University of Greenwich at a time when many midwives were upgrading from diploma to BSc level academic qualifications: our programme could be used as credit towards a BSc )Hons) degree in Professional Practice. Although it is not currently academically accredited, we retain some link with the university sector by having an Academic Conduct Officer who is a senior lecturer in two universities, whose job is to monitor Expectancy’s robust assessment processes and ensure parity with other academic organisations and equity for students.
However, when it comes to accreditation for complementary therapy education for midwives, most accrediting organisations are in uncharted waters because the specialism transcends two professional borders – midwifery and complementary therapies. Midwifery accrediting organisations cannot easily assess the validity of the complementary therapies content; conversely, complementary therapy organisations cannot monitor the calibre of the maternity elements (and in any case, only provide maternity-related courses as CPD for therapists who are not registered healthcare professionals). Applications for accreditation from the course provider are assessed by the accrediting body based on what is in the documents presented (very rarely is direct observation of a course included). The documentation requires explicit demonstration of course aims and outcomes applied to midwifery practice and an academic level commensurate with at least that required for pre-registration midwifery education (academic levels 4-6, or preferably higher for post-registration education, at levels 6 or 7). Applications must also demonstrate the credibility of the course providers, with at least one of the teachers / facilitators being required to be a midwife (and in the case of complementary therapies, teachers must have a full qualification in the relevant therapy).
This does not, however, mean that the course is “good”. The course may be enjoyable but in practice may have little relevance to contemporary midwifery practice. Usually this is not by inclusion but by omission, for example, not setting the subject in the context of NMC parameters, or not focusing on the legal and professional issues pertinent to midwifery practice. This is noticeable in many of the short courses available to midwives on subjects that generally sit outside standard practice, particularly complementary therapies. A course may be taught by a therapist (who may or may not have maternity experience) and – in order to obtain accreditation – facilitated by a midwife (who may or may not be qualified in the therapy). Courses may focus on the benefits and only include safety and risks in a very limited manner – perhaps because the perceived negativity of risk issues detracts from participants’ enjoyment of the therapy during practical work on the course. This approach does not adequately meet the requirements of the NMC Code 2018 which requires midwives to “maintain knowledge and skills required for safe practice” (6.2) and to “work within the limits of their competence” (13).
Whilst many midwives still adhere to studying only those courses which have been accredited by the RCM this will no longer be possible from 2022. So how can they be assured of the quality of a complementary therapy course? The NMC leaves this decision very much in the hands of inpidual registrants and it can be difficult to determine the credibility and appropriateness of a course. Complementary therapy courses for midwives must be taught by dual qualified midwives – they must be fully qualified in the therapy, qualified and insured to teach it and have had considerable experience of using the therapy within their own practice. They must be able to imbue in their students an understanding of both the benefits and the pitfalls of using the therapy for expectant and birthing parents, within the parameters outlined by the NMC and within the NHS and other institutional settings. The midwives with whom I discussed this issue were kind enough to point out the credibility of Expectancy’s courses based on my personal reputation from 40 years of experience of teaching complementary therapies at higher education level and a tenacious adherence to safe practice.
It’s up to you to decide whether the complementary therapy courses you attend are “adequate and appropriate” for use within your midwifery practice.
The incidence of allergies is increasing with everyday exposure to allergies and pollutants. Fragrance allergies and intolerances are common, although it is not known if this is allergy to the actual fragrance or to the chemicals within them.
Long Covid is being recognised for an ever-expanding list of unusual symptoms and alterations in the sense of smell is now well known. However, in addition to this and total loss of the sense of smell(anosmia) a new phenomenon is now being recognised - allergy to smells in general and in particular to chemical fragrances such as perfumes.
This poses the question of whether midwives and doulas offering aromatherapy should check if each pregnant or birthing parent has had Covid and particularly if they have long Covid. Anosmia does not mean that people are unaffected by the essential oil chemicals, and allergies to fragrances may, as yet, be unrecognised by the individual.
Midwives and doulas offering aromatherapy in pregnancy or birth should, as part of their standard assessment for suitability to receive aromatherapy, ask about the woman's Covid history, the presence of long Covid and the sense of smell. This should include asking about alterations, absence or hypersensitivity to smells and any reactions which might suggest existence or recent development of an allergy to perfumes, chemical vapours, cleaning products and other substances with fragrance such as aromatic candles, diffusers etc. In these situations it might be prudent to abstain from using aromatherapy for or near the parents.
Today, Denise discusses a strange phenomenon that can occur in pregnancy and how complementary therapies may help.
Excess salvation is a distressing symptom that occurs in pregnancy more than you might think. It's hormonal and often occurs with severe sickness - or the salvation itself triggers nausea - but the causes are not understood.
It appears to be most common in women of black origin, particularly those from West Africa, although no one knows why. It commonly resolves spontaneously towards the second trimester but may persist throughout pregnancy for an unlucky few. Some women produce up to two litres of saliva daily and need to keep spitting it out.
In addition to keeping the mouth clean, sipping water to keep hydrated and avoiding starchy foods which often make it worse, sucking limes of lemon may help. However homeopathic remedies can also be effective, but the most appropriate remedy depends on the symptoms:
Taking one 30c strength tablet three times daily for 3-4 days should help but if the symptoms are no better, 're-evaluate and try another remedy. It's important not just to keep taking the remedy for longer if it hasn't worked in a few days as it can have a reverse effect and make things worse.
Acupuncture or osteopathy may also be effective, and there have been reports of hypnotherapy improving the symptoms. These therapies will require consultation with a qualified practitioner if self-administration of homeopathic remedies brings no relief.
Martin Bromiley, an airline pilot, founded the Clinical Human Factors Group after the death of his wife from minor surgery, which was later found to be due to “human factors” including poor communication between individuals and departments. (See http://chfg.org/).
Bromiley asserts that safety is integral to compassionate care and cannot be separated from it. If maternity care is unsafe then it cannot claim to be compassionate. This applies equally to the use of complementary therapies in pregnancy and birth. Midwives justify their use of complementary therapies as enabling them to return to being “with woman”, offering relaxing and pleasant strategies to help women through pregnancy, birth and new motherhood.
They defend their practice by alleging that complementary therapies combat the negative, often unwanted and unwarranted interventions which are so prevalent in maternity care today. They use the misconception that complementary therapies are “safe” because they are “natural” as an argument to support their introduction into maternity care.
However, this unthinking and incorrect declaration is, in itself, unsafe, adherence to which risks the wellbeing of mothers and babies, and of staff. Where midwives have long-standing complementary therapy services in place, there is a risk of complacency which could threaten the safety – and thus the compassionate delivery - of the strategies provided.
Compassionate care should apply equally to the incorporation of complementary therapies within maternity care, especially since these “alternatives” are often required to justify themselves twice over in order to convince the sceptics that they are safe, effective, satisfying and cost-effective. Several maternity units are known to this author where, it could be argued, midwives no longer provide compassionate – or safe – complementary therapies to pregnant and childbearing women because there has been little, if any, on-going updating, evaluation or development. Adapted from Denise’s book Complementary Therapies in Maternity Care, an evidence-based approach 2018 (Singing Dragon).
Today, Denise has chosen to remind us all of the NMC Code in respect of requiring mandatory Covid vaccinations.
The government has decided that all NHS front line clinical staff must be fully vaccinated against Covid by spring of 2022. Of course, there are many who raise the ethical dilemma of effectively forcing all staff to submit to something they may not want - or risk losing their jobs. Then there will be those whose political opinions differ from the government’s and those who see this as one more step away from our democratic or human rights. All of these are issues for the individual and are not the point of my post today.
Healthcare workers have long been required to undergo occupational health assessments to ensure physical and mental fitness to practice. Midwives must be immune to rubella or agree to receive the rubella vaccination. Those exposed to blood products, including midwives using acupuncture in their practice must ensure they are immune to hepatitis B – or receive the vaccine in order to practice. increasingly midwives and nurses are required to have the annual influenza vaccination and others working in particular clinical fields may need to have vaccinations against tuberculosis, hepatitis A and other infectious diseases. Mandatory vaccinations to work in the healthcare professions are not new.
As registrants with the Nursing and Midwifery Council, we are all bound by The Code (2018) which directs nurses, midwives, health visitors and nursing associates towards safe, accountable practice. The NMC’s responsibility is to uphold the safety of the public and to ensure that its registrants are working within the guidelines on which professional healthcare workers should depend. We can apply many of the NMC Code’s clauses to this issue:
Finally, there are two other clauses in the NMC Code that relate directly to discussing this current issue on social media:
Individuals are, of course, entitled to their views on the issue of mandatory vaccinations. However, whilst we welcome your comments on the content of this post, we will immediately delete anything which contravenes these principles. Be Kind!
It's very alarming to see some Facebook pages or websites making suggestions for the use of complementary therapies (CTs) in pregnancy that are completely unsafe. Here Denise discusses when aromatherapy and reflexology should NOT be used in pregnancy and birth.
Complementary therapies offer midwives a range of additional choices to help expectant and birthing parents. Aromatherapy and reflexology can be very effective when used appropriately and cautiously. However it is very worrying that suggestions are often made for using CTs to help with medical or obstetric complications.There are certain situations when aromatherapy or reflexology should not be used at all in pregnancy and birth:
Liver disease or obstetric cholestasis - essentail oils are metabolized via the liver and may exacerbate any existing hepatic issues. Women taking prescribed medication for any major medical issue should also avoid using oils which may interact with the drugs. Reflexology can also compromise drug metabolism or impact on the liver if there is cholestasis or cirrhosis or other hepaticcondition - over-working the foot reflex zone for the liver can accelerate drug metabolism and reduce their effectiveness.
Other major medical conditions including cardiac disease, unstable or insulin-dependent diabetes, epilepsy, thrombosis or clotting disorders or severe thyroid problems - indeed, any condition requiring medication or that is compromised by the pregnancy.
We must remember that aromatherapy and reflexology are intended to complement rather than replace medical treatment. They can have serious adverse effects when used injudiciously by women with more complex pregnancies. Midwives and doulas offering therapies, or.discussing parents' self-administration should be alert to those situations when CTs are inappropriate and possibly even dangerous.
Further, CTs are generally less well accepted by medics and less well researched than obstetrics, but more importantly, less effective than proven medical treatments for major medical conditions. They do not replace medical treatment. Even when used simply for relaxation, they may do.more harm.than good.
Caution is the watch-word here - if in doubt, leave them.out!
Denise was concerned this morning to receive an email from a midwife stating that she has completed two days of aromatherapy training with Expectancy in 2013; she continues to use it in the NHS, and was wondering if she could now use it in private practice.
Denise says: It is really worrying when midwives believe that it is acceptable to continue including complementary therapies (CTs) in their midwifery care for years without any updating.
The Nursing and Midwifery Council Code (NMC 2018) states that registrants must keep up to date in ALL aspects of their practice. Much has changed in aromatherapy since 2013 (indeed, in the last two years) and the context of its use within the NHS has changed too. The law has tightened up, Brexit having required a change to laws and regulations that govern certain aspects of essential oil use.
The NHS is more focused on risk aversion and avoiding litigation than it was in 2013 and several health and safety laws have changed. Medicines management regulation have transferred from individual regulatory bodies to the Royal Pharmaceutical Society. The NMC Code has changed at least twice in this period too, with some clauses having been changed, firmed up or, occasionally, removed. Indemnity insurance issues have also changed and this may also apply to NHS vicarious liability insurance in certain circumstances.
This midwife is in urgent need of updating of her knowledge of aromatherapy in relation to using it in midwifery practice. At Expectancy we recommend updating and reflection on existing practice every two years. This does not have to mean paying for expensive courses – although in this case, I would certainly recommend a full refresher course. However, professional development can be achieved also by many other means. CPD can be achieved by reflecting on situations where aromatherapy has worked well and where, perhaps, it has not been successful or caused adverse effects for individual women, or searching the research literature to ensure you remain contemporary and able to justify your actions in terms of the evidence-base. It is really worrying that midwives believe that a short training course is all they need to incorporate CTs into their midwifery practice - and that is it.
Why do some midwives feel that they do not need to keep updated on aromatherapy, moxibustion, reflexology or acupuncture and that they can just continue to use it in their care of expectant and birthing parents.
These midwives are actually jeopardising their NMC registration and potentially putting parents and babies, as well as staff, at risk.
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.
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!
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?
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.
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.
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 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 (Peterson, Mühlemann, Humphreys 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.
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
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.
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.
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.
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.
We often think herbal teas are just pleasant drinks but some are not safe in pregnancy or need to be used with caution
All herbal remedies including teas contain chemicals that act like drugs.
Although chamomile tea can aid sleep, drinking too much can have the opposite effect and over-stimulate the brain.
Peppermint tea can be good for nausea but is a cardiac stimulant and if drunk to excess, can cause palpitations, so should be avoided by anyone with a heart problem.
Raspberry leaf is good for birth preparation but should be avoided by women with a uterine scar from a previous Caesarean.
See Denise's latest book, Using Natural Remedies Safely in Pregnancy and Birth for more information.
New Australian research by Mollart et al 2021 again advocates the need for education on “complementary therapies” to be added to midwifery programmes. Here, Denise comments on the implications of the research:
I am pleased to see an abstract of the latest research by Mollart and colleagues, due to be published in November in the Complementary Therapies in Clinical Practice journal, on the education of midwives on complementary therapies. The results are unsurprising, revealing that just over 50% of midwives have had some “training” in CTs, ranging from being self-taught up to diploma level, primarily in aromatherapy, massage, reflexology and acupressure. The recommendation that evidence-based education needs to be included in pre-registration midwifery education is spot-on but requires some clarification.
First, we need to look at the calibre of the training in CTs that is provided for midwives and students. Student midwives are preparing to practise midwifery not complementary therapies. While they need a basic understanding of the main CTs and natural remedies used by expectant and birthing parents, they do not need, at the point of registration, to be able to practise the therapies or incorporate them into their care of parents. Pre-registration education should provide students with an overview of the commonly-used therapies including – crucially – safety issues. This is particularly pertinent to aromatherapy and natural remedies which are often self-administered, sometimes unsafely. Midwives should be able to answer parents’ questions on safe use of the therapies, rather than be competent in the skills of providing the therapies.
Post-registration midwifery education should offer interested midwives the opportunity to undertake higher level training in therapies of their choice. There is a difference between skills “training” and academic education. Courses for midwives MUST be midwifery-specific and taught at least at academic level 6 so that midwives not only develop skills but also acquire deep knowledge and understanding, with an appreciation of the available evidence, safety issues and the parameters within which they can practise. There are many courses available to midwives that provide only level 4 training – usually based on enjoying a day of massage or blending of aromatherapy oils or learning specific acupressure of reflexology points to treat specific situations in labour.
In addition, it is not appropriate for midwives to train fully in a therapy and then undertake to implement that therapy in midwifery practice, without help to apply the principles of the therapy to maternity care. The use of CTs must be set in the context of the institutional area of practice – the birth centre, main obstetric unit or parents’ own homes. Midwives must appreciate how therapies are regulated within their midwifery practice – by medicines management, health and safety laws and by local, national and international regulations. The use of CTs must also be set in the context of the healthcare services, relevance to the service rather than to individuals, equity of service provision so that as many as possible can benefit from the therapies, evidence-based practice and the need to minimise risk and potential litigation.
Having taught CTs to midwives for almost 40 years, I am, of course, keen that the subject should be included in midwifery education. However, I am concerned – and have written frequently on the subject – that the enjoyment of using CTs often overrides the professional requirements to practise CTs safely. CTs education for midwives should be provided by midwives who are fully qualified in the relevant therapy and experienced in using it within midwifery practice and education. Lecturers should be qualified to teach adult learners and qualified and insured to teach the theory and practice of each therapy. Cascade training is NOT appropriate – students only to retain around 60% of what they learn, so midwives who have themselves only just learned a therapy and then attempt to teach others risk a natural dilution of content and understanding as their learners only retain 60% of what they have provided. Before we can include the subject in the midwifery curricula, we need to concentrate on educating midwifery lecturers and senior clinicians and researchers in order to develop and maintain appropriate standards of safe practice.
We must also remember that the field of “complementary therapies” encompasses many different professional disciplines. Complementary medicine practitioners are increasingly well trained, sometimes to degree level. Their professional bodies have codes of conduct, continuing professional development requirements and disciplinary procedures to maintain standards and safety in the same way as midwifery and nursing. Midwives need to appreciate that lack of knowledge and understanding potentially puts parents and babies, as well as colleagues, managers and their own midwifery registration at risk.
The Alexander technique may benefit expectant mothers with low back pain, sciatica and symphysis pubis discomfort. The Alexander technique aims to teach the woman how to move and use her body mindfully, correcting habitual postures, movements, coordination and balance, as well as patterns of accumulated tension which interfere with the innate ability to move easily and efficiently. Daily activities, - sitting, lying, standing, walking, lifting and other physical activities - become easier by using the body in a more efficient manner, with less risk of pain and discomfort. The Alexander technique is energising because the client learns how to move with less energy expenditure, thus promoting an enhanced sense of wellbeing. Unfortunately, although the Alexander technique is popular amongst actors to assist optimal positioning for voice projection (it was devised by an actor), its use as a general complementary therapy has declined in recent years and it may be difficult for expectant mothers to access a local teacher of the discipline.
If you’re asked by expectant parents about moxibustion for breech presentation, how do you know if it is appropriate or safe for them? The contraindications to moxibustion are the same as for external cephalic version plus hypertension and respiratory conditions such as asthma. These last two reasons are because the heat of the moxa sticks can temporarily increase the blood pressure and the smoke from the burning sticks can cause respiratory irritation.
Are you allergic to any essential oils? Denise has been allergic to geranium for many years, and is now becoming increasingly intolerant to rose oil.Even a brief exposure to geranium when teaching aromatherapy can cause nausea, and prolonged exposure leads to headaches.Geranium and rose share some of the same chemicals which is why rose is also starting to cause symptoms. Other common oils that can trigger allergic reactions include citrus oils - orange, grapefruit, mandarin etc. Denise has also had midwives react adversely to different oils in class - including one midwife who simply took a quick sniff from a bottle of clary sage and had a major respiratory attack. If you have a reaction to inhaling oil vapours it is vitally important not to continue being exposed to that oil as eventually it can cause anaphylactic shock.We'd be interested to know if you have had any adverse reactions to oils.
Frankincense oil is "the ultimate calmer" and a quick sniff of a single drop on a tissue can be very effective for women in the transition phase of labour. The power of frankincense calms the woman and helps her through that last short period before the birth. It's also useful for helping those who are frightened of having blood taken.
Reflexology is NOT the same as foot massage
When reading research studies on reflexology in labour, it's important to clarify what treatment is being given.
There are several studies that claim to reduce labour pain and duration with reflexology, but most studies use basic foot massage and not reflex points on the feet. It's OK in a clinical sense - foot massage can be a wonderful aid to labour care - but there is very little research using specific reflex points to stimulate contractions or reduce pain.
On the other hand, reflex zone therapy, the style of reflexology taught by Expectancy, can be very effective for postdates pregnancy, latent phase, stalled labour and retained placenta.
How many expectant parents with a breech baby have asked you about moxibustion? This Chinese technique, performed from 34 weeks of pregnancy, is around 68% successful in turning a breech to head-down. But there are certain women who shouldn't try moxibustion. If an ECV is contraindicated, then so is moxibustion. Also, high blood pressure - because the heat of the moxa sticks can raise the BP slightly; and asthma or other respiratory condition - because the smoke from the burning moxa sticks can increase symptoms.
Ginger biscuits are NOT the answer to pregnancy sickness! There's not enough ginger in a biscuit to have any therapeutic effect - and the sugar content causes peaks and troughs of blood sugar that can make sickness worse. Ginger tea, made from half a teaspoon of grated root gjnger, may be better but it's not appropriate or safe for everyone. Ginger contains chemicals that thin the blood so should not be used by expectant parents on anticoagulants including aspirin and clexane, or by anyone with a threatened miscarriage.
It’s great to receive compliments and testimonials!
‘I have really enjoyed studying the Diploma in Midwifery Complementary Therapies. Working alongside Denise has been a real privilege, she is a real inspiration and a transformational midwife. I feel focused and motivated to approach my new midwifery career after being guided, supported and skilled by Expectancy.’ Nicola Rai
‘Dr Denise Tiran is simply the most knowledgeable and experienced authority on the subject of midwifery complementary therapies, and I feel extremely privileged to have been a student with Expectancy.’ Alexis Stickland
‘A professional and academic course with lecturers who are also clinicians who share a passion for alternatives to NHS midwifery care.’ Becky Franklin
‘I have thoroughly enjoyed learning with Expectancy and being part of a like-minded community of midwives to be able to develop myself to offer better support for women.’ Charlotte Williams
‘The Diploma is a holistic course aimed at offering women naturally safe options for both their own and their infants’ wellbeing.’ Nicki Hennighan
Denise saw a question from someone planning a home birth about whether she could have her cat and dog with her. The family also wanted to use an aromatherapy difuser during the first stage. But did you know that aromatherapy oils can be toxic to cats and dogs? If an animal inhales the aromas, or if oil comes into contact with the skin, or if the animal ingests the oil (such as licking it off the skin or drinking spilled oil from the floor) it can cause serious side effects. Cats are particularly badly affected because they lack an enzyme needed to metabolise the oils, so the oils can cause liver problems or cause death. Birds, fish and reptiles can also be badly affected. Denise once had a midwife on one of her courses who had been told by the vet that oils would affect her pet iguana! The most significant oils include tea tree, eucalyptus, cinnamon, ylang ylang, peppermint, citrus oils and others. Don't use diffusers in the areas where your animals go - it could be fatal.
Did you know that homeopathic remedies, such as arnica, are chemically very fragile and can be inactivated by strong aromas from essential oils, moxa sticks, Deep Heat and Vicks vapour rub? Expectant parents using homeopathic remedies during pregnancy should also avoid drinking coffee, using mint flavoured toothpaste and chewing mint gum. Homeopathic remedies should not be stored near aromatherapy oils, microwave ovens or mobile 'phones. Birthing parents wanting to take homeopathic remedies during labour should not use aromatherapy.
It's day 2 of our latest postdates pregancy online course today for an NHS trust, and Denise will be talking about natural remedies before Amanda takes over to teach the acupressure. Denise says:
It's worrying when I hear midwives advising parents to try a whole range of natural remedies to start labour, without giving them any advice about how to use them, and without having assessed whether it is appropriate for the individual. All herbal remedies - such as raspberry leaf, clary sage, evening primrose, castor oil - have their benefits but they also have risks if taken inappropriately. Importantly, they should not be combined - this is likely to cause more problems with labour, not fewer. Searching some Facebook pages this morning, I see women are using up to four times the recommended dose of some remedies - such as evening primrose oil - either because they've been given the wrong information or because they've not been given enough information.
Midwives, doulas, antenatal teachers and other birth workers must offer comprehensive advice to enable parents to make informed choices about natural remedies. This includes information on:
And if professionals cannot give this information they should refrain from advising on the remedies. Continuing to do so without adequate knowledge and understanding is as risky as coercing women into induction when their bodies are not ready - and can equally lead to a cascade of intervention. Giving incorrect or incomplete information jeopardises not only the wellbeing of mother and baby but also the registration of the midwife if their advice leads to complications.
I was concerned this week to have a midwife on one of our online postdates pregnancy courses repeatedly challenge what she perceived as the "negativity" of the session on the risks of self-help natural remedies used by women to start labour (raspberry leaf, clary sage, pineapple, castor oil etc). We were discussing the possible complications of these popular remedies and when not to use them - such as in conjunction with medical induction of labour. The issue was not that she had raised the point but that she did not seem to understand the need for midwives to know about the risks in order to advise parents appropriately.
Of even more concern was that this midwife was a manager, yet all she wanted from the course was a "how to do it" on using aromatherapy and acupressure for postdates pregnancy. This is what, in academic terms, is called level 4 thinking, or being a "knowledgeable doer" without the underpinning theoretical understanding that comes with level 6 learning and evidence-based practice. This attitude is particularly prevalent when it comes to learning about complementary therapies in midwifery and reinforces the incorrect and dangerous belief that "natural" equals "safe". It is not enough for midwives only to learn how to mix and administer oils or use pressure points to stimulate contractions. It is vital to appreciate the safety aspects of what we do - even more so perhaps when it comes to complementary therapies as opposed to other aspects of practice. If something has the power to do good, it also has the power to do harm when not used appropriately. We need to know about the risks, both for our own practice and to ensure the advice we give to parents is correct, comprehensive, balanced and evidence-based, so that they can make informed decisions about whether or not to use the remedies and therapies.
Complementary therapies are often denigrated as not being sufficiently evidence-based or not fitting with conventional maternity care options. There is some truth in this although I would not have been teaching the subject to midwives for all these years of I didn't feel we could overcome that and promote the therapies as adding beneficial elements to the care of expectant and birthing parents. However, whilst even midwifery managers remain ignorant of the need to balance the benefits of complentary therapies with some understanding of the risks, we are not going to validate the subject as worthy of being part of standard midwifery practice and safe care of parents. We also risk parents' and babies' wellbeing by not knowing where to draw the line between enjoying the therapies and enjoying them so much that we cause harm.
I have written before about compassionate care and the Human Factors issues in relation to complementary therapies. It is not compassionate or caring to use complementary therapies in a "doing" way without understanding the risks of inappropriate use. Midwives need to get past the "niceness" of introducing complementary therapies into their care and start appreciating the balanced and caring approach that an understanding of possible contraindications, precautions, side effects and complications if therapies are not used correctly.
That midwifery manager needs to re-evaluate her managerial responsibilities to staff for whom she is responsible and for parents in her care to ensure midwives are able to offer complementary therapies safely in her unit.
Here Denise explores some of the issues of teaching birth preparation for expectant parents via the original "hypnobirthing" method.She says:
I recently read a Facebook post from a midwife questioning whether "hypnobirthing" could contribute to birth trauma rather than reducing it. I have to agree with her that the emphasis on expecting birth to be pain-free is not helpful to those in labour who actually DO feel pain despite having learned "hypnobirthing". The essential intense, repetitive, increasingly powerful muscular contractions of the uterus aid the birth process, and like any exercise, everyone experiences it in different ways. Labour is a biological process that, whilst being natural, is a rite of passage for women that CAN be painful - and has been since time immemorial.
What contributes to birth being perceived as more painful than it might be is the psychosocial impact of western society, the medicalisation of childbirth and the contemporary emphasis on "doing it right". "Pain" is a dirty word in "hypnobirthing" classes which sometimes focus so much on imbuing a sense of denial of pain that it can be a real shock when labour is found not to be quite what the parents expected. This can lead to emotional trauma that may have long term consequences including mental ill health, poor bonding with the baby and fear of embarking on another pregnancy.
Further, "hypnobirthing" can place a barrier between mothers and midwives that is unhelpful and unnecessary. Midwives are there to work in partnership with parents, to be their advocates and to guide them through a life event that can make them feel out of control, especially in hospital. Parents enter labour already viewing the midwife as "the enemy", which increases their stress and further contributes to perceiving birth as painful. Some "hypnobirthing" teachers are so anti-establishment that they increase parents' fear of the birth process and the (lack of) care they may receive from midwives.
Birth preparation classes started in the 1950s when Grantly Dick-Read introduced his "birth without fear" principles - and those of "hypnobirthing" are very similar. I have every support for these principles. I taught them myself as a community midwife in the 1980s, long before Mongan coined the now-trendy name of "hypnobirthing" - which is something of a misnomer since it is not actually hypnosis.
Other companies have come along more recently with "new" approaches to birth preparation - but they are all the same under the skin. They provide information and advice, suggestions for physical and mental preparation for birth and parenthood and, in groups, an opportunity to meet other expectant parents. Unfortunately, the demise of much NHS provision of antenatal classes has meant midwives are more and more excluded from birth preparation - which has given these companies inroads into teaching commercially-labelled systems.
There is nothing inherently wrong with any of these systems but let's be honest about what it is we're trying to do - to help expectant parents. Let's stop being divisive, with "hypnobirthing" teachers implying that they have all the answers to a failing NHS maternity service which no longer has time to address the fears and anxieties of its "customers".
Many midwives are moving away from the inflexibility of the original "hypnobirthing" method, adapting the basic principles to be more individualised, and dismissing the notion that birth can always be pain free. We should be honest about birth and help parents to learn strategies to cope with the pain, not to imagine that there will be none. Pain in labour is NOT a negative issue - it is the way we deal with it that is negative. We need to look closely at the long term adverse impact of unrealistic ideas and consider ways that enable parents to embrace birth and to feel a sense of achievement of having coped with whatever happens, whether it is painful or not.
Did you know that seaweed was previously used as a means of dilating the cervix in postdates pregnancy? Laminaria is an algae from seaweed, also known as kelp or kombu. It wastraditionally used to facilitate labour, and remains popular in the USA.
Laminaria has the ability to form a viscous gel in water, and laminaria "tents" are inserted intra-cervically to absorb ambient moisture, gradually swelling to 1 cm diameter over 4-6 hours. This may be due to the presence of a foreign body in the cervix initiating prostaglandin release, or possibly due to a high content of arachidonic acid, a prostaglandin precursor.
However, it can cause pelvic cramping and cervical bleeding and has been associated with fetal hypoxia and intrauterine death. Also, the “tents” can fragment and be retained in the cervical or vaginal canal, causing cervical wall rupture and infection.
Reearch on laminaria shows it is not significantly effective although it may reduce the need for medical induction. The new NICE guideline on induction of labour states that there is insufficient evidence to support its use in postdates pregnancy.
The number of midwives - and NHS trusts - considering complementary therapy training is at an all-time high.
The interest in incorporating aromatherapy, acupuncture, reflexology, hypnosis and moxibustion into midwifery care appears to be a direct consequence of the out-of-control medical management of pregnancy and birth.
But how do you know whether the complementary therapy courses you find are adequate and appropriate for midwives? It's certainly not necessary to be fully qualified in a therapy - and to be honest it's a bit of a waste of time and money to learn how to use aromatherapy, acupuncture or other therapies for non-pregnant women, for men, the elderly or people with cancer. On the other hand, remember that each therapy is a professional discipline in its own right, and midwives cannot expect to know everything after a short introductory course. More importantly, midwives must set the use of complementary therapies in the context of midwifery practice, the NHS and the laws and directives that govern our practice as midwives.
So here's our top ten tips to choosing an appropriate course so you can include complementary therapies in your midwifery care:
1) Is the course accredited by the Royal College of Midwives or other relevant organisation such as the Federation of Antenatal Educators? (It does not have to be accredited by the therapy's regulatory body)
2) Are the teachers experienced midwives, fully qualified in the therapy, with teaching qualifications that provide them with insurance to teach the therapy? (check where, and with whom, they themselves trained)
3) Do the teachers have at least five years' experience of practising the therapy in midwifery, including having implemented the therapy into an NHS setting, as well as at least five years' experience of teaching the therapy to midwives?
4) Is the course taught and assessed at academic level 6 so you understand how to apply principles of the therapy to midwifery practice? (This is very different from an academic level 4 course that just teaches you skills without ensuring understanding)
5) Does the course include the relevant physiology and other sciences (eg chemistry, anatomy, neurology) to aid your understanding of the therapy, especially in pregnancy and birth?
6) Will you learn enough about the safety - contraindications, precautions, side effects, complications and institutional Health and Safety regulations - to give you the confidence to practise the therapy safely?
7) How much attention is given during the course to the Nursing and Midwifery Council Code, other relevant midwifery documents such as medicines management, and the process of change management to help you implement the therapy appropriately?
8) Is there an emphasis on evidence-based practice - do the teachers have experience of researching complementary therapies in relation to pregnancy and birth?
9) What requirements and provisions are there for continuing professional development in the use of the therapy in midwifery, in accordance with the NMC Code?
10) If you want to offer the therapy in private practice, does the course accreditation provide you with the option to obtain appropriate personal professional indemnity insurance? (This is different from the RCM's medical malpractice insurance)
Today, Denise was asked by a midwife who had completed Expectancy’s aromatherapy training, if it’s acceptable to give a telephone consultation to another midwife, not trained in aromatherapy, to enable the non-trained midwife to blend and administer aromatherapy to a birthing person. Denise says:
The answer, I’m afraid, is a resounding “NO”. Midwives need to think about this in the same way as medicines management, their Nursing and Midwifery Council registration and the trust’s vicarious liability insurance. Midwives would not provide a ‘phone consultation to a midwife about a birthing woman she has not met, then prescribe drugs and allow another midwife to dispense and administer them – and the same applies to aromatherapy oils. If you are actually on-site you could do a face to face consultation with the mother, prescribe and blend the oils, leaving a non-trained midwife, student or support worker to administer them under your direction. You cannot be on the community (off-site) or off duty (invalidates your right to vicarious liability insurance) – you must be accessible in case the mother has an adverse reaction so you can deal with it. YOU are accountable for the use of aromatherapy oils (chemicals in the workplace, classified under Health and Safety regulations). If the non-trained midwife makes a mistake, it is YOUR NMC registration that may be in jeopardy as well as theirs. Midwives who are not trained in aromatherapy are NOT permitted to choose (prescribe) or blend (dispense) the oils. The best thing is for those midwives not yet trained to use just carrier oil and provide basic massage, although they must be trained sufficiently to understand any contraindications and precautions and how to record the massage treatment in the notes.
Denise continues to challenge NICE on its inaccuracies when it comes to complementary and alternative medicine. She says:
Having recently seen the revised NICE guideline on induction of labour, currently out for national consultation, I was disappointed - but not surprised - to see a paltry single paragraph on the use of more natural methods to aid labour onset. Basically their stance is that there is insufficient evidence to support the use of almost all complementary therapies (CTs) although they singularly fail to include aromatherapy, one of the most commonly-used methods of encourage contractions, despite a growing body of randomised controlled trials to support its use.
Further, NICE erroneously refers to CTs as “non-pharmacological”. The term “pharmacological” refers to the uses, effects and modes of action of drugs and other chemical substances. Manual therapies such as reflexology and massage, energy-based modalities including acupuncture and homeopathy, and psychological therapies such as clinical hypnosis ARE non-pharmacological as they have different mechanisms of action. However, ALL herbal medicines and aromatherapy oils act in exactly the same way as medicines, being absorbed, distributed, metabolised and excreted, and are, therefore, definitely “pharmacological”. They can interact with drugs and other herbal remedies, and can have serious toxic effects in some cases.
Not only is NICE wrong, but this continued use of terminology that belittles the clinical power of complementary modalities, that do not fit with the politically powerful medical profession’s dominance, is potentially unsafe. Until the medical and allied professions, including midwives, nurses, paramedics, physiotherapists etc, understand the risks of herbal medicines and essential oils when used inappropriately, we will continue to encounter real clinical issues. For example, overuse of raspberry leaf tea has a dose-dependent effect that prolongs rather than shortens pregnancy, and excessive use of clary sage oil in labour can cause cessation of contractions rather than facilitating them.
For more information see Denise’s book, Using Natural Remedies Safely in Pregnancy and Childbirth (2021).
WHO IS RESPONSIBLE FOR PROVIDING ESSENTIAL OILS WHEN MIDWIVES OFFER AROMATHERAPY FOR BIRTH? Denise was very concerned today to hear from a midwife working in a trust in which aromatherapy is offered in the birth centre, but whose community midwives apparently have to purchase their own oils if providing aromatherapy for home births. She says:
Midwives are permitted to use aromatherapy in their practice if they have had adequate training and keep updated, have the trust’s permission and local clinical guidelines – this means they are protected by the trust’s vicarious liability insurance. Chemical substances in the workplace – including aromatherapy oils - are regulated by the Health and Safety at Work Act and Control of Substances Hazardous to Health regulations. Aromatherapy oils must also be used in accordance with the same principles as medicines and must be of good enough quality for safe clinical practice. It is the trust’s responsibility to supply the oils and to ensure they are purchased from a reputable supplier, that expiry dates and batch number are centrally recorded and that there is a system in place to monitor midwives’ practice and record any adverse effects on parents, babies, visitors or staff.
Midwives’ attending home births must remember that the home setting is their place of work and that all the regulations relevant to the birth centre or maternity unit also apply in the community. The oils must be the same brand as those used in the hospital, the individual oils must be included in the trust aromatherapy guideline and midwives must also comply with requirements for safe storage. Asking individual midwives to provide their own oils is not only unethical, it is potentially unsafe. It is akin to asking midwives to purchase their own paracetamol rather than dispensing the trust’s approved brand of the drug.
Compare this situation to a trust in which midwives visiting parents at home are required to request that no one in the home smokes for at least two hours prior to the visit, since the home becomes the midwife’s workplace. The midwives asked me if the same should apply to the use of aromatherapy in the home, especially when parents often use oils to aid contractions during home birth, which may be dangerous for midwives in early pregnancy. In principle, the same cautions should apply to aromatherapy oils as to cigarette smoking. I would far rather the midwives were ultra-cautious like this, than irresponsibly maverick as in the first trust.
Midwives studying our Diploma and preparing for private practice through our Licensed Consultancy scheme had a great "finance" webinar last night with the wonderful Joanne Bell from Bell's Accountants in southeast London. We discussed starting up in business and what expenses you can claim, dealing with HMRC, completing self-assessment returns, VAT and Corporation tax and much more.
If you're thinking of moving into private practice, there's so much to learn. On our business training module we include everything you need to know about starting and growing your business, advertising and marketing, legal and professional aspects including avoiding conflicts of interest for midwives continuing to work in the NHS and much more. It's a whole new world when you step outside the comparative safety of the NHS to become self employed!
Now the lockdown is being lifted it seems that midwives are keen to get back to working in ways that enhance care. We've been inundated with enquiries for training in maternity units and birth centres, with requests for everything from aromatherapy and postdates pregnancy to hypnosis and acupuncture. Denise comments:
The interest in using complementary therapies for labour and birth is at an all-time high. It's as if the plug has been pulled on the pandemic and midwives are desperate to provide holistic care for expectant parents so that their birthing experiences are memorable for all the right reasons.
Complementary therapies offer so many ways to help, not just for relaxation, but for pain relief and aiding progress, for dealing with all those symptoms of pregnancy and sometimes for treating problems that occur. When used appropriately and cautiously, complementary therapies can make the difference between a home or hospital birth or between a physiological or medically managed birth.
However, whilst the NHS website and NICE guidelines are right to advise caution, their reliance on evidence to support the use of CTs - and consequent advice to parents to use them as.little as possible is missing the point. Expectant parents ARE using CTs, they want them to be available for birth and are prepared to pay for therapies during pregnancy.
This means that midwives have a duty to know more about CTs and natural remedies so they can advise parents about using them safely. Yet the revised 2020 education standards for.midwifery from the Nursing and Midwifery Council have removed any overt mention of CTs to be included in pre-registration midwifery programmes.
From a national, regulatory perspective CTs continue to be marginalised and disregarded. From the parents' perspective, this is something they want, sometimes without understanding the possible risks of misuse - so midwives have a duty to help. Conversely, we only have to look at the number of maternity units wanting to offer CTs to see that grass-roots midwives are trying to respond to the demand. Isn't it about time the NHS accepted this and took steps to accommodate the public's desire to use CTs whilst still advising caution?
Whilst around 5% of expectant parents experience excessive nausea and vomiting in pregnancy, with dehydration and weight loss, even more suffer mild to moderate sickness which does not normally require medical attention or hospital admission. Many women cope with mild symptoms but it is those caught in the middle, with ongoing vomiting and constant nausea who may need support which is not readily available. Midwives and GPs are ill equipped to help them and often make inappropriate suggestions such as the ubiquitous advice to “try ginger biscuits”, which is neither universally appropriate nor safe. Therapeutic doses of fresh root ginger (about 1gm daily) may help some but should be avoided by those with any bleeding or who are taking anticoagulant drugs such as heparin, enoxaparin or even preventative aspirin. Travel sickness bands may help – these are based on an acupuncture point on the inner wrist. Or try the Morningwell™ app which uses sound pulsations that bounce on the balancing centre in the ear to reduce nausea. Even more effective is acupuncture or homeopathy from a qualified practitioner. Aromatherapy oils are not always effective and may make symptoms worse if the nausea is exacerbated by smells.
Denise and Amanda were teaching our popular online course on complementary therapies for post dates pregnancy this weekend. Reflexology can be useful to start labour, but there are some concerns about inappropriate treatments. Denise says:
Many practitioners believe that contractions can be stimulated by massaging the area of the foot that represents the reflex area for the uterus - on the inner heel. However this is incorrect and potentially dangerous as overzealous stimulation of these areas may lead to placental separation. Labour contractions need oxytocin from the pituitary gland to activate the uterus, so it is more appropriate to work on the reflex zones for the pituitary gland - on the big toes.
However, my research over many years suggests that the pituitary gland reflex zone is not where many practitioners traditionally position it. I place the pituitary reflex zone on the outer side of the big toes, nearest to the second toe. I also found that the reflex zone on the right foot reflects the anterior pituitary gland while that on the left corresponds to the posterior pituitary gland.
Further, this relocation was confirmed in my research on using reflex points to detect stages of the menstrual cycle. It is possible to use these points to work out which ovary is active, estimate where in the cycle the woman is, and then to predict the next menstrual period. This process can then be applied to pregnant women, to predict the imminence of the onset of labour.
Denise was contacted today by a midwife concerned to see an Instagram post from a US midwife who advocated placing an opened bottle of essential oil to the nose of a newborn to calm the baby (and to promote a particular brand of oils). Here is Denise’s reply:
Newborn babies should not be exposed to - and especially not treated with - essential oils for five very significant physiological reasons: 1) the skin is very sensitive and dermal contact may cause severe skin irritation 2) the aroma masks the baby's ability to use their sense of smell to recognise their mother 3) all essential oils are metabolised via the liver and the neonatal liver is immature – inhaling oil chemicals could risk increased jaundice, possibly even kernicterus 4) the neonate has an immature blood brain barrier - inhaling oils causes rapid, potentially toxic absorption to the brain, risking jitteriness 5) all essential oils are antibacterial - neonatal exposure to oil vapours could interfere with the maturation of immune system, which could lead to a lifelong difficulty in fighting infection
In this interesting video, academics, researchers and medics discuss homeopathy and the presumed "placebo" effect.
Denise comments: Homeopathy is a little-understood complementary modality that can be useful in pregnancy and birth. Highly diluted and agitated (shaken) substances release energetic potential to treat "like with like". If a substance is completely inert, it will have no effects at all - but this is not the case with homeopathy. Remember, if something has the power to do good, it also has the potential to do harm when not used correctly. Excessive or inappropriate homeopathic use can trigger the symptoms the remedy aims to treat. Homeopathic arnica, can be useful to reduce perineal trauma and bruising after birth, but excessive use may trigger a reverse effect, leading to systemic bruising. This is NOT a placebo effect. For more on homeopathy and herbal remedies, see Denise's book Using Natural Remedies Safely in Pregnancy and Childbirth (2021).
Did you know that using too much clary sage aromatherapy oil to aid labour contractions can have the opposite and actually stop labour? Here, Denise discusses the growing incidence of hyperpolarisation arising from misuse of clary sage oil in labour.
Clary sage is one of the most misused aromatherapy oils for labour. There is no doubt that it can aid the onset of labour when a woman is overdue. It may also help to accelerate the latent phase, encouraging contractions to become well established. However, both parents and professionals are over-using clary sage to the extent that I now receive reports on a regular basis of situations where labour has slowed down or even stopped despite the use of clary sage. Clary sage oil should be considered to be aromatherapy’s equivalent of oxytocin and should only be used when there is a justification to use it to aid contractions; it is, of course, completely contraindicated until term pregnancy (37 weeks).
Prolonged use, excessive doses or continual environmental diffusion of clary sage oil can, in the first instance, cause excessively strong uterine contractions, possibly leading to fetal distress. However, continuing to use clary sage oil, administered either by inhalation or via the skin, may eventually cause a situation in which contractions slow down and eventually stop. This is a condition called hyperpolarisation, an effect that can occur with any pharmacological agent, including drugs, herbal remedies and aromatherapy essential oils. When a drug / oil is commenced, it triggers an action potential of the neurons in the relevant organ to make the body receptive to the substance (this process is called depolarisation). In the case of clary sage oil, it stimulates an action potential to encourage the uterine muscles to contract. Eventually, a stage of optimum effect is reached, after which the oil becomes less effective (repolarisation). Ultimately, a state of hyperpolarisation is reached, in which the clary sage oil will start to have the opposite effect, namely relaxing the uterine muscles and interfering with the progress of physiological labour.
To prevent clary sage oil causing hyperpolarisation and leading to reduced or no contractions, midwives should:
Many midwives will not be surprised to read a recent article in the the Independent on the possible departure of thousands of midwives from the NHS. Whilst the pandemic has exacerbated the pressures, it has really only brought to the fore a dissatisfaction that was already simmering amongst midwives. Midwives want to provide care for families in the way they were trained to care - holistic, individualised safe and empathetic care that provides choices for parents. Midwives also need choices - about how, where and when they work.
NHS maternity services do not provide choices, for expectant parents or for midwives. They are designed to provide medical treatment for the majority, in effect to number crunch within the budget. And the result is dissatisfied parents and dissatisfied, exhausted and angry midwives. Yes, there are some wonderful initiatives in some areas where midwives try to return to nurturing pregnant and birthing women. However in the greater scheme things these are just papering over the cracks of the NHS. All the dimmed lights, aromatherapy oils and gentle music in the world will not solve the fundamental problems of working in the current NHS with inadequate staffing and poor resources.
On the other hand, midwives who have taken the step to work independently have control over their working lives. They can work in a way that suits them and enables them to offer that holistic, individualized, safe and empathetic care for families. Yes, they may not earn as much as they did in the NHS but job satisfaction far outweighs the issue of salary. Some midwives offer full antenatal, birth and postnatal care under one of the organisations through which they can obtain insurance. Others provide pregnancy and postnatal care, including antenatal classes, lactation support, complementary therapies and other maternity related services.
Solving the problems of the NHS maternity services is extremely complex and is not related purely to financial and organisational issues. Any effective solution will require an attitudinal change from government, management, employees and by those who use the services.The NHS comes into its own when dealing with high risk situations, emergencies and end of life situations. Maternity services for the majority do not fit into these categories - pregnancy and birth are generally not high risk or emergency situations and, thankfully, rarely have to deal with end of life issues.
Perhaps one of the options is to adopt the system used in some other countries where birth services and basic antenatal monitoring are provided within the standard maternity services and all other care is offered by midwives and other professionals working independently? That does not necessarily have to mean "privately" as in paid-for by service users, but could involve midwives working in independent practices and contracting their services to the NHS. In that way, services could become responsive to demand and both parents and midwives would have increased satisfaction.
One thing is certain - unless something is done, and done soon, there will be no midwives left in the NHS - and those who remain will become increasingly burned out, putting their own health at risk. This does not bode well for those families having babies, nor for the profession of midwifery.
Here is an extract from an article published by the Complementary Medical Association. Although it relates to chemicals in the home, this includes fragrances such as perfumes and aromatic candles. Although essential oils are not mentioned by name, the same principles also apply to the diffusion of essential oils in the home. The key is to use aromatherapy diffusers in the home for no more than 15-20 minutes at a time and to keep babies, children, ill people and animals away from the aromas.
Chemicals in the Kitchen
The development of chemicals in the last hundred or so years that would serve to help us be cleaner, live more efficiently and generally ‘improve’ our lives has had a devastating effect upon our immune systems. It is estimated that anyone living in a “Westernised” environment encounters up to 2,100,000 man-made chemical exposures every day. The truth is that we simply don’t know what most of these chemicals do – and they have never been researched in combination. We are sitting on the top of a ticking time-bomb – and only time will really tell us about the true effects of synthetic chemicals.
The potential dangers of these chemical exposures are worrying – to say the least – as they are associated with numerous health issues, including cancers, obesity, hormone disruption, dementias and much more. These toxic chemicals also accelerate ageing and are associated with many of the health concerns that we associate with ageing.
In this article we’ll look at just a few of the harmful chemicals in your kitchen – and ways that you can avoid them – or find substitutes that really work.
Many commercially available ‘antibacterial’ soaps (and toothpastes) on the market boast that they contain the antimicrobial chemical ‘triclosan’. This chemical is believed to disrupt thyroid function and hormone levels in people; and furthermore, when it goes down your drain and eventually mixes with wastewater, it has been shown to cause sex changes in aquatic life.
Even more worrying is that overuse of this and other antibacterial chemicals is promoting the growth of bacteria that are increasingly becoming immune to antibiotics and other anti-bacterial substances.
Better alternative: Good old-fashioned soap and warm water kills just as many germs as the chemical soaps. If you have to use a hand sanitizer, choose and alcohol based product that doesn’t contain triclosan, triclocarban or any other synthetic substances described as anti-bacterial or anti-microbial.
The chemical compounds that we are most often exposed to in our kitchens are fragrances. These surface in in soaps laundry detergents, fabric softeners, dryer sheets, cleaning supplies, disinfectants and outside the kitchen they are founding abundance in air fresheners, deodorisers, shampoos, hair sprays, gels, lotions, sunscreens, perfumes, powders, and scented candles. Fragrances are a group of chemicals that are well worth the time and effort to avoid. The words “fragrance” or “parfum” on product labels can act as an euphemism for hundreds of harmful chemicals that are known to be carcinogens, endocrine disrupters, and reproductive toxicants, even at low levels.
Better alternative: Freshen the air with better ventilation and by setting out a saucer of bicarbonate of soda. You also can place a bowl of white vinegar in a room to dispel a stale smell. I often spritz my environment with a small spray bottle containing water and a few drops of my favourite essential oils.
Harsh Cleaning Products
It is really quite scary that we inadvertently contaminate our air when we use harsh chemicals—some of which are known to cause cancer—to “clean” our homes? Ammonia can trigger asthma attacks, and harsh oven cleaners and drain openers can cause respiratory damage or burn the skin anyone who comes into contact with them – and these chemicals are even more dangerous to children – who have much lower body mass than adults.
Better alternative: Take any synthetic cleaner with an ingredient list that reads like a chemistry textbook to your local recycling centre – they’ll know how to dispose of these chemicals properly – don’t pour them down the drain as they end up in our water supply! (Check those products which boast ‘natural ingredients’ as there are a great many synthetic products out there which try to promote their ‘green’ credentials by adding a few natural products to a synthetic chemical soup – and there’s very little labeling legislation in place to stop this grossly misleading practice.)
Here, Denise discusses whether midwives provide enough information to enable expectant parents to give informed consent for complementary therapies.
Informed consent is the process of agreeing to, or declining, a course of action in healthcare, based on a clear appreciation of the benefits, risks, implication and consequences of the treatment. Where possible, the information given should be based on contemporary research, as well as local directives and national and international laws. Whilst the Nursing and Midwifery Council and medical laws require midwives to obtain informed consent for all treatment options throughout pregnancy and birth, the process is often not done well, even for major interventions such as induction of labour or Caesarean section.
When it comes to complementary therapies such as aromatherapy, reflexology, acupuncture or hypnotherapy, midwives frequently allow their enthusiasm for the benefits to overshadow any real discussion of possible risks. Indeed, some midwives do not themselves possess adequate knowledge of the therapy to be able to provide all but very basic information. In fairness, it should also be recognised that expectant parents are usually so keen to take advantage of what they see as purely "relaxation therapies" that they may disregard any need to appreciate the opposite side of the debate.
However, since complementary therapies are not part of mainstream midwifery practice (or education), it is almost more important to ensure that fully informed consent has been obtained than for other standard components of midwifery care. In the event of any untoward consequences of complementary therapy use, midwives must be sure that parents have been given and understand this information, together with opportunities to ask questions and seek clarification. The information should be given verbally and in writing prior to any complementary therapy interventions.
Midwives introducing the option of a complementary therapy as part of pregnancy and birth care must provide parents with the following information in order that fully informed consent can be given:
If you're a midwife using complementary therapies in your practice, are YOU informed enough to be able to offer this information in sufficient detail when discussing complementary therapies with clients?
For more details of Expectancy's courses that prepare midwives to provide this information, contact us on email@example.com
Here, Denise discusses the controversial issue of "cascade training" of complementary therapies and asks why midwifery managers feel it is acceptable. She says:
During our online course this week, on aromatherapy and acupressure for post dates pregnancy, a midwife asked about cascade training, the practice of returning to base to teach other midwives how to use the therapy the students have just learned. This is a common question that causes me great concern. It usually originates from managers who see it as a cheap way to get all the midwives trained up to use the therapy (most commonly aromatherapy but also reflexology or acupuncture).
There are several reasons why cascade training is completely inappropriate when it comes to complementary therapies:
Each therapy is a professional discipline in its own right, which takes at least a year (for aromatherapy) or up to four years (for acupuncture) to become fully qualified. Midwives would not sanction someone taking a few days or weeks of midwifery training and then being allowed not only to practise but also to teach it. Indeed, there is great concern amongst complementary therapy educational and regulatory organisations about the way in which other professionals such as midwives, nurses or physiotherapists, "cherry pick" a few aspects of a therapy discipline without deeper understanding of the scientific basis and the legal requirements underpinning its practice. Those who teach midwives to use complementary therapies in their practice must first be fully trained in the therapy, have consolidated their own learning, have extensive experience of using it in midwifery practice and be qualified and insured to teach it.
"Training" to be able to carry out practical skills of a therapy is one thing but becoming sufficiently educated to understand the implications of safe practice and to be able to minimise the risks is entirely different - this is the difference between academic level 4 and level 6 study, or between "doing" and "understanding". It is evidenced that people only retain 60% of what they first learn so there is a natural dilution when that 60% is passed on to others who then also only retain 60% of what they have been taught. Further, midwives must be able to apply the principles of the therapy to its practice within maternity care. Midwives who undertake post-registration courses such as Examination of the Newborn are not permitted to return to practice and immediately start teaching other midwives up to a level of competence - so why do midwifery managers presume this is permissible when it comes to complementary therapies?
The truth is that most midwifery managers have absolutely no understanding of the issues relevant to complementary therapy - not only its practice but the health and safety, legal, ethical and regulatory issues relevant to safe practice. Permitting midwives who have only studied a few days of a therapy then to train others could put everyone in a very invidious position. It risks the safety of parents and babies and the registration of midwives using the therapy and of those teaching it. It also risks the registration of midwifery managers who have unwittingly assumed that those teaching the therapy know enough to ensure safe accountable practice of those they train.
Midwifery managers have a responsibility to ensure that what is included in the care provided by their employees is safe and appropriate. They must take account of institutional issues and adhere to the law - this is a direct requirement under the NMC Code (2018). Managers have a legal duty to comply with the Health and Safety at Work Act, regulations such as Control of Substances Hazardous to Health regulations and medicines management requirements. Midwives are insured to practise complementary therapies under NHS vicarious liability insurance on condition that they have managerial permission - but managers must understand what their staff are doing before giving that permission.
The truth is also, perhaps, that midwifery managers want to respond to the trend to include complementary therapies in their care provision so that expectant parents will want to book for their birth centre or maternity unit. They also want to introduce new initiatives as cheaply as possible in the cash-strapped NHS - but this risks cutting corners which, in the long term, may be counter-productive to the intention of complementary therapies - and detrimental to the wellbeing of all concerned.
Much is written about "compassionate care" and the introduction of complementary therapies is seen as being an element of this. However, compassionate care also means safe care - not cheap care, not ill-informed care and certainly not illegal care. Before midwifery managers approve cascade training of complementary therapies for their staff, they need to think about the consequences.
All of Expectancy's courses set complementary therapies firmly in the context of midwifery practice and focus on safety, professional accountability an evidence-based care. Contact us now if you would like courses for your unit, online or face to face - firstname.lastname@example.org
I’ve been publishing on maternity complementary therapies for many years but the huge increase in popularity of natural remedies, including aromatherapy oils, herbs and homeopathic remedies led me to write this latest book. Expectant parents frequently ask midwives, doctors, doulas and antenatal teachers about the use of remedies such as raspberry leaf tea, and for remedies such as castor oil and evening primrose to start labour. The massive rise in popularity of aromatherapy in pregnancy and birth also means that parents often ask about essential oils, or want to bring them into the birth centre for use in labour. This can sometimes put the midwife or doctor in a difficult position because they may know very little about the oils and which are safe or not.
There is a huge amount of information – and mis-information - available online, but it presents a confusing minefield for both parents and professionals. The subject is not included in conventional medical or midwifery education, yet increasingly, maternity care providers need to know about the popular remedies and how to advise pregnant, labouring or newly birthed parents. Safety and accountability are the principles that underpin all that I teach in my Expectancy courses on complementary therapies for midwives but there is still the misconception that “natural” means “safe”. This just simply is not true. Anything that has the power to act therapeutically can also cause harm if used inappropriately. The issue is intensified when remedies such as herbal medicines are used alongside prescribed drugs.
This book aims to provide a ready reference for health professionals in both the maternity and obstetric fields as well as complementary therapy practitioners who may be working with pregnant clients. It aims to provide enough information to advise parents about the safety, or otherwise, of particular remedies, when working in the clinical situation.
Clinical hypnosis involves deep relaxation to create a state of focused attention similar to daydreaming. This increased the person’s suggestibility so that positive cues can be used to help deal with issues such as fear of childbirth, stopping smoking in pregnancy or needle phobia.
There are many different styles of reflexology. It is not simply foot massage but involves precise pressure point work all over the feet, and the location of organ points may vary according to the style being used. When reflexology is used for labour care, all midwives must use the same style and the same locations of points. This is particularly important when locating the reflex zone for the pituitary gland, the most significant point used in midwifery.
Many pregnant women thinking about having acupuncture to treat sickness, backache or other symptoms, imagine that it will be painful. Although acupuncture does involve the insertion of fine needles into precise points around the body, it is not usually felt as more than a tiny pin prick, sometimes not at all. In fact, it is common to experience a buzz of energy as the needle reaches the correct spot – and acupuncture treatment has been shown to reduce stress hormones and increase feel good factors, so it can be quite relaxing.
Here Denise reflects on changing times in the pregnancy and birth arena and considers how stressful life is now compared to 40 years ago.
When I was first a midwife in the mid-1970s women either became pregnant or they didn't, but everyone accepted that nature would take its course. There were very few tests for fetal abnormalities, no electronic monitoring in labour and limited vaccinations for infants. If women worked, they took maternity leave from around 32 weeks of pregnancy and often chose to be full time parents, not returning to work until several years later. Midwives had time to spend with women at all stages, with frequent antenatal appointments. Home births were still quite common but even in hospital there was continued one to one care in labour. And the midwife provided welcome daily postnatal visits to the home for at least ten days after the birth.
In today's world, couples often leave it "physiologically late" to start a family, then are so stressed that conception takes longer than they want, or not at all. Pregnancy is stressful while women strive to continue working until the last moment, and to cope with "unexpected" - but completely normal - discomforts of pregnancy symptoms. Labour is "managed" either by the couple or by professionals instead of being helped to follow its natural course. New parents, who have generally given birth in hospital, have no time to recover from interventionist care before being thrown into the stressful world of attempting to be a "perfect parent".
Society expects perfection but nature isn't perfect and sometimes it lets us down. Extra social and medical choices are welcome but too much choice brings uncertainty - and uncertainty brings more stress. Stress increases hormones that interfere with conception, pregnancy and labour, recovery from birth and establishment of lactation.
The internet - and particularly social media - exacerbates expectant parent's distress, with childbirth tales, either of perfection or disaster. From the posts I'm currently seeing, there is a definite "them and us" attitude amongst a proportion of the pregnant public, spreading fear that midwives and doctors are ogres to be avoided at all costs, who will "make" parents accept care against their will and who are uncaring and unkind.
This saddens me greatly, to think that we've lost the respect of the people for whom we care. It saddens me, too, to see posts from students and newly qualified midwives who are so disillusioned with the maternity services that they feel they can no longer work in them. Yet these are the very people we need to take forward, to develop and improve the maternity services we offer. Recognising the problem is part of the solution, but we need motivated midwives to work on achieving the solution.
As long as I've been a midwife, there have been battles in the field of pregnancy and birth: midwives versus obstetricians, natural versus interventionist birth, parents versus professionals. But we're all there for the same reason: fundamentally, to continue the human race. Let's stop the fighting and start working together to improve services for expectant parents. Let's start respecting one another for the amazing work we do - respecting women's bodies for their ability to conceive, grow, birth and nurture babies.A nd respecting professionals who are, after all, there to help families, to ensure a safe and satisfying passage through the journey that is pregnancy, birth and parenthood.
Today, Denise expresses her continued concern about the continuing misuse of complementary therapies and and reinforces the need for both complementary and conventional health practitioners work within their professional boundaries. She says:
I continue to see some extremely alarming social media comments and suggestions on the use of complementary therapies. Some of the posts recently have included:
There are several issues with these posts. First is the lack of understanding of the general public about the risks, as well as the benefits of therapies, notably aromatherapy oils. This is a continuing problem and experienced therapy practitioners, as well as conventional healthcare professionals, need to keep putting the message out there to the public.
Secondly, nurses (or midwives) who enthusiastically condone the use of complementary therapies or natural remedies without any knowledge or understanding of the potential dangers, are putting their patients in jeopardy, and risking mistakes that could lead to loss of their professional registration. This is particularly significant when people are seriously ill, since the therapies could complicate the medical condition or interact with drugs.
And thirdly, the credibility of professional therapy practitioners is seriously undermined by a few individuals who seek to overstep their boundaries. I have worked with many reputable practitioners of reflexology and other therapies who specialise in working with people with diagnosed conditions, especially cancer patients or expectant parents. They have undertaken additional training and understand how to apply their experience of using the therapy to the physiology and pathology of the person’s condition.
We are delighted to announce that Denise has received the advance copies of her new book, Using Natural Remedies Safely in Pregnancy and Childbirth, to be published by Singing Dragon in mid-March 2021.
If you would like to win a signed copy of the book, please email@example.com with the answer to the question below, your email address and your name as you would like it in the book if you win. The draw will be made on Friday 12th February.
Here’s the question: If an expectant parent wishes to take raspberry leaf to facilitate labour, when should it be commenced?
a) 37-38 weeks’ gestation
b) 30-32 weeks’ gestation
c) 40-41week’s gestation
Denise has been extremely busy since the new year preparing for all the online teaching. We've already had one course this year on aromatherapy in midwifery, with rave reviews, one midwife emailing us afterwards to say it's the best course she's done in a long time. Over the next two weeks, Denise has courses for midwives and therapists in China and Japan, as well as upcoming webinars and a post dates pregnancy course.
It's been an interesting time, moving to teaching online but there are certainly benefits. Rather than being constrained by the size of an actual room, we've been able to give more midwives and birth workers the opportunity to study with us, with some overseas groups having up to 200 students. We run our study days in real time with three 2-hour sessions (and breaks between), from 9am to 4pm. This can be quite intensive so we break the day up with group work and time to chat socially. Students receive everything in advance so they have all the course materials. For the aromatherapy and post dates pregnancy courses, midwives receive a set of aromatherapy oils to use during the care planning sessions, and those on our acupuncture course receive a set of needles, a mini sharps bin and a practice pad (better than sticking needles in an orange which is now we practised to give injections!). I seem to spend my time packaging up parcels and getting them shipped off. We're also getting more students from overseas, with midwives joining us from Malta, Cyprus, Italy, Austria, Qatar and Slovenia. This has led us to offer the option to study our Certificate in Midwifery Complementary Therapies completely online, with ten study days, optional extra webinars, "open house" sessions and tutorials, taken over an academic year.
Join our online webinars on complementary therapies for pregnancy and childbirth
Date - Saturday 23rd January 2021 10:00 - 11:00 hours
Subject - Introduction to reflexology in midwifery practice with Denise Tiran, author of Reflexology for Pregnancy and Childbirth
Introduction to the principles of reflexology, the different types of reflexology used around the world and the benefits of using reflex zone therapy, the style taught by Expectancy, in midwifery practice. Suitable for midwives and students
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Pineapple has long been held as a symbol of fertility and is also often used to trigger labour contractions in women who are overdue. Pineapple core contains a chemical called bromelain which has been shown to have anti-inflammatory properties and possibly also some anti-cancer effects. When fertility issues are linked to internal scar tissue, perhaps caused by infection or previous surgery, it is thought that bromelain may reduce the inflammation and aid conception. It is also thought to have certain anti-coagulant (blood thinning) effects which is why it is thought to aid blood flow to the uterus. To date there is no pure research on the potential for bromelain to aid fertility and most of the information available on the subject appears to be based on a 2012 Indian paper which was a review of much older research.
However, for those who want to harness the fresh, bright image of pineapple as an aid to conception, there is no real problem unless you are allergic to pineapple or to latex or experience tingling in the mouth when eating pineapple (which may be the start of a more significant allergy). The main source of bromelain is in the fresh raw core of the pineapple, and it is destroyed by juicing, canning or cooking. Those taking prescribed aspirin or other blood thinning drugs prescribed to aid fertility should avoid eating large amounts of the core. Once pregnant, pineapple should be eaten only in moderation, avoiding the central fibrous core.
In the week before Christmas, Denise explores the medicinal uses of some of the popular Christmas spices and foods.
Cinnamon and cloves are both used extensively in cooking at this time of year and are safe in the small amounts used in cooking. Cinnamon is effective for various digestive conditions, but the essential oil is also used in some countries to stimulate labour at term, so should be avoided during pregnancy. This means that the oil should not be added to aromatherapy diffusers to fragrance the room if there is anyone in the family who is pregnant – or if there are cats or dogs in the house as it is toxic to animals. Clove is another popular spice, and the oil is sometimes used to treat toothache, but should be avoided in pregnancy. In some countries clove oil is used to ease the pain of teething in babies, but this can cause damage to the emerging teeth if the oil is rubbed into the baby’s mouth and gums. Like cinnamon, clove oil is also toxic to dogs and cats.
Many people like to add cranberry sauce to their Christmas dinner, but did you know that it can be used medicinally for urinary problems? Pregnant women are prone to urinary infections and cranberry juice can be a useful preventative – but it must be sugar free juice. A few people are allergic to cranberries, especially those who have asthma or who are allergic to aspirin and excessive consumption of the juice can cause irritation when passing urine.
Who doesn’t enjoy a few dates from those little wooden boxes at Christmas? However, whilst dried dates are suitable for pregnant women, fresh Medjool dates should be eaten in small amounts if you are pregnant. Research has shown that eating several large fresh dates every day in the last weeks of pregnancy can trigger labour contractions – but it’s best not to go mad on them at Christmas if you are not yet ready to give birth. Indeed, in some Middle Eastern countries dates are considered to be “forbidden fruits” in pregnancy.
Frankincenseevokes the sense of Christmas, perhaps more than any other spice. It is, however, a useful medicinal plant, being antiseptic and very good for colds and nasal congestion. The essential oil is a particularly useful one for stress and anxiety and is what Denise calls “the ultimate calmer”. It is especially effective for the transition stage of labour, just before the baby is ready to be born – just sniffing a couple of drops on a tissue calms you down (don’t put it in the birthing pool). If using it in a diffuser at home, just turn it on for 15-20 minutes – this is enough to fragrance the room for a good couple of hours and avoids overwhelming the air with the chemicals in the oil as it can cause headaches or nausea in some people.
When I was a student midwife in the late 1970s we offered parentcraft classes to all pregnant women and their husbands (I use the word advisedly). This meant that there was plenty of opportunity for students to observe midwives conducting classes and we then had to prepare and teach a class ourselves under supervision.
Classes started at around 34 weeks'gestation and we offered a.course of six sessions that usually included fetal development and dealing with"minor disorders" (rather late); one class on normal labour and one on complications (very scary), one on pain relief when the anaesthetist would come and talk about pethidine and Entonox (the dads liked this one and would often go off to the pub with the doctor afterwards!), a session on baby care in which we demonstrated baby baths and a session on infant feeding in which we covered breast feeding and demonstrated how to make up bottle feeds.
Most classes were offered in the daytime, usually in the afternoons, and the lecture was followed by an hour of relaxation in which the expectant mums would lie on mats on the floor in long rows. They were encouraged to go through some basic breathing techniques for labour with muscle relaxation - this was called the modified Laura Mitchell technique and included some guided imagery to music, followed by a period of sleep (the original "hypnobirthing").
Some classes excluded husbands, to offer the choice of being in a women- only group, but there were no specialist classes for women with different needs. All women were addressed as "Mrs" - in my unit this followed a survey in the clinic in which we asked women what they wanted to be called - even the very few unmarried women wanted to be addressed as Mrs so they didn't stand out and risk married women's disapproval!)
There was no mention of natural remedies - indeed, I remember one of my first classes as a community midwife when a woman expecting her first baby was not only insisting on a homebirth but was intending to receive acupuncture from her acupuncturist husband - what a maverick!
Neither was there any mention of rushing to get into labour. Women - and doctors - understood that babies come when they're ready and induction was not the cloud hanging over women that it is today.
Some advice we gave back then would raise eyebrows today. For example, to stimulate lactation women were advised to eat a Mars bar every day (for the sugar) and drink a glass of Guinness (for its iron content).
At the end of each class the students would make the tea and all the women would sit around chatting whilst the midwife answered individual questions. The women really got to know one another and often made lifelong friends. It was all very civilised and student midwives learned a great deal, not only about delivering antenatal classes but also about women, their families and the psychosocial factors that impacted on their pregnancies and labours. Oh - and we also learned how to make a good cup of tea!
Today, in what is bound to be a controversial discussion, Denise comments on the numerous worrying posts on social media from aromatherapy and reflexology groups which have caused her to reflect on professionalism in the complementary therapy disciplines.
I see dozens of posts on social media about complementary therapies and have become increasingly concerned about their professional calibre. Blanket suggestions on using aromatherapy in pregnancy come with no warnings about precautions. Some posts advocate aromatherapy for babies and toddlers, yet it should never be used on or near newborns and rarely, if ever, for toddlers. I've also seen posts on aromatherapy for animals despite the fact that many of the oils can be toxic to household pets.
Even more worryingly, I frequently see pictures of client's feet in reflexology groups posing questions to members on what the possible "diagnosis" might be and asking for suggestions for treatment. No indication is given as to whether client consent has been obtained, and making a diagnosis is impossible without a history and full examination. That's without the fact that reflexologists are taught that they should not "diagnose".
Whilst there are many highly professional complementary therapy practitioners including many who have additional training to treat people with specific clinical conditions, such as cancer, multiple sclerosis and - of course - pregnancy, this sort of posting does the complementary therapy disciplines no favours in terms of credibility, both with the public and with colleagues who are registered healthcare professionalsOf course, you could argue that these ideas are on social - rather than professional -media which has hundreds of inappropriate and dangerous suggestions on all sorts of topics. However when inaccurate and potentially harmful advice is offered by so-called professional practitioners it causes me real.concern. I worry not only about the level of knowledge, understanding and experienc; of the individuals posting, but also, vicariously, about the impact on the wider disciplines of complementary therapies.
Having worked in midwifery complementary therapies for almost 40 years, I have been part of the movement to professionalise complementary and alternative medicine (CAM) that was particularly active in the 1990s when the then Foundation for Integrated Medicine, with the patronage of HRH Prince of Wales, campaigned for increased standards of education and research to facilitate greater integration of complementary therapies with conventional.medicine.
Since then CAM has lost much of its impetus although disciplines such as osteopathy and chiropractic are now firmly included, by law, in the allied health professions and acupuncture and medical herbalism are self-regulated and have high levels of training and professional Codes of Practice to monitor standards. Sadly, however I have to question whether aromatherapy and reflexology have slipped backwards into simply being relaxation therapies with no real professional or clinical credibility.
Denise is having a busy week in the office, preparing the prospectus for the new.academic year's courses. She is delighted, but not surprised, already to have received applications for our unique Diploma in Midwifery Complementary Therapies for next September from some very enthusiastic midwives, several of them wanting to combine this with our Licensed Consultancy scheme for private practice. However she questions why so.many.midwives in the last.few.years have been keen to explore the move into having their own businesses offering maternity services such as complementary therapies,. antenatal classes and breast feeding support. Denise says:
Midwives love caring for expectant parents but need also to care for themselves. Midwives are leaving the NHS in droves, newly qualified midwives are choosing not to practise and older midwives are retiring early - and it seems as if this is due, at least in part, to burnout. It may also be due to the insidious erosion of the midwife's role or the risk-averse, litigation-conscious, blame-throwing culture of the NHS.
Conversely, midwives are beginning to realise that the NHS doesn't own them and that they are entitled to use their considerable skills,.knowledge and.expertise to.provide women with what they want - services that are generally not available on the NHS. In the UK there is a grave misconception amongst midwives (and nurses) that they are trained by - and therefore solely for - the NHS but this simply isn't true. Qualification grants midwives a licence to practise midwifery anywhere and in whatever way they choose, subject to national law and professional regulations.
Further, there is a demand from expectant parents for services to be available that provide them with services that ease their progress through pregnancy and birth and transition to becoming a parent. These services are not available in the NHS largely because the maternity services are obstetric-led for the benefit of the majority of users. The maternity services remain focused on the biological (physical) wellbeing of pregnancy and, give less credence to the psychosocial elements.
Pregnancy is a stressful time, more so now than ever before. To be able to call upon a professional who can provide relaxation treatments such as massage or reflexology, antenatal advice and support or specialist services to ease backache, nausea or avoid induction of labour is very appealing to many during pregnancy, and expectant parents are often prepared to pay for them.
Our team of Expectancy-trained midwives working in private practice is growing and more and more women are discovering the benefits of having the support they can offer. This current academic year we had more midwives than ever before choosing to join us to train as Licensed Consultants so that they too can provide a range of complementary therapy services for expectant and new parents. Why don't you come and join us?
Denise was delighted to receive a ‘phone call this week from an old friend, Fiona. Denise, who developed and managed the BSc (Hons) degree in complementary therapies at the University of Greenwich, and Fiona, who was a health visitor, were lecturers in complementary therapies in the 1990s and early 2000s and were both instrumental in promoting the practice of complementary therapies within their respective professions. As is the way when you have not heard from someone for a while, they fell to reminiscing about the “good old days”. Denise left the University of Greenwich in December 2004 to set up Expectancy and Fiona reminded her of those early forays into freelance work.
Denise had arranged her very first private aromatherapy course for midwives and had booked a room in a small local hotel to run the course for eight weeks on a Tuesday evening from 5-8 pm. Nearing the day, she was worried that only four midwives had booked on the course and she asked Fiona if she should cancel it – to which Fiona replied “absolutely not!”. In order to boost numbers to a viable group, Denise then offered the course at a knock-down price to some of her midwifery friends, asking them to act as a pilot, so in the end there were eight midwives who attended.
The course was not without a few issues. The hotel room overlooked the car park and the windows did not have curtains wide enough to close – so when the midwives were due to do the practical work, including back massage for labour, they had to tape all their coats over the windows to stop hotel residents coming in from the car park from looking into the room. Another problem was that all the midwives had rushed to the hotel ready to start the course at the end of an already tiring day of clinical work. Denise had originally requested teas and coffees to be available – but the midwives were so hungry and tired on that first day that she ordered chips to be brought in with the drinks. This became the routine every week and it was great fun studying aromatherapy whilst munching on hot chips with salt and vinegar – but Denise does admit that it meant she made no profit at all from that first course! Thankfully, things have improved and although she no longer provides chips with the courses, midwives still keep coming and Denise has now taught complementary therapies such as aromatherapy to over 3000 midwives since starting her business in 2004. Fiona was obviously right then!
The use of complementary therapies (CTs) by expectant parents is at an all-time high – but are they actually safe? Today, Dr Denise Tiran considers the minefield around the advice available to those expecting a baby who wish to use therapies such as aromatherapy, acupuncture, reflexology and herbal medicine. She says:
The advice pages on www.NHS.org.uk take a cautious approach to CTs, stating that there is generally insufficient research evidence to support their use during pregnancy, yet making blanket statements for the apparent safety of massage, aromatherapy and (incorrectly) ginger for pregnancy sickness. The National Institute for Health and Care Excellence (NICE) goes further by actively discouraging women from using modalities that, they suggest, are inadequately researched. Similarly, Cochrane systematic reviews, whilst being somewhat more sympathetic, also consider the inadequacy of research on the safety of CTs for pregnancy and birth. Unfortunately, these national guidelines fail to acknowledge the huge number of expectant parents seeking support from professional therapists or – more worryingly – self-administering natural remedies. CTs such as massage, aromatherapy, and reflexology are commonly used for relaxation; acupuncture and hypnotherapy are accessed for the treatment of specific physical and emotional symptoms. Natural remedies (NRs), including aromatherapy oils, herbal medicines and homeopathic remedies, are increasingly being used at home to prepare for and encourage the onset of labour.
The issue of research evidence is almost irrelevant if CTs and NRs continue to be used by expectant parents (and by those attempting to conceive). Certainly, the amount of evidence available is limited and largely explores the effectiveness of different CTs – it is impossible to conduct formal research into the safety of different types of CTs. So how should maternity professionals advise expectant parents about CTs and NRs? It is a difficult balancing act for midwives, doctors, doulas and others providing care for the pregnant population. Simply advising against CTs and NRs risks people using them surreptitiously without informing their maternity care providers. Avoiding the subject altogether similarly risks people taking remedies or receiving CTs which may be inappropriate at that time and potentially harmful. Lack of knowledge amongst health professionals risks them giving inaccurate or – more often - incomplete information which may equally compromise maternal, fetal or pregnancy wellbeing. Conversely, advocating the benefits of CTs and NRs without adequate and specific knowledge, may lead to side effects and complication from inappropriate use.
Suggested guidelines for maternity professionals and complementary therapy practitioners working with expectant parents:
We are delighted to announce that our very own Denise Tiran, CEO and Education Director for Expectancy, has been awarded an honorary doctorate by the University of Greenwich for her pioneering work in developing “complementary therapies” as a specialist area of practice, education, research and publication in midwifery. Her award was conferred at a graduation ceremony held mostly online on 27th October, but Denise was able to visit the University and receive her award in person from the Vice Chancellor (socially distanced, of course).
Denise, who also received a Fellowship from the Royal College of Midwives in 2018, says;
I am so proud to receive this honour from the University of Greenwich where I spent many happy years as a midwifery lecturer and had the opportunity to develop the UK’s first practice-based BSc (honours) degree in complementary therapies. I feel the award acknowledges the area of complementary therapies as a specific discipline and aids the credibility of a subject that still has many sceptics. This award is not only for me; it is for all those midwives who are interested in complementary therapies, all those I have taught, both in the University and, since 2004, via my own company, Expectancy, around the world. Most of all, it is for my son, Adam, who makes it all worthwhile – looking forward to celebrating with friends and family when circumstances allow us to be together again.
Denise reflects on changing childbirth since she first became a midwife over 40 years ago.
When I was first a midwife, women became pregnant spontaneously, if they were lucky - there was no fertility treatment available for those who could not conceive. The maternity benefits system allowed those who worked to start maternity leave at around 32 week's gestation without financial penalties so they could test and prepare for the birth and parenthood.
Pregnancy was accepted as a set of physiological symptoms and women coped with the sickness, backache and swollen ankles. Labour started when it started and lasted as long as it took.....
There were no scans in pregnancy and no monitors in labour - midwives and doctors used their five senses to monitor progress and wellbeing of mother and baby. There were no epidurals for pain relief - but midwives had time to be "with woman" and provide physical and emotional support.
Caesareans were rarely carried out and only for life threatening emergencies. Mostly women stayed at home to care for their babies and the local community provided support for new families.
Today, couples often leave it late to start a family whilst they develop their careers. When they decide it's time, they expect to get pregnant immediately but are often too stressed out by daily living for the body to do its work.
Once pregnant, women expect to sail through the next nine months and become frustrated when their bodies let them down and they experience the natural aches and pains of pregnancy. They expect (or need) to work almost up to the estimated due date, stop work, go into labour spontaneously and give birth in precisely the way they have planned, whether it is completely naturally or with all the technological interventions available - and feel disappointed and let down when labour doesn't go along with their plans. Parents assume their babies will feed regularly and sleep contentedly between feeds so they can continue with their normal (pre-baby) lives, including returning to work within a few weeks.
Many people planing pregnancy are not well-enough nourished today, despite the plethora of foods available. Environmental pollution adds to the imbalance of healthy chemicals in the body, affecting fertility, as does the negative energy from technology - mobile phones, computers and more. Posture is adversely affected from too much sitting in cars or at work and not enough walking. the incidence of breech pregnancy is higher because the ergonomics of our bodies has changed and women are not on their hands and knees scrubbing the kitchen floor as they did in the 1970s - the ultimate optimal fetal positioning.
Added to this is all the social stress - the negativity in the world, politics, pandemics and a social expectation that you must have a perfect pregnancy (what ever that is) and be seen to be a perfect parent. No wonder pregnancy, birth and parenthood is so stressful.
It concerns me when I see posts from pregnant women on social media trying to find answers to questions that cannot always be answered. Maternity professionals need to encourage expectant parents to chill and take it as it comes a little more. Of course there are some with very real physical, mental or social problems but for those whose pregnancies are progressing well, enjoy it and don't let it get you down. Go with the flow and don't expect too much. Consider all those aches and pains as good signs that your body is doing its work well. And look forward to the birth as "the end of the beginning".
A few words from Denise about Expectancy’s essential oils supplier, Absolute Aromas
I have known David Tomlinson, owner and managing director of Absolute Aromas for over 25 years, having met him at one of the annual complementary medicine shows that used to be held every year in Earls’ Court. He and his wife, Kay, are lovely and very knowledgeable about essential oils. Their company has grown considerably since I first met them and they are now based in Alton in Hampshire.
The essential oils are of very high quality and I have used them ever since I met David. We use them on the Expectancy courses (although I always make the point I am not on commission!).
Midwives who have completed our courses can also purchase the specially compiled Expectancy kits for maternity aromatherapy – there is a full set of the 16 essential oils we teach on the courses, together with some carrier oil, a mixing glass and stirrer in a wipe-clean carry case, with space for more oils.
More recently, as a result of changes to our courses due to Covid, we have been teaching our aromatherapy courses online and each midwife who attends receives a mini kit with twelve of the 16 oils we teach, in a lovely wooden presentation box.
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.
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.
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.
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
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!
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.
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.
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.
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 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".
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.
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.
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 email@example.com for more information.
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.
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”?
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
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 firstname.lastname@example.org for more details.
“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!”
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Old Books For New:
Z is for ZuSanLi
Y is for ylang ylang