This week is World Reflexology Week!

Reflexology in pregnancy can offer a range of potential benefits for expectant mothers, including:

• Relief from pregnancy discomfort
• Stress reduction
• Preparation for labour
• Improved sleep

During my time at the University of Greenwich, I discovered that by using foot reflex zones linked to the reproductive tract and pituitary gland (based on my research), I could identify different stages of the menstrual cycle in non-pregnant women with a 65-70% success rate.
I've since taught midwives worldwide how to perform this assessment through my courses.

Complementary Therapies and The M25 

I frequently drive along the M25 motorway around London, particularly the stretch from southeast London to Heathrow.  As I drive, I’m struck by the analogy between drivers on these busy roads and midwives venturing into the field of complementary therapies (CTs).

Having been practising, teaching, researching and publishing on CTs for over 40 years, I consider myself an experienced “driver” of this aspect of midwifery care. I was in the right place at the right time to pioneer the subject as a midwifery specialism in the early 1980s. I’m well qualified in several therapies and practise safely; I recognize difficulties and can deal with them, or recognise when to withdraw temporarily. I understand where I can cut corners and when I need to `drive by the book' and I’m fully informed about the rules and regulations relating to practice, both in CTs and in midwifery.

But what about those midwives who are only just starting out on their CTs journey? In observing other road users on the M25, I can see that midwives are similar to many drivers – the plodders, the safety conscious, the sceptics and the mavericks.  

There are the “lorry drivers” who proceed slowly in the inside lane, struggling up the inclines and rarely able to overtake others, but eventually reaching their journey's end. This is similar to midwives who press on competently with their existing practice, but who are fearful of moving out of the `slow' lane to drive new initiatives. There is nothing wrong in this: we need midwives to deliver fundamental services in the same way as lorry drivers deliver goods around the country. Midwives who are “plodders” wanting to introduce CTs into practice, may take a long time to make it a reality, but are safe, reliable, conscientious practitioners. They’ve thought through all the issues, sought answers to numerous questions and eventually achieved their aims of enhancing care for women with CTs.  

Next come the safety conscious midwives, like mature, experienced drivers whose reactions may be slower but who painstakingly observe all the rules of the road. Their practice of CTs is based on adequate and appropriate preparation and adherence to the laws, regulations and guidelines dictating safe practice. These are by far the most professional when it comes to using CTs in midwifery practice, with a focus on both theoretical and practical training and an acknowledgement of prescribed boundaries, especially within the NHS. 

Conversely, there are those maverick lorry drivers who rampage along the motorway, tailgating other vehicles and – increasingly – breaking the law by moving into the outside lane in their time-restricted rush to get where they’re going. Similarly, drivers of fast sports or status cars - the typical exhibitionist “boy racers” - believe they can charge along with little regard for others, blaring their horns or flashing their lights to make their presence felt so that everyone else is forced to make way for them. This is a case of appearances being deceptive, of course, because these drivers may be no better (and are sometimes considerably worse) than the more cautious ones. They antagonise fellow road users and are a danger to themselves and others. 

Midwives who advocate the `racing car approach' to implementing CTs, often with a misplaced ideal of being the first or the best, are far more likely to make mistakes and cause safety issues that could result in a managerial knee-jerk response of abandoning the CTs services. There is more to it than looking good on the surface whilst vociferously forging ahead with ideas and ideals at the expense of colleagues who work more slowly but with more attention to detail. Implementing CTs into midwifery care will be far more effectively achieved by respectful, professional and reasoned dealings with colleagues than by riding roughshod over sceptics or those who are already working in their own professional `fast lanes' in different ways.

Likewise, the `white van syndrome' is also inappropriate. We have all had experience of the drivers of transit vans, often tradesmen, attempting to force us into slower lanes so they can get ahead. Increasingly too, there are those who disregard the rules: I’ve seen impatient white van drivers barging their way across several lanes to exit the motorway at the last possible minute. Many are so familiar with their route that they become complacent with the task of driving, preferring instead to monopolize and control the road and its users. 

Complacency is definitely an issue for midwives, especially those who have been using CTs for some time. They may think they are competent because they have refined their practical and manual skills, but this does not make their practice contemporary, nor is it necessarily safe or evidence based. As regular readers of my blogs will know, this is a group of midwives which concerns me greatly. Failing to keep up to date, arrogantly believing that they’re “experienced” and know what they’re doing, can only lead to safety incidents, some of which have come under national scrutiny in recent years. There is no place for those wanting to use CTs to demonstrate either complacency in their work or superiority over colleagues. There is always something to learn from others, most of all the need for good teamwork. Those who think they know it all will eventually make mistakes which may be fatal to themselves, their colleagues and even the people in their care.

There is also the novice motorway driver. In order to venture onto the motorways a full driving licence is required and drivers should preferably have some experience of driving on non-motorway roads. In the same way, midwives moving into the field of CTs must be qualified and experienced clinical midwives in order to add to their basic practice. It is daunting taking those first journeys into a new area, especially when others may appear competent and confident. Sympathetic drivers already on the motorway may slow down to enable newer ones to join the road, and this should also be the case when introducing CTs into midwifery care. Often those who are new to the road take time to learn and understand what they’re doing - and may sometimes remind more experienced `drivers' of some of the rules they have recently learned. 

The road itself often presents dangers and problems. The surface may be icy, blocked by debris or altered by new roadworks, and drivers need to negotiate their way around carefully. Possession of well-developed driving skills, knowing the rules and regulations and remaining alert to changes all contribute to achieving a safe journey. Midwives using CTs must be appropriately skilled, cognisant of relevant local, national and international rules and must take account of new developments in practice and policies in healthcare. 

There is one section of the M25 between the junctions of the M3 motorway and the M4/ Heathrow turn-off where mandatory variable speed limits are imposed at peak hours to regulate traffic flow. These can be likened to clinical guidelines on CTs in midwifery, which are used to protect the public (and practitioners) and avoid individuals becoming too independently autonomous at the expense of safety. It is occasionally necessary to slow down the pace of change in order to consolidate what has happened so far and prevent enthusiasts from racing forward inappropriately. Once the restrictions have passed it is perfectly acceptable to regain speed and press on.

So where do you fit in with all this? Are you continuing to be the plodding “lorry driver” or the newly licensed novice lacking in confidence? Do you want to be seen as a sports car or white van driver? Do you recognize the ups and downs of the road? Are you familiar with the rules and regulations? Will you reach your destination or fail at the first set of “roadworks”? Whatever category you fit into it is ultimately essential to appreciate that we all have a part to play in the greater journey we are taking together - with care, attention and integrity we will all achieve a safe and satisfying outcome and complementary therapies will hopefully become integral to midwifery care.

This blog post is adapted from a 2000 article I wrote for the Complementary Therapies in Clinical Practice journal. Unfortunately, things do not seem to have progressed very far in some respects. Whilst CTs are far more prevalent in maternity care and midwifery practice, we still have midwives who want to be sports car drivers and rush ahead without planning, or lorry drivers who break the rules. There are still midwifery managers who do not acknowledge the need for proper training and expect staff to teach others immediately after learning CTs themselves, despite the recognition that all other aspects of midwifery require consolidation and experience before passing on the mantle to others. And we still have midwives who fail to update because they believe themselves to be experienced, yet conveniently forget the NMC requirement to remain updated in all aspects of their work. 

Today is Expectancy’s 20th Birthday! 🎉

For two decades, we’ve proudly remained the only company worldwide dedicated to providing professional academic courses that teach midwives and birth workers how to integrate complementary therapies into their care.

From designing our unique programmes to launching the signature Licensed Consultancy, it’s been an incredible journey preparing midwives to build their own businesses in maternity complementary therapies.

Thank you all for your unwavering support—here’s to another twenty years! 🌟

Pass The Baton - Where Is The Next Generation Of Leaders In The Specialism Of Midwifery Complementary Therapy?

Whilst in Tokyo recently, I was invited to contribute to an aromatherapy forum discussion on changes in the profession. One question focused on how - indeed, whether - the aromatherapy world is preparing the next generation of authorities for the profession as it moves towards the 2030s. Those who have made a name in aromatherapy, such as Robert Tisserand, Gabriel Mojay and Kurt Schnaubelt - and my host was kind enough to include me in this group - are reaching an age when we will all soon be retiring and leaving day-to-day involvement in the discipline. Yet there is no name that shouts out to us about who might be one of the next generation of aromatherapy leaders.

This led me to thinking about the midwifery specialism of complementary therapies (CTs) and to whom I should hand over the baton when I retire (not that I intend to, yet!). Many midwives are interested in CTs but are not fully qualified in any therapy. It is important to acknowledge that the field of “complementary therapies” is not just about aromatherapy (the most commonly used therapy in pregnancy and maternity care) but requires training and a comprehensive academic knowledge of several other therapies. Whilst interest in a subject is a great starting point, developing an area of expertise requires dedication, a lengthy time commitment and a single-mindedness that is similarly applied to achieving a PhD. However, having a postgraduate qualification in a subject does not, in itself, make an expert in the overall subject matter. Within midwifery, becoming a specialism leader requires a combination of advanced clinical practice and academic involvement including teaching, research and publication. 

However, most midwives have not been in positions to enable them to gain wide clinical experience of using CTs in their practice. Yes, there are many several midwives who have introduced an aromatherapy or postdates pregnancy service and sustained their involvement in CTs, but most have other roles within the organisation and are unable to focus solely on CTs. Almost all of these midwives are not qualified teachers (as is required by the therapy regulatory bodies), nor have they engaged in the higher-level teaching of colleagues (and I don’t mean “cascade training” here).  There are a few senior academics in the UK and Australia who have engaged in research around midwifery CTs, but who do not necessarily have the direct clinical experience of working with CTs in pregnancy and birth. Additionally, whilst most of these have published their research, which provides a valuable contribution to the subject area, very few, if any, have added to the textbooks available on the subject. 

That “complementary therapies” is an established specialism within midwifery is still under debate, despite my having spent forty years developing it. Many still see CTs as an add-on to physiological birth care, but do not appreciate that there are many more facets to the specialism that should be incorporated into midwifery education, at least as a post-registration activity. I have long campaigned for pre-registration education to include a general introduction to the subject, but lack of educators with adequate knowledge and understanding of this vast subject area means that inclusion in the programme is patchy at best. Acquiring a working knowledge of CTs in midwifery is NOT just about learning some massage and throwing a few aromatherapy oils about. It requires an understanding of safety and safe practice, and an ability to apply the principles of the therapies to their use within midwifery practice and their self-administration by expectant and birthing parents.  

So which midwives are interested in developing the requisite skills, knowledge and attitudes to become the new leaders in midwifery CTs? Where are they – and importantly, how can we prepare them to continue CTs as a midwifery specialism and to develop it further? I have a few colleagues whom I would trust to take over my own work – but that is not the only issue here. We need new leaders who can sustain the subject of complementary therapies as a significant field within maternity care.

Our Woman In Tokyo

I've been coming to Tokyo since 2001, incredible to think that's almost a quarter of a century. Apart from the pandemic years, I've made the long journey at least I once, If not twice a year, and occasionally even three times .

Safe Care Cannot - And Should Not - Be Done On The Cheap

This slogan refers to the Royal College of Midwives' campaign calling for better salaries for midwives, implying that better funding for recruitment and retention leads to safer care for mothers and babies.

However, this same principle also applies to the introduction of new practices, including complementary therapies. Any new initiative requires a financial and educational commitment to ensure safety.  I find it inconceivable that midwives want to introduce complementary therapies to facilitate physiological birth - yet they want to do so as cheaply and quickly as possible with no investment in training or professional development.

I was recently contacted by a birth centre manager interested in training 20 midwives in aromatherapy, acupressure, moxibustion for breech and reflexology - and wanted me to do this in a single study day! This is not an uncommon request, which is triggered by a laudable interest in and enthusiasm for complementary therapies, and a lack of understanding of what each therapy involves or how difficult they can be to learn the knowledge and skills effectively. This particular request involved four different therapies and professional disciplines requiring a minimum of ten days' training to prepare midwives to use the therapies effectively and safely.

Midwifery budget holders want to be seen to be introducing new initiatives to reduce intervention yet fail to recognise the need for comprehensive training of both the midwives who will practise the therapies and the managers who will monitor standards of practice. They have little appreciation of how complementary therapies need to fit into NHS care and the various laws and regulations relating to their use. 

Further, there is concern amongst complementary therapy educators and regulators about other professionals "cherry picking" aspects of therapies to add to their own professional disciplines. We would be horrified to think a therapist would want to study a few days of midwifery and then go out to practise - or even worse, to teach it to others, yet midwives and their managers sanction this very same concept when it comes to complementary therapies.

SAFETY in midwifery requires comprehensive theoretical as well as practical education so that midwives can apply the principles of each therapy to its practice in maternity care. It requires an understanding of how to minimise risk and how to practise cost effectively and equitably as well as safely and effectively and in line with available evidence.

Other experienced midwifery educators will attest to the general decline in students' desire to understand their practice (becoming a knowledgeable doer) and an increase in just becoming a "doer" without that underpinning knowledge. In today's fast paced world students want to "achieve" their certificates as quickly and cheaply as possible, especially as pre-registration students are generally "customers". 

However, when it comes to complementary therapies as a post-registration option, it is even more essential to be knowledgeable enough, not only to be able to justify their actions but also to counter the sceptics. Perhaps even more crucially, since midwifery complementary therapies have come under national scrutiny by the CQC and Ockenden review teams in some units, adequate education of an appropriately academic calibre is paramount to SAFE practice. 

In twenty years of Expectancy, I have always stuck to my absolute belief that safety, professional accountability and evidence-based practice are fundamental to the use of complementary therapies by midwives. This has often been at the expense of my business, but I steadfastly refuse to compromise my own principles to offer courses that do not adequately prepare midwives to practise complementary therapies SAFELY. I am always happy to offer a single introductory awareness study day to interested midwives and students - but the profession must understand that this, in no way, prepares midwives to practise the therapies. So - to quote the RCM - Safe care cannot - and should not - be done on the cheap, either in terms of cost or education.

Guest Blog : Annual Networking Day

I recently had the privilege of attending the Expectancy Annual Networking Day in London, for the “endorsed by Expectancy” midwives working in private practice .

The event was set up to network, share experiences and to explore successes and hurdles encountered with the daily running of their midwifery businesses. Some midwives are already in business and some are bravely starting up their own — I am sure this opportunity served as a valuable insight into setting off on the rewarding yet sometimes intimidating path of going it alone. Denise was there to offer sound business advice and encouragement, she must be very proud of her midwives — and rightly so! 

It was lovely to hear people talk about their reasons for having gone it alone, how they came to that decision, and how things are going for them now. It’s been a difficult time in the UK of late, but I really admired their determination to press on, adapt to changes and grow their businesses.

It was clear from the pulse in the room that the discussions were hugely beneficial for the fledgling midwifery entrepreneurs in attendance. The opportunity to explore business issues together and share information and advice was inspiring for all involved. Not to forget the camaraderie which was so vibrant and motivating. 

We all left feeling positive, full of inspiration and determined to keep flourishing. I salute these lovely and enthusiastic midwives — you are wonderful ambassadors of the Expectancy community! 

Why I Love Reflex Zone Therapy 

Having trained in aromatherapy and massage, I decided, for some unknown reason, to train in reflexology in 1989. Like many others, I naively thought reflexology was just foot massage – but I was in for a big shock. The course I started was not actually reflexology in the standard sense, but a very specific form of clinical reflex zone therapy, a German style devised by a former midwife. In the UK, the British School of Reflex Zone Therapy was headed up by a very formidable South African lady, also a former midwife, who knew her stuff and ruled us with a rod of iron – but how blessed we were to be taught by her.

Training at the end of 1989, my son was only nine months old at the time and I was still breastfeeding him. During the first weekend of the course, I realised I was producing much more milk than before I started the training. When I asked the tutor why this had happened, she explained that we had been practising the day before on the parts of the feet that reflect the endocrine system and that the student I was working with had slightly over-stimulated the reflex zones on my feet relating to the pituitary gland. These was my ah-ah moment and my lifelong fascination with reflex zone therapy was born.

Many midwives have heard me tell this story before, but this was only the beginning. I went on to develop and refine my skills and experience in reflex zone therapy and over the next fourteen years I treated almost 6000 pregnant women with a variety of symptoms and antenatal and postnatal issues. For a while, having experienced shocking pregnancy sickness myself, I specialised in treating women with nausea and vomiting and developed new theories about the causes of the issue and new reflex techniques to treat the problem. Sometimes, using something I call the “advanced technique” – a rather forceful toe-twisting manoeuvre - I could treat a woman in just ten minutes, reducing the severity of her symptoms almost immediately.  I learned ways to treat other symptoms such as backache, sciatica and pelvic girdle pain or carpal tunnel syndrome, with short dynamic, focused treatments, a necessity when my clinic at that time was NHS-based and a teaching clinic for my students at the University of Greenwich.

The focus of my work was less on relaxation therapy and more on resolving specific problems, although most women reported feeling much more relaxed even when the hands-on treatment was only fifteen or twenty minutes. Whether this was directly due to the manual treatment or the fact that women had an opportunity to talk to me and to have their symptoms validated, is debatable and was probably a combination of both. Everyone working with complementary therapies understand the power of holistic therapies and the importance of reducing stress hormones to enable an increase in feel-good hormones including endorphins and oxytocin, both so fundamental to progress in pregnancy and birth.

I was in an invaluable position, being a university lecturer, to undertake research on reflex zone therapy and other complementary therapies and to spend time writing for publication. Although my book, Reflexology for Pregnancy and Birth was published in 2010, the gist of it is still valid today, apart from the research component which is, of course, now quite old. As the years went by, I actually made some changes to parts of the map used in reflex zone therapy (which is different from those used in other forms of reflexology) and did some research into using the reflex points on the feet to predict stages of the menstrual cycle. I am over 70% successful in being able to detect whether a woman is in the first pre-ovulatory or later post-ovulatory stage of the cycle, to identify which is the active ovary of the month and to predict when the next menstrual period will commence, certainly to within a day or two.

This led on to becoming absolutely fascinated by what the feet can tell us. I have a friend in South Africa, Chris Stormer, who is a worldwide authority on reading the feet, who first introduced me to this element of the therapy (although her style is very different from mine). Chris takes a more spiritual approach to foot reading, almost an esoteric approach, whereas I am firmly focused on the anatomical and physiological aspects of detection from the feet. Many reflexologists are taught that they should not “diagnose” but this is largely to avoid those who are not conventional healthcare practitioners from making assumptions about what they see or feel on the feet. In my opinion, it is difficult to avoid making some form of diagnosis about wellbeing of the client, otherwise we would not be able to individualise the treatment to her specific needs. I have detected various medical issues via the feet and was once asked by an obstetrician if I would try to find a diagnosis because the medical staff had been unable to do so. I can often tell you which teeth need filling, whether you have had an appendicectomy or hysterectomy, or whether to advise someone to get their breasts checked for lumps.

This is what makes reflex zone therapy so amazing. It is not just a relaxation therapy, but a very powerful clinical tool, both to aid diagnosis and treatment. In midwifery, I have used RZT techniques to treat gastrointestinal, musculoskeletal and reproductive system issues. In pregnancy, RZT can be used to treat almost all physiological symptoms and to prevent some complications from becoming more severe. Later, it is invaluable for aiding the onset and progress of labour, easing contraction pain and dealing with retained placenta. Postnatally, it helps recovery from birth, eases complications from epidural or Caesarean labours and encourages lactation.

Later, when I set up Expectancy, now in its 20^th year, I started to teach reflex zone therapy to other midwives. Initially, I offered a short course of three days but soon realised not only was this not enough to gain practice and understanding of such a dynamic and complex therapy, it was also too much for midwives to receive repeated treatments from fellow students on three consecutive days. I changes the course to two 2-day blocks which was less stressful for the students’ physiology, but still didn’t give enough time to learn the theory and engage in the practice to feel entirely confident in using RZT in clinical practice. The course was finally expanded to a six-day course, one weekend per month, which gives time to practise in between study blocks and provides midwives with some fascinating insights into the power of reflex zone therapy.

Although I am experienced in practising and teaching several different therapies in midwifery practice, reflex zone therapy remains my favourite. I have practised, studied, researched and taught it now for 35 years and still love it – although the impact on my somewhat ageing hands is beginning to tell (repetitive strain). Although I could probably not now practise regularly on real clients, if I had to give up teaching it I would be very disappointed. I am still learning about German reflex zone therapy and other forms of reflexology and hope to be able to do so for many years to come.  

Annual Networking Day

Saturday 13th July saw the annual networking day for our Licensed Consultants – midwives who’ve completed their studies and are already in business as well as those just finalising their plans to start up a private maternity complementary therapies practice. We got together for a relaxed day of chatting about our businesses and meeting new midwives. We started with networking bingo where everyone had to talk to each other to find out interesting facts such as “I love rice pudding” or “I’ve changed jobs in the last year” , We went on to explore our successes and challenges from the past year as well as planning our goals for the coming year. We also enjoyed a lovely lunch from the local falafel shop.

My Favourite Aromatherapy Oils

My absolute favourite essential oil is lime – to me it smells like the old-fashioned Opal Fruit sweets (not Starburst!), you can even taste it in your mouth because the smell and taste senses are closely linked. Lime is a gentle oil and can be effective for sickness in pregnancy but also goes well with many other oils to balance some of the heavy aromas of oils such as black pepper or ylang ylang. Should be avoided by anyone allergic to citrus fruit such as oranges.

Ylang ylang is another firm favourite, which is surprising as it is quite a heavy floral aroma and something I don’t usually like. The oil comes from the flowers of an Indonesian tree. Ylang ylang is incredibly relaxing and can be sedative so useful for relaxation and aiding sleep. It is also claimed to be aphrodisiac, presumably because it is so relaxing.  It blends well with lighter oils such as lime, grapefruit and even cypress. In practice, my only precaution is to avoid it when working with women with postnatal depression – it is so deeply relaxing that it seems to push negative emotions deeper inside, whereas these women may benefit from more uplifting oils.

Spearmint is also a firm favourite. It has a lighter aroma than peppermint but is equally as effective for nausea and vomiting in pregnancy and during labour. Spearmint is a very uplifting oil and enhances the mood. It is a good oil to use for pain relief in labour and can be helpful for headaches (with the proviso that they are not a symptom of pre-eclampsia) and for respiratory congestion, coughs and colds.

My least favourite oil is geranium – indeed, after many years of using it when teaching,  I am now allergic to it, developing headaches and nausea and increasingly experiencing throat irritation when inhaling it. This is an important issue to take on board when using essential oils and I always discourage midwives learning aromatherapy from using oils which they dislike. This is due to certain smell receptors in the nose being aggravated by one or more chemicals in the oil – and repeated use will exacerbate this effect until eventually an allergy can occur. Having said that, many women like geranium and it is a useful oil for relaxation and aiding labour progress.

The Conveyor Belt Of Childbirth

OK, so now we have a new US research paper concluding that epidural in labour reduces maternal morbidity by 35% (Kearns at all, BMJ 2024). Of course, it's a team of anaesthetic and obstetric doctors which has completed the study, which gives it the political power to affect policy and to lead organisations such as NICE potentially to recommend epidural in labour as the optimal method of pain relief. If this happens, epidural will become even more of a routine than at present, with even more risk of needing other interventions in labour, likely leading to Caesarean section.

Intervention in birth is at an all-time high, to the extent that it affects service users, service planners and service costs. Women are either petrified that they will be coerced into unwanted and unwarranted induction or Caesarean, or conversely, they have lost all confidence in the ability of their bodies to give birth naturally. Midwives are fast losing their knowledge, skills and understanding of birth as a physiological process, and have certainly lost their confidence to enable women to labour spontaneously. Service managers and budget holders have completely lost sight of the fact that physiological birth is cheaper, more fulfilling for parents and staff and far less likely to lead to ultra-expensive litigation.

Having trained as a midwife in the middle 70s,. I've seen the battle for "normal" childbirth go round and round. In the 1980s we had the Maternity Care in Action reports, in the 90s it was Changing Childbirth and more recently we've had Better Births. Despite these initiatives, we are further away than ever from physiological childbirth and midwifery seems almost to be a dying profession. The incredibly vocal anti-natural childbirth lobby has inveigled itself into the debate too and is using the sad loss of many babies to add weight to the argument that medical management of birth is essential, a move guaranteed to increase unnecessary intervention.

Midwifery is no longer the autonomous ,champion of birth that it was 50 - or even 20 - years ago. Midwives in the NHS are bowed down by petty rules and regulations, too much paperwork and not enough time to care for parents. Childbirth is a conveyor belt of monumental proportions, In which all parties - parents, midwives, doctors, managers - are supposed to know their places in the system and behave accordingly to avoid breakdowns that might interfere with the complex mechanism of the maternity services. The more checks and balances we put in, the better that mechanism will run - supposedly - but at what cost?

Woe betide any maverick who challenges the system. They are subjected to coercion and emotional blackmail if they are service users, or to extreme bullying and unnecessary managerial processes if they are staff. This means that everyone either puts up and shuts up or leaves the system. Parents choose to employ independent midwives or Douglas or even to freebirth, while midwives and doctors leave their professions completely or risk alienating themselves by daring to work in private practice. 

I am not alone in despairing for the maternity services, for expectant and birthing parents and for the midwifery profession. I recently saw a post from another Facebook page, In which someone with a well-paid but unfulfilling job was considering training as a midwife and was asking midwives whether it was a good idea. Without exception, all the respondents said "don't do it" - a very sad indictment indeed for the profession. Yet if the current midwifery profession doesn't encourage new blood, the only thing that will change is the loss of midwifery as we know it and the further pathological approach to birth.

Best Foot Forward: Teaching Reflexology In Hong Kong 

I was so excited to be back in Hong Kong last week for the first time since before the pandemic. Travelling Business Class on BA, I was able to benefit from the new “pods” which provide an individual little area with a flat screen for films and, more importantly, a flat bed, so much more comfortable than the previous arrangement which required stepping over the next passenger’s feet to get out to the washroom during the night. I arrived on the Saturday afternoon, well refreshed, and was met by my lovely colleague Elce, head of the school of midwifery at the Prince of Wales Hospital. All week, I was so well looked after and treated as an honoured guest, being presented with a School of Midwifery teddy bear at the end of my stay – he had to be rather ignominiously shoved into an already full suitcase as I was leaving straight for the airport to come home.

In 2019, I had taught aromatherapy but this time I was asked to teach two 2-day introduction to reflexology courses for almost 60 midwives. This proved logistically challenging as the close supervision required to ensure students can accurately locate and palpate reflex points on the feet means that I usually only have about 12 in a group in the UK (and the course is six days, not just two). We also had some ongoing discussion before I left the UK about a suitable bed / couch on which I could demonstrate and how to position the midwives so they could comfortably work on their partners’ feet. For the first course, we had everyone working on mats on the floor although this was not particularly comfortable, so we arranged the second course with everyone working on chairs, which was much better. The midwives were fascinated by reflex zone therapy and learned a mini relaxation and some first aid points for treating women with backache, carpal tunnel syndrome, constipation, heartburn and, of course, pain relief in labour.

Midwifery practice in Hong Kong is very similar to UK midwifery, unlike in mainland China which is even more medicalised than the UK. Currently, the Beijing government is challenging midwifery numbers, claiming that there are too many midwives in Hong Kong. This is despite midwifery managers and educators stating that there is a shortage of midwives. The government has counted all those on the midwifery register but not accounted for those who have returned to nursing (midwifery is a post-registration qualification) or those who are not working at all at present. My colleague had a busy week of meetings to discuss this issue as it is likely to impact on student midwife numbers.

Back home, I had one day to recover and then it’s back to work with a vengeance as we come to the end of the current academic year and assignment marking and prepare for the new intake of midwives starting in September. Before that, I have my second trip of the year to teach aromatherapy in Tokyo and then I am back in Hong Kong in October to speak at the Normal Birth conference. Happy days!

Safe Use Of Natural Remedies In Pregnancy: Guidelines For Maternity Professionals

The use of natural remedies is at an all-time high, especially in pregnancy. Women are advised not to take drugs unnecessarily, yet many do not appreciate the potential risks of inappropriate self-administration of herbal and other remedies. Natural remedies (NRs) have, of course, been used for centuries and were traditionally a significant part of midwifery care until around the 17^th century when the emerging medical and pharmaceutical professions took control of healthcare. We know that, today, around 80% of expectant parents resort to complementary therapies and particularly to self-medication with NRs, perhaps as a means of recapturing some of that control of pregnancy and birth that has been lost in the mists of time. Herbal medicines, including many traditional and folk remedies, act in exactly the same way as drugs (and can interfere with them). They are not regulated in the same way as drugs and are relatively easy to access in health stores.   

Midwives, doulas and doctors may be asked for information or advise on herbal remedies such as raspberry leaf tea for birth preparation, clary sage and other aromatherapy oils for use in labour or to avoid an induction or, occasionally on homeopathic medicines such as arnica for perineal bruising. However, this is not a subject that is taught within pre-registration training for midwives and obstetricians, despite the increasing use by the public. Whilst herbal medicine is a self-regulated profession in its own right with graduate level training of at least three years, the issue for birth professionals is not those women who consult medical herbal practitioners but those who wish to use remedies and oils at home, sometimes without adequate knowledge to use them safely.

Many people, including conventionally trained healthcare professionals, believe that because these remedies are “natural” they are also safe – but this is not the case. Anything that has the power to do good also has the potential to do harm if not used appropriately. No remedy is suitable for every expectant, labouring or newly-birthed woman – and many are not suitable at all.

So how can maternity professionals advise expectant parents? Here are some guidelines to help you:

• All NRs should be treated with the same respect as that given to pharmaceutical drugs.

• No remedy should be used routinely for prolonged periods of time and NEVER as a replacement for proven medical treatment, especially in the event of an emergency.
• Women should be advised to avoid ALL NRs before and during pregnancy, labour and breastfeeding unless under the supervision of an appropriately qualified, insured professional.
• Women should be asked at their first antenatal appointment to reveal if they are using any NRs and their answers recorded in the maternity notes.
• Women should be advised to seek professional advice on NRs and not to rely on information obtained from the Internet, social and other media or friends and family.
• Women should be informed that not all NRs are approved, regulated or evidence based. NRs obtained from the Internet may be falsely labelled, contaminated with chemical impurities or contain banned or toxic ingredients.
• Women should be informed about the possible risks of taking pharmacologically active herbal remedies or using aromatherapy essential oils, including adverse effects such as allergies and interactions with other NRs, prescribed medications or foods.
• Advise women against combining several different NRs / complementary therapies: take only one remedy at a time, particularly at term when women may seek to expedite labour.

• Aromatherapy essential oils should not be applied to the skin neat; they should not be taken orally, rectally or used in or around the vaginal opening; keep away from eyes. Avoid using oils in the birthing pool.

• Pregnant maternity professionals and birthing companions should avoid exposure to (inhalation of)  essential oils intended to promote uterine contractions during labour eg clary sage, jasmine.
• NRs should be avoided / discontinued in the event of any medical, obstetric or fetal pathology, either pre-existing, gestationally-induced or occurring incidentally during pregnancy, labour or postnatally.
• Maternity professionals should consider the possibility that deviations from normal progress in pregnancy or labour may be linked to undisclosed use of NRs.
• Women admitted to the antenatal ward have, by definition, pathological complications requiring medical attention; they must be asked directly if they are self-administering NRs.
• Women should be advised to discontinue all pharmacologically active NRs (herbal and traditional medicines) at least two weeks prior to elective surgery or dental extraction to reduce the risk of excessive bleeding.

Why is it that “money” is a dirty word in the NHS?

Recently, I was teaching aromatherapy and acupressure to midwives at a large London hospital. In the course evaluation, I was accused of being too commercial because I was providing information on my textbooks (offered for sale as a learning resource) and on other courses they could take with Expectancy (in response to direct questions from a few midwives). This was not only distressing but blatantly unfair as I am always conscious of not being overly “sales-y”. This was a group that had been funded by the NHS trust to attend the course – and who were also able to attend it in their work time – so there was no obligation to appreciate the financial element of having the course.

Why is it that “money” is a dirty word in the NHS? Did the midwives think the course was provided free of charge? Did they not recognise that the training not only cost the fees that were paid to Expectancy by the trust but also that the clinical hours “lost” to training had to be replaced with other midwives? Further, did they think I was providing it from a misplaced sense of altruism? Midwives do not seem to understand that everything costs money – and that they are paid for the services they provide in the form of a salary. Just because no money physically changes hands at the point of providing the service does not mean our “customers” (expectant parents) are not paying for it. Healthcare costs the UK over £180 billion a year and is funded largely through taxes - so working people pay for the NHS, including care for those who do not pay tax. However, ask any midwife how much it costs for a spontaneous vaginal birth, a Caesarean, a urine specimen pot or an epidural and no one can tell you – a factor that contributes to huge wastage since employees do not have to take personal responsibility for equipment, medicines and other tools used in client care, unlike in the private sector.

Midwives who choose to go into private practice, whether as independent midwives providing full birth services or in a self-employed capacity offering services such as pregnancy complementary therapies, antenatal classes or tongue-tie division, are often castigated by colleagues because they dare to charge their clients. Yet there are services provided in the private sector that are not available on the NHS – and which some expectant and birthing parents choose to access and to pay for.  Similarly, increasing numbers of midwives are choosing to work outside the NHS – perhaps because they want a better work-life balance or are committed to offering services less accessible in the NHS. This is, as I have said before, about choices.

Prospective clients know that there will be a charge, should they choose to access private services – and it is not a problem for them. If they don’t want to pay it, they don’t become clients. If they become clients, they are happy to pay. Midwives who choose to work for themselves usually find it really difficult to price their services and to ask clients for the money – but they need to tackle this issue if they are going to be successful. If a midwife goes to the hairdresser, she expects to pay the going rate – so why is it so difficult to ask to be paid for the services offered? Obstetricians who work in private practice have no such qualms – although in fairness, they usually have an administrator who actually invoices their clients, effectively removing doctors from actually asking for the money. It would, however, be well worth any midwife considering private practice to have a chat with an obstetrician about this aspect before they set up their business.

Charging a realistic price for services can make the difference for a self-employed midwife between success and failure. Being aware of exactly what it is they are charging for is the first step on this difficult road. Prices are based on costs of training, setting up the business, costs of the actual service equipment and other aspects that have to be factored in – insurances, unpaid holidays of sick leave, legal and accountancy services and much more. On my business training days, we discuss “money” a lot and try to work out realistic pricing strategies so that clients feel they are receiving value for money without being fleeced, and midwives feel appropriately remunerated to fund their lifestyle without the guilt of over-charging. It’s a fine balance, but one that has to be confronted. If you’re considering starting your own business – come and find out how to “get over ” the charging-for-services  hurdle!

It’s Aromatherapy Awareness Week!

I strongly believe in the power of holistic care for expectant parents and maternity service professionals.

As a midwife, staying updated with the latest advancements in aromatherapy and other complementary therapies is essential.

We recommend updating your aromatherapy knowledge every two years to ensure you provide the best care possible.

Tips for practitioners:

🌸 Start with basic essential oils like lavender and sweet orange for relaxation.

🌸 Integrate aromatherapy into birth care to create a calming environment.

🌸 Stay informed about the latest research on aromatherapy benefits and risks.

Learn new knowledge and skills on our Expectancy Certificate in Midwifery Aromatherapy.

Making The Move To Starting Your Own Maternity-Related Business

So … you have decided to set up your own business … but where do you start? It’s vital to research what you want to do and how you want to do it. Don’t be tempted to rush ahead with enthusiasm as this may cause you to make mistakes (which can be costly – professionally, financially, or even legally) or you may find you have to “unpick” something you initiated too early. I have mentored many midwives who become so excited about branching out on their own that they forge ahead with ideas that are only partly thought-through, often with disastrous consequences (I’ve also done it myself in the early days!). Make sure you are deciding on private practice for the right reasons – are you moving towards something better or running away from an untenable situation? 

Once you’ve decided that you really do want to set up your own practice - and having looked honestly at your reasons for doing so - you now need to start by making some concrete plans. Decide on the specific services you wish to provide and consider how you would like to provide them. Take time to think about things, leaving it for a while and going back with fresh eyes once you have had time to consolidate your ideas. Try to identify exactly what you wish to offer – if you don’t know, then neither will your potential clients understand what you are offering. It’s also counter-productive to include too many different elements at the start of your new venture and you need to be flexible enough so that other services can be added later.

When I set up Expectancy, I made the mistake of trying to be all things to all my potential customers. I wanted to offer clinical services to pregnant women, as well as professional courses. Not only did I want to provide education for midwives, but also for doulas, antenatal teachers and therapists. This meant that I was trying to spread myself and my colleagues (and my limited advertising budget) across at least four different markets. Indeed, my adverts were completely unclear because we had tried to have a “one size fits all” leaflet – which just did not work. Everyone was confused – including the team. It was only later that I made the decision to focus solely on offering professional courses preparing the students to provide their own clinical services that it started to make sense. When I finally decided to concentrate entirely on marketing courses and business services for midwives there was a consequent substantial growth in income. If I’d taken time and explored specifically what I wanted to do, I may have achieved success more quickly and more productively. You can’t start everything at once, and your business will develop as you grow.

Discuss your thoughts and plans with your family, your colleagues and, if possible, talk about your ideas with potential users of your services. Is there a market in your area for what you want to offer, and will women pay for it? You will need to be aware of what’s available to women via your local NHS services. For example, if you’ve decided to offer postnatal care and lactation services, be sure that you know how much - or how little – of this is provided by the local maternity services. Similarly, it would be difficult, both in business and professional terms, to offer a service for women who want to avoid induction of labour by accessing complementary therapies if your local maternity unit had already implemented a postdates pregnancy clinic. Perhaps you could start earlier than 40 weeks’ gestation and offer a pre-birth preparation package instead? Research the competition and look at ways in which you may be able to offer something different or better. Which service providers in your area are successful, or more successful than others? Do they have a particular focus on how they market (sell) their services? Are there other midwives or doulas in your area already offering what you are considering?

Taken from Denise’s book The Business of Maternity Care, a guide for midwives and doulas setting up in private practice (Tiran 2019)

What Is A Practising Midwife?

Why is it that many midwives believe - incorrectly - that those who are not working in NHS clinical midwifery are not practising midwives? 

 I recently saw a Facebook question asking who had left midwifery and wanting to know what they were doing now. Almost half of respondents actually stated that they had "left" midwifery - yet they were still registered for NHS bank work or had roles that required a midwifery (or nursing) registration, such as safeguarding. There were one or two ex-midwives now working as doulas (in which case they are required to lapse their midwifery registration), but the majority were practising midwives by virtue of still being on the NMC register, even if they were not employed by the NHS.

This disrespect for midwives not working in NHS clinical practice extends across the whole profession. At the recent RCM annual conference, I overheard a midwife joking about a colleague having "gone over to the dark side" ie, into midwifery teaching. When I left the university sector, where I had worked as a midwifery lecturer, to set up Expectancy, I had colleagues wishing me well "on my retirement" - despite the fact I was about to embark on a journey on which I would work harder than ever before. There was even one who implied that I could not possibly be as good a lecturer now I was about to go freelance as I had been the previous week when I had been employed.

Even at the highest levels, there are often comments made about the number of midwives who have "left" the profession. And yes, midwives are leaving the NHS in droves, but they have not all rescinded their midwifery licence to practise. Some move into independent midwifery, whilst others set up their own businesses providing maternity complementary therapies, antenatal education, lactation support or tongue-tied division. Leaving the NHS to work in a self-employed capacity is seen as traitorous by many, and the notion of actually charging for their services is the ultimate treachery. This is despite the fact that these same midwives do not work for nothing in the NHS - they receive a salary.

When I teach business studies to the midwives who join Expectancy to start their own businesses, we spend some time discussing their personal attitudes to becoming self-employed and to physically charging for the work they do. There are some who never quite overcome what I call "the NHS mentality" - and who consequently only achieve a "hobby business" that they enjoy and that gives them some pin money for a few extras in their lives. But there is a growing number of midwives who embrace this new challenge wholeheartedly and who become successful as "endorsed by Expectancy" business owners.

The nature of maternity care is changing and pregnant women are increasingly prepared to pay for what they want. We talk a lot in midwifery about giving women choices - but what about the midwives? Don't they deserve to be able to make choices about the way they work? A qualification in midwifery prepares you to practise midwifery anywhere in the world (subject to local national requirements) and in any setting in which pregnant, birthing or new parents require our support. This includes teaching and private practice. The NHS doesn't own you and charging for your professional midwifery services is not the heinous crime some would infer.

Let's learn to respect ALL our midwifery colleagues wherever and however they choose to work. The term "practising midwife" refers to anyone with a midwifery qualification who - in the UK - is currently registered with the Nursing and Midwifery Council.

The Power of Reflexology: Predicting Stages of the Menstrual Cycle

Reflexology is a popular relaxation therapy and often used as a therapeutic technique to ease physiological discomforts of pregnancy and the postnatal period. “Reflexology” is not a single complementary therapy, but a generic term for a wide variety of different modalities. The principle of all types of reflex therapy is that one small area of the body (usually the feet) represents a “map” of the whole, with all parts of the body reflected in that defined area. Almost all styles of reflex therapy focus primarily on using the two feet to represent the “map” or chart of the whole, with every part of the body identifiable on one or both feet, although the precise location of different organs varies considerably between different styles of reflex therapy. The application of manual pressure to specific points aims to induce a sense of relaxation, relieve pain, reduce stress and, with some modalities, to treat specific clinical conditions. By working on these precise points on the feet, impulses are thought to be directed to the various organs, having a physiological effect on that distal part of the body to which the foot point relates.

Most forms of reflexology currently used in the UK, USA and southern Europe are based on modified versions of early 20^th century charts. In the 1950’s, a German midwife, Hanne Marquardt, refined reflexology into a dynamic clinical tool for treating various clinical conditions. The Marquardt style of reflex zone therapy (more recently renamed as “reflexotherapy”) is notably different from generic reflexology, with a different “map” of the feet, different terminology, different therapeutic techniques and different pressures. It is commonly used by midwives in Germany, Switzerland, Austria and Scandinavia. RZT is the basis of my personal style of practice which I have taught to many midwives around the world and Expectancy is the only UK organisation offering RZT courses specifically for midwives.  

RZT can be useful from the preconception period to the end of the postnatal period. Regular reflexology treatments allow women to take time for themselves; the accumulative physical and emotional effects assist in preparing them for the birth through a proven reduction in stress levels which automatically increases oxytocin levels. When physical discomforts occur during pregnancy, specific techniques can be used to reduce symptoms such as sickness, backache and sciatica, carpal tunnel syndrome, constipation and oedema. Receiving regular RZT in the final weeks of pregnancy may contribute to spontaneous labour onset, reduced duration of the first stage and greater parental satisfaction.  During labour, it can reduce anxiety, pain and duration of the first stage. 

Many reflexologists claim to be able to “read” the feet and there is growing evidence to suggest a correlation between reflexology points and physiology as well as actual, impending or previous pathology. From my work whilst at the University of Greenwich, I found I was able to identify stages of the menstrual cycle in non-pregnant women, using the foot reflex zones for the reproductive tract and the pituitary gland (a different location from most styles of reflexology, defined by my own research). It is possible to identify in non-pregnant woman with average 28-day menstrual cycles whether they are in the follicular or luteal stage of their cycles, which ovary is active and then to predict the date of onset of the next menstrual period. My results showed a 65-70% success rate and I have since taught midwives on my courses how to do this assessment.  I also adapted the technique to enable an estimation of the onset of labour based on palpation of the two reflex zones for the pituitary gland. Accumulated experience over many years suggests that the pituitary reflex point on the right foot is tender throughout pregnancy, inferring that it is consistent with ongoing anterior pituitary activity. However, the pituitary point on the left foot becomes increasingly tender as term approaches, potentially reflecting the changes in hormonal activity as pregnancy hormones decline and labour hormones increase in readiness for the birth. When the pituitary zone on the woman’s left foot is more tender than (or at least equal to) that on the right, this suggests that labour is imminent, albeit based on a subjective assessment by the woman on the severity of tenderness. The pituitary gland reflex zones are fundamental to midwifery practice of RZT and the primary points to be stimulated for facilitating labour onset. In addition to using this point for postdates pregnancy or to avoid early term induction. It is also useful for encouraging progress in the latent phase of labour, as well as for stalled first stage, retained placenta and, postnatally for lactation, all of which rely on the production of oxytocin. 

If you would like to learn how to use RZT in midwifery, including estimating stages of the menstrual cycle and onset of labour, contactinfo@expectancy.co.uk for details of our Certificate in Midwifery Reflex Zone Therapy commencing 28^th September 2024.

Aromatherapy in Fife

I can hardly believe that April is almost over. Time has flown by so quickly!

One of my highlights was leading the aromatherapy and acupressure course for postdate pregnancy in Fife, Scotland.

It was wonderful visiting the midwives who are eager to embrace the nurturing aspects of midwifery and to establish a service for women seeking alternatives to induction for being overdue. They are committed to promoting natural birthing processes and reducing medical interventions at the unit.

Twelve enthusiastic midwives are now dedicated to this new initiative!

A special thanks to Louise Hepburn and the group for their warm hospitality. 

What has happened to childbirth?

When I teach our postdate pregnancy courses, midwives tell me that term labour is considered to be “overdue” if it has not started spontaneously by 41 weeks and five days gestation or – if you’re lucky – by 42 weeks.

Why are obstetricians – and increasingly, many midwives - so frightened of physiological birth that they feel the need to manage it as a pathological medical condition?  

Why is there such an obstetric dependence on measuring time limits or other numerical markers? Induction rates and other interventions have sky-rocketed, with some units having a 60% induction rate.

There is so much reliance on watching the clock that we are producing midwives who have rarely witnessed an entirely physiological birth. I talk more about the “Institutional Ticking Clock’ in my  blog post.

You can read it here - https://pulse.ly/ukzr1isgag (Photo: Mateus Campos-felipe via Unsplash)

Denise looks back

On my first trip to teach obstetricians in Hong Kong in 2001, I visited a typical Chinese medicine clinic, which was a fascinating experience.

Acupuncture was sometimes used as the primary treatment for a condition, sometimes with herbs or massage, and sometimes the patient was referred to the "bone-setter", who appeared to be a sort of Chinese osteopath.

However, on this trip, my medical peers, trained in the West, had mixed feelings, especially witnessing the informal atmosphere of the clinic and unconventional methods of prescribing herbs.

Yet, years later, I've seen Traditional Chinese Medicine (TCM) evolve into a blend of tradition and modernity in clinics across Hong Kong, China, and Taiwan - bustling, professional, and as popular as ever.

With nearly 66,000 hospitals and 19,000 clinics dedicated to Chinese medicine in China by 2019, and an increasing amount of research evidence, it's clear: TCM's impact is profound and growing.

Raspberry Leaf – Not A Way To Start Labour

Did you know that raspberry leaf tea (or tablets), one of the most popular herbal remedies used by pregnant women, should not be used to trigger labour contractions? Whilst almost 60% of pregnant women in the western world may be self-administering raspberry leaf, it is of concern that over 50% of midwives, doulas and antenatal educators may be advising women (incorrectly) to take it as a means of avoiding.

The active ingredient is primarily fragarine, which works on smooth muscle and aids cervical ripening. Taking raspberry leaf in the third trimester has been shown to reduce the likelihood of pregnancy going beyond term and may lead to a shorter first stage. Another ingredient, quercetin, is thought to have vasodilatory effects, both on the systemic circulation and the respiratory tract (it is sometimes used for asthma), as well as on other systems containing smooth muscle such as the gastrointestinal tract. Women desperate to avoid induction who start drinking copious amounts of the tea or taking excessive numbers of tablets are more likely to overstimulate the uterus, leading to hypertonic uterine action and fetal distress.

Raspberry leaf should generally be avoided in the first and second trimesters unless prescribed by a qualified medical herbalist, who may use it to prevent or treat threatened miscarriage. However, women should not be advised to wait until 37 weeks’ gestation before commencing it as it is a preparation for birth, toning the muscles of the uterus in readiness for labour. It should be started in the third trimester - one cup of the tea daily, increase gradually to two, then to three a day over three-week period. Overdose has been shown potentially to prolong pregnancy and the duration of the first stage of labour, probably due to the quercetin. The tea can be drunk in labour until well established and in the early postnatal period to aid uterine recovery. Indeed, raspberry leaf should not be discontinued suddenly – the amount should be reduced slowly over two or three weeks to avoid sudden relaxation of the uterus, leading to haemorrhage.

However, when it comes to commercially prepared raspberry leaf tablets or capsules, information via the internet is inconsistent, with advice to take between one and four tablets, with strengths between 35mg to 750mg per tablet. Some sites advise commencing from 30 weeks’ gestation until birth, daily or twice daily, plus, somewhat confusingly, a product marketed as 750mg tablets (no specified daily amount), “suitable for use after the third trimester of pregnancy and beyond birth”. However, the general advice for the capsules seems to be to take between one and two 750 mg tablets daily (approximately equivalent to one to two cups of the tea made from fresh leaves) from about 30-32 weeks’ gestation for the remainder of the pregnancy. Since these are not regulated under medicines law, no medicinal claims can be made, nor are the manufacturers required to provide any further safety advice beyond that required for nutritional supplements in general. As with many products, the “get out” clause on some products may simply state “do not take in pregnancy”, whereas those purporting its value in pregnancy generally do not include any precautions beyond the suggested gestation for commencing the remedy. Many years ago, there was a raspberry leaf product labelled “do not take until two hours before labour” – although I am not sure how you would know when that was!

There are certain expectant parents for whom it is not appropriate, including anyone with medical or obstetric complications, those requiring elective Caesarean for specific indications and – crucially – those with a scar on the uterus from a recent Caesarean (within the last 2-3 years). This latter is a difficult one because so many women wanting a vaginal birth after Caesarean try anything and everything to avoid another operative birth.  Raspberry leaf should not be taken in combination with oxytocic drugs or natural remedies with similar effects such as clary sage aromatherapy oil, castor oil or evening primrose oil which may be used to start labour, nor if there is any smooth muscle condition such as irritable bowel syndrome or hypertension. It appears to have some anticoagulant action so should not be used if a woman is on anticoagulants or other drugs including aspirin and enoxaparin. It can sometimes cause excessively strong Braxton Hicks contractions, in which case it should be reduced – but not stopped suddenly. 

The Institutional Ticking Clock: Have We Lost Sight Of What Is Normal?

When does a physiological labour become pathological? When I teach our postdates pregnancy courses, midwives tell me that term labour is considered to be “overdue” if it has not started spontaneously by 41 weeks and five days’ gestation, or – if you’re lucky – by 42 weeks. If you’re unlucky, then the cut-off might be 41 weeks and 2 days. There are also those women who are recommended to have labour induced even before their estimated due date for various medical, obstetric or social indications, occasionally justifiable but frequently questionable, such as high BMI or even – until challenged vociferously – ethnic origin.  Further we have the issue of the definition of “latent phase” of labour, in which any woman whose labour has not become “established” within a certain time limit (variable) is advised to have intervention such as artificial membrane rupture or oxytocic drugs to accelerate the process. Similarly, a “prolonged” third stage is defined as one in which the placenta has not spontaneously separated and been expelled, usually around an hour after the birth of the baby. The concept of a vaginal breech birth or twin delivery is alien to most midwives even though there may be no deviations from physiological progress.

What has happened to childbirth? Why are obstetricians – and increasingly, many midwives - so frightened of physiological birth that they feel the need to manage it as a pathological medical condition? Why is there such an obstetric dependence on measuring time limits or other numerical markers? There is, in fact, a difference between the parameters defined by the NHS and those who work outside it. Women who choose home birth, especially with an independent midwife, or those who wish to freebirth, do not rely on these time constraints and labour progresses at its own rate. As a community midwife in the 1980s, I knew of several women whose pregnancies lasted 43 weeks, those who had latent phases of 48 hours or longer and others who had third stages lasting up to four hours (myself included in this latter case, with a first stage of 24 hours at home). Even in the 1990s, an obstetric colleague was happy for some women to wait up to 44 weeks before being advised to have an induction of labour – because he trusted in the ability of a woman’s body to do its own work. 

Induction rates and other interventions have sky-rocketed, with some units having a 60% induction rate. This includes one large tertiary unit with 8000 births a year, in which women are coerced into induction for often-unspecified reasons, then has 20-25 women per day who have delayed inductions due to lack of bed space (despite having had the fear of God put into them by forceful doctors or midwives). This is clinical negligence in the extreme, yet the professional governing bodies, the scrutineers such as the Care Quality Commission, and NICE which sets practice guidelines, do not appear to recognise nor acknowledge this, nor do they express any concern for the very real possibility of the cascade of intervention leading to Caesarean section or risks of fetal or maternal morbidity and even mortality. 

There is so much reliance on watching the clock, that we are producing midwives who have rarely witnessed a completely physiological birth – and students who are now permitted to record as “normal” a birth in which they may have cared for a woman for the first stage and helped her to birth her baby, but who have had to step aside because a manual removal of placenta is required. If this was not allowed, they would likely never meet their 40 required “normal” births. But these are NOT normal, indeed, neither is a labour in which the third stage is actively managed with drugs to expedite the separation of the placenta, although this has become standard practice. As educators, we are producing midwives who are basically obstetric nurses, who lack the knowledge, understanding and experience to facilitate physiological birth, and the “dumbing down” of educational requirements is complicit in this. Clinicians are putting babies’ and women’s lives at risk, and managers and budget holders are basing decision making on financial and institutional factors rather than clinical factors.  

The simple answer is that maternity professionals are scared. In an overworked, blame-throwing, litigation-conscious autocratic and paternalistic maternity service, midwives and obstetricians do “the job”. At the risk of criticism, I would almost – but perhaps not quite yet – say that many midwives are no longer autonomous birth professionals, able to assess progress in pregnancy and birth, to facilitate a woman’s body and mind to grow and birth a baby, to encourage her to make her own decisions based on being given comprehensive information to make an informed choice and to have the confidence to deal with a situation when things do start to go awry.

This leads expectant and birthing parents to be scared – but they may not be aware that what they are scared of is not pregnancy and birth. They are scared of the system which attempts to manage them for its own benefits. Yes, we have a totally overburdened workload, we have far more women with complex pregnancies than ever before and a pregnant population that expects a “service” that is individualised and gives them what they want. But those who are assertive enough to express their wishes, especially if those wishes go against NICE guidance and unit policies, are often labelled as “difficult patients” or are told that there are not enough facilities to “allow” them their rights, for example having a home birth on the NHS. Those who do not baulk against the system and who unquestioningly accept what is provided often have unsatisfying experiences which can have a lifelong impact on their relationships with their babies and partners.

For all expectant parents, pregnancy and birth has become a battleground that causes immense stresses – the very fact that interferes with the fine balance between stress hormones and birth hormones. Lip service is paid by professionals to relaxing pregnant women and to providing information to answer their myriad questions, despite evidence indicating that these can facilitate physiological birth. Some maternity units provide complementary therapies during first stage labour (primarily aromatherapy) but so much more could be achieved by offering more during pregnancy. We have also largely lost the provision of antenatal education within the NHS, although the increasing number of options for those families who wish to pay for classes is admirable and offers a much-needed service. However, despite this, women mostly give birth in NHS services where the “institutional ticking clock” interferes with parents’ choices – and even with the actions of the most well-intentioned midwives. Let us learn to stand back and facilitate birth from the sidelines for those who progress is within physiological – not institutional – norms.

Forty Years In The Making! Denise Celebrates A Milestone In Her Career

April 4^th marks 40 years since I started teaching midwives. I qualified as a nurse and midwife in the 1970s. After a short time on the labour ward back at St Bartholomew’s Hospital in London,  I was accepted as a “district” midwife in Surrey, which I loved. In 1984 I decided on a change of direction and went into midwifery teaching, starting as an clinical tutor at the Middlesex Hospital in Goodge Street, London (which closed in 2005). Here, I was responsible for the 4-week maternity secondment that all student nurses were required to take, so I had a new group of students every four weeks. I had a little classroom and worked alongside the students in the clinical areas – with a labour ward that had only three rooms.

About 18 months later, I moved to the British Hospital for Mothers and Babies (BHMB) in Woolwich, southeast London, where I stayed until going to Surrey University to complete the postgraduate education certificate. BHMB was a wonderful place to work, a tiny, personalised, Christian hospital, where even in 1980s, prayers were still said on the wards every morning. I suppose it was what would be classed as a large birth centre now. We did have an operating theatre, but unfortunately, we didn’t have an anaesthetist or obstetrician onsite. For any emergencies and for the very few elective Caesareans (always scheduled for Fridays), the medical team would come from the Brook Hospital about two miles away. We didn’t have CTG machines or epidurals and students really learned to use all their senses to assess women’s progress in labour. Ultrasound scans were not routine – and not available at BHMB – and we were sometimes faced with sad consequences, such as a baby born with anencephaly (a serious neural tube defect) who died shortly after birth. One of the downsides of these rare occurrences was that everyone was encouraged to go and see the baby and his abnormality – in the sluice. Baby loss was not dealt with as compassionately in the 80s as it is now.

Following my time away at the university, I returned to teaching, but BHMB had closed in one of the early rationalisations of the maternity services, so I was sent to Queen Mary’s Hospital at Sidcup (now also closed). It was here that my interest in complementary therapies started and where I was able to develop it as a specialist field in midwifery. Having undertaken a massage course in 1984, I returned to Queen Mary’s and started to teach massage and touch for labour care. I went on to train in reflex zone therapy (a German clinical style of reflexology) and aromatherapy. In 1990, the Greenwich and Bexley schools of midwifery and nursing were incorporated into what became the University of Greenwich and we transferred from being employed by the NHS to become university staff. The benefit of being part of the academic institution was the opportunities to develop areas of interest and expertise and I was able to develop, first, a post-registration module for midwives and nurses on complementary therapies, which evolved into one of the few BSc (Hons) degrees in complementary therapies, which I managed for 14 years. During this time, I also studied other therapies including acupressure and moxibustion, herbal medicine, homeopathy and Bach flower remedies.

As part of this work, I established a complementary therapies antenatal teaching clinic at the hospital, where student midwives and those on the degree programme could observe and gain experience in working with pregnant women receiving different therapies. This wasn’t simply a relaxation clinic but offered alternative options for women with problems such as sickness, backache, fear of labour, postdates pregnancy and more. Over a ten-year period (1994-2004), I was privileged to treat almost 6000 women and gained immense experience of combining therapies for different conditions. However, as with any large institution, I eventually became burned out with the university bureaucracy and the changes occurring in the NHS. I was aware of the huge increase in interest amongst the general public in the use of “alternative” or complementary medicine and had been active in some of the national initiatives including the Prince of Wales’s Foundation for Integrated Health. I also knew that midwives in particular were frequently asked about natural options but were unsure where to learn more; conversely, expectant parents wanted to explore these options but didn’t know where to find credible practitioners.

I decided to leave the university and set up Expectancy in 2004 to offer academic and professional complementary therapy courses for midwives and birth workers, as well as for therapists wanting to specialise in working with pregnant women. This was, by far, the scariest thing I have ever done, and a real change from being a highly paid principal lecturer in the university sector to having to charge for services and build up from nothing, working in the commercial sector. As far as I know, Expectancy is the only  company in the world offering a unique range of courses on midwifery complementary therapies and has gained a reputation for high calibre university level education that focuses on safety and professional accountability when midwives use complementary therapies in their care of expectant and birthing parents.  I am proud to say that Expectancy celebrates its 20^th anniversary on September 4^th 2024 – watch this space for more about that later in the year.

A Career Milestone!

Join me in celebrating a remarkable milestone in my career! 

This week, it's been forty years since I embarked on a journey in midwifery complementary therapies education. I can't quite believe it!

Here's a flashback photo of me at the beginning of my career in the 1970s when I was training as a nurse at St Bartholomew’s Hospital, London.

I went on to train as a midwife at Northwick Park Hospital in North London, before returning to work on the labour ward at Bart’s. I was then a community midwife in Surrey before moving into midwifery teaching in 1984 at the Middlesex Hospital, London.

My career then took me to the British Hospital for Mothers and Babies in Woolwich, and it was here and in subsequent positions that I honed my expertise, both in midwifery and in complementary therapies. This field was in its infancy back then.

At Queen Mary's Hospital in Sidcup, my passion for complementary therapies, such as reflex zone therapy (clinical reflexology), and aromatherapy, grew. When midwifery education joined the university sector, we became part of the new University of Greenwich.

I was given opportunities to develop courses that combined midwifery with complementary therapies, reflecting the growing interest in complementary medicine among the public and professionals alike.

I developed and ran a BSc (Hons) degree in Complementary Therapies and established a specialist teaching clinic for students to gain experience of using therapies for pregnant women, which was honoured in the Prince of Wales’s awards for healthcare in London in 2001 (see pic!).

In 2004, recognising the increasing need for credible professional education in complementary therapies, I set up my own company providing courses for midwives wanting to learn more about the subject.

Expectancy is unique in offering a range of university-level courses and is committed to ensuring that midwives practise complementary therapies safely, professionally and in line with current evidence.

I'll be reflecting on my journey with pride and gratitude this week.

A Big Welcome To The Expectancy Community!

I want to reintroduce myself to new followers and connections and a big welcome to the Expectancy Community! 

I'm Dr Denise Tiran, an internationally recognised expert on complementary therapies in midwifery, a field I've pioneered as both an academic and professional speciality since the early 1980s.

As founder, CEO and Education Director of Expectancy, I lead in providing unique complementary therapy courses for midwives both in the UK and abroad, having taught nearly 4000 professionals and helped numerous maternity units adopt therapies, particularly aromatherapy for pregnancy and birth care.

Throughout my 40-year career, I've been dedicated to safety, accountability, and evidence-based practices in midwifery, earning notable accolades like an honorary Doctorate from the University of Greenwich and a Royal College of Midwives’ Fellowship. My work with Expectancy, which won a 2012 award for our educational contribution to complementary medicine, has made significant impacts in midwifery.

At the University of Greenwich, I launched one of the first undergraduate degrees in Complementary Therapies and ran a specialist clinic that supported nearly 6000 mothers.

My research, textbooks, and published papers have advanced complementary therapies in midwifery. I've also played a key role in developing professional guidelines, including the recent RCM guidelines for midwives using complementary therapies. I have been privileged to act as a trusted consultant on maternity complementary therapies.

I love connecting with midwives, maternity and birth workers, and complementary therapy practitioners who want to progress in their careers either within the NHS or privately.

Breast Feeding

Whilst I am all for people’s choices and enabling those who wish to live different lifestyles to do so, I am concerned that this article (and a few others in the press) is advocating transitioning men taking hormonal medication to stimulate milk production. If men were meant to produce milk, they would do so. Men have a small amount of breast tissue  but if they were intended to lactate they would have more, not simply chest tissue. Having said that, there are a few occasions when testosterone deficiency causes milk production, but this can be associated with a pathological illness. Further, if babies were meant to have milk that was very high in fat then biological women would produce milk higher in fat. We also have to consider the longterm epigenetic effects of babies growing into adults who have been raised on drug-induced high-fat milk.

https://yhoo.it/3TaiIFU

Do You Play Music In The Workplace? 

Did you know that if you wish to play music in the workplace, whether it is for patients / clients or staff, you are required to purchase a Music Licence otherwise you are infringing copyright legislation? The issue is about playing music in a public place - without paying for this licence, the artists do not receive their royalties. A “public space” is deemed to be anywhere other than your own home. Even therapists who work from home and wish to play music for relaxation of their clients are required to have this licence. You cannot just turn on the radio or TV or play music from your ‘phone from Spotify. There have been a few occasions where businesses, including a local borough council, have been fined a considerable amount of money for failing to purchase a licence before playing music at public events. Conversely, if birthing parents bring their own music into the birth centre that is for their personal use and they would not need to have a licence. For midwives, doulas and therapists working with expectant and birthing parents, the best option is to purchase royalty-free relaxation music, of which there is a good selection – just avoid those which include babbling brooks or crashing waves, which could lead pregnant women to need the bathroom! See https://pplprs.co.uk/themusiclicence/ for more information.

Has "Birthing Person" Become the New Jargon?

Denise recently met a new father at one of her business networks, who complained about the care of his wife during the birth of their son. Here she explains: This father's comments were not about the physical care, but about the midwife's repeated reference to his wife as the "birthing person". Here was a married, obviously heterosexual couple, excited to become a mother and father, yet it seems, from his account, that the midwife was so desperate to use inclusive language that she was unable to individualise the language to the people for whom she was caring.

It has always been difficult for new health professionals to differentiate between inter-professional language (jargon and abbreviations) and using words that are more easily understood by service users. Whilst inclusive non-genderised language is a way of embracing people who choose different lifestyles, it is vital to consider everyone's preferences. When I was a student nurse, we had to ask every patient what they would like to be called. Older people generally preferred a formal address such as Mr or Miss, younger people welcomed the use of their chosen given name or commonly used version of it. When I was a midwifery tutor in the early 1980s, we conducted a survey asking women how they would like to be called from the waiting area into the antenatal clinic rooms - most wanted to be addressed as "Mrs" even when they were not, to avoid the embarrassment of being shown up as an unmarried mother.

In 21st century terms, it seems that some midwives are so hung up on the use of inclusive language that they find it difficult to change when necessary. In this instance, referring to the woman in the impersonal third person is inappropriate. Failing to find out how a woman in labour would like to be addressed is  disrespectful and uncaring. This is certainly how it was perceived by this father, whose experience was marred by the midwife's approach. It is vital that we do not forget that many of our service users are women and wish to continue to be considered as women or mothers. It is also important that "birthing person" or "birthing people" are professional.terms.to encourage inclusivity when discussing service users amongst ourselves and NOT a generic term to be applied when actually caring for them face to face.

Managerial Responsibilities When Midwives Use Aromatherapy in Their Practice

Aromatherapy is the most popular therapy used by expectant and birthing parents. It can ease anxiety, aid relaxation and, by reducing stress hormones, can increase oxytocin and endorphins. Using aromatherapy as an adjunct to midwifery care can reduce the need for intervention in childbirth, with less cascade of intervention. This in turn reduces the risks for parents, the possibility of litigation – and saves money! When clinical midwives incorporate essential oil use into their care, midwifery managers are responsible for monitoring the safety, effectiveness and equity of service provision. Aromatherapy, whilst not being a medicine per se, acts in the same way as drugs and should therefore be used along the same principles of medicines management. Managers are also responsible for complying with health and safety legislation and the Control of Substances Hazardous to Health (COSHH) regulations. Where midwives provide oils for parents to use at home, they are legally required to conduct an initial face to face consultation and then give parents the remainder of the same blend used for the first treatment, together with written information on how to use it safely, how to deal with adverse effects and what to report if they are concerned. The use of aromatherapy within midwifery should be viewed as a clinical tool, not simply as a pleasant environmental aroma. For guidelines for midwives using complementary therapies see the new RCM document or contact Denise on info@expectancy.co.uk

The Use of Combs in Labour

Here’s our lovely Amanda Redford talking about combs in labour from last week’s Midwifery Hour broadcast

https://youtu.be/2UGVG6_bja4

Complementary Therapies in Pregnancy and Birth: What is Fully Informed Consent?

When women wish to receive antenatal or intrapartum complementary therapies (CTs) such as aromatherapy, reflexology, acupuncture or clinical hypnosis, it is vital to obtained informed consent. But what do we mean by “fully” informed consent? It’s easy to inform parents about the benefits but what do you tell them about the possible risks? Here is a list of the information you should be able to provide to enable parents to give their fully informed consent to CTs:

WHO: assess the woman to ensure she is eligible to receive the therapy and has no contraindications or precautions
WHAT: what does it involve? explain what the therapy is, how it works (mechanism of action) – how does it help with relieving pain, aiding contractions, reducing stress or other reason for its use?
WHY: what are the reasons you are advising using the therapy on this occasion? Is it likley to be more effective / quicker / easier than a conventional solution?
WHERE: areas of the body where it will be given, what position does the woman need to adopt to receive it?
WHEN: how long is the treatment, how many appointments if a course of treatment is advised
HOW: mention any research that may support its use or explain its effectiveness, with statistics. Explain possible healing reactions (normal), side effects (abnormal) and complications – and how to recognise them if going home after treatment.
Provide after-treatment advice to ensure the woman gets the benefits of the therapy (applies mainly to pregnancy treatments rather than labour care).

Guidelines for Midwives on Complementary Therapies for the RCM

The Royal College of Midwives has published guidelines for midwives using complementary therapies. Written by our own Denise Tiran, they provide general guidance on complementary therapy use by midwives.

https://www.rcm.org.uk/publications/

Introducing Reflexology in Pregnancy and Birth

An Introduction to Reflexology in Pregnancy and Birth

By Dr Denise Tiran HonDUniv FRCM MSc RM

Complementary therapies are often used or sought by women during pregnancy. Reflexology is one such therapy. Did you know there are different types of reflexology? Expert in complementary therapies Dr Denise Tiran, CEO and Education Director for Expectancy, explains the differences in reflex therapies and how they may be used to support during pregnancy and birth
               ______________________________________________

Introduction to reflex therapies

“Reflexology” is a generic term for a range of complementary therapies based on the principle that one small area of the body represents a “map” or chart of the whole. It is not simply foot “massage” – reflex therapies have their own theories, mechanisms of action, effects, contraindications and precautions, as well as a developing body of research evidence.

Not all forms of reflex therapy are the same. Some western styles focus on holistic relaxation, similar to massage,  any therapeutic effects arising largely from reduced stress hormones, such as cortisol, and a corresponding rise in endorphins, oxytocin and other hormones. Eastern reflexology is based on acupuncture energy lines and is very different from western reflexology, both in theory and practice.

Reflex zone therapy (RZT), which I practise and teach in my courses, was devised by the German midwife, Hanne Marquardt, in the 1950s and is often used by midwives in Germany, Austria, Switzerland and Scandinavia. RZT is a clinical tool based on anatomical and physiological principles and usually practised only by registered healthcare professionals, including nurses, physiotherapists and midwives. The relaxation effect is a pleasant but less significant element of treatment which is focused specifically on easing or resolving physiological symptoms and sometimes pathological conditions.

It is still not clear exactly how reflex therapies work, although there is ongoing research to “map” the reflex points on the feet, using technology such as MRI, ECG and EEG. Sceptics believe that it is a placebo effect or that the touch or the interaction between client and therapist induces relaxation. Reflex therapy is, however, known to be analgesic, possibly via the gate control mechanism, stimulates peristalsis and circulation and may have neurological effects. It remains difficult, however, to draw definitive conclusions as to the precise mechanism of action of reflex therapies. I have refrained from providing research references in this article because many recent papers are from the Middle East where practice is very different, and studies in which “reflexology” is performed more frequently involve superficial foot massage. For futher exploration of reflexology research, especially in relation to postdates pregnancy, see Tiran 2023.

Reflex zone therapy

In RZT, the “map” of the feet is different from generic western styles such as Ingham or Bailey reflexology. RZT encompasses the entire surfaces of both feet, where as other styles may not use the upper surface of the feet (dorsum). The right foot relates to the right side of the body and the left foot to the left side. The dorsum represents the front of the body, with reflex zones for the face, breasts and abdominal muscles. The outer edge of each foot represents zones for outer aspects of the body eg shoulders, hips, ovaries – whereas the inner edges of the feet represent midline organs such as the uterus, vagina and spine. The soles are mapped with points for all the internal organs (heart, lungs, gastrointestinal zones etc). Where there are two organs (eg eyes, kidneys) there is a reflex zone on each foot, but if there is only one organ the reflex point will be on the same side eg the liver zone is on the right foot. The stomach and heart are central organs but displaced to the left, so there is part of the reflex zone on each foot, that on the left being noticeably larger.

Most styles of generic reflex therapy involve a treatment session of around an hour in which full-foot coverage by the practitioner’s hands help to relax the client. Conversely, in RZT, a treatment is generally much shorter (no more than 35 minutes, especially in pregnancy) or may involve focused treatments of just 5-15 minutes to treat specific symptoms.  By working on precise points on the feet, impulses are thought to be directed to the relevant organs, having a physiological effect on that distal part of the body to which the foot points relate.

One aspect in which I am particularly interested is the diagnostic potential of the reflex zones on the feet. It is possible to see or feel aspects which may indicate current, previous or even impending disorders, from teeth that may need a filling to breast lumps requiring medical referral. Whilst working at the University of Greenwich, I investigated prediction of stages of the menstrual cycle by examination and palpation of the relevant foot zones. I consistently have around a 70% success rate in identifying the active ovary in the current cycle, estimating the day of the cycle and predicting when the next menstrual period is due.

RZT in midwifery practice

Reflexology is a popular relaxation therapy and many expectant parents seek treatment from independent practitioners. However, offering general relaxation reflexology in the NHS may not be practical due to the time required for each individual. In order to offer an equitable service it is essential to rationalise which women can receive it and it may be preferable – and easier – to introduce RZT for specific indications, eg postdates pregnancy or antenatal and postnatal issues. Given the variety of styles of reflexology, it is paramount that all midwives in one unit practise the same style to ensure standardisation of treatments and reflex point location and to allow for audit of the service.

RZT can be used to reduce stress, anxiety and fear and to ease pain in pregnancy, birth or the postnatal period, but it comes into its own when treating specific symptoms. Whilst at the University running a degree in complementary therapies, I established a clinic offering RZT and other therapies (aromatherapy, herbal medicine, moxibustion for breech etc) to treat pregnancy issues. During the ten years of the clinic, I treated almost 6000 women with RZT. Over these years, I had considerable success in  treating women with symptoms such as backache, sciatica, pelvic girdle pain and carpal tunnel syndrome, constipation, irritable bowel syndrome, sickness and haemorrhoids. I was involved in setting up a postdates pregnancy clinic in which we used RZT, combined with aromatherapy and acupressure to help avoid induction, and showed that RZT can facilitate labour progress and ease pain; it may even be effective in dealing with retained placenta. RZT can also aid postnatal recovery and stimulate or supress lactation.

Conclusion

RZT is a specific form of reflex therapy which was devised by a midwife and which fits well with contemporary midwifery practice.  Its somewhat more reductionist approach enables short treatments to ease symptoms and reduce the need for intervention, particularly in labour. Although the evidence base is limited, there is an increasing body of knowledge to support its use – and because treatment does not involve any oils or creams, it is safer than aromatherapy, both for individual parents and for staff.

RZT is not an easy therapy to learn. It is necessary to learn the whole therapy before applying the principles to midwifery practice, unlike aromatherapy in which a small selection of oils and massage techniques can be studied for labour care. I am honoured to offer the only UK reflex zone therapy course for midwives and many graduates are now using it in private practice, with a few maternity units incorporating RZT into postdates pregnancy clinics.

Reference: Tiran D 2023 Complementary therapies for postdates pregnancy. Singing Dragon, London

Further information: www.expectancy.co.uk / info@expectancy.co.uk

Osteopathy in Pregnancy 

Denise came back from Tokyo to a week of severe lower back pain – probably a result of that 15-hour flight! Eventually, she took herself off to a local osteopath and is having a course of treatment which is definitely helping.

Osteopathy is a statutorily regulated healthcare profession in the UK, having been legalised back in 1993 and practitioners are registered by the General Osteopathic Council. It is based on the principle that structure and function of the body are inter-related – if the body’s structure is affected by injury or disease, it impacts on the bones, joints, ligaments, tendons – and even on the soft tissues of the body. An example is related to fertility: injuries to the pelvis such as a skiing accident, causing the pelvis to tilt and one leg becoming shorter than the other, can impact on the position of the ovaries and either stretching or kinking of the tubes conveying the egg to the uterus, thus interfering with conception.  Another example is the effect of whiplash injury from a car accident contributing to more severe sickness in pregnancy because of the tension on the neck and upwards to the vomiting centre in the brain. Treatments usually involve gentle manipulations aimed at correcting musculoskeletal misalignment. Of course, in pregnancy, issues can arise because of the impact of relaxin, progesterone and other hormones impacting on the whole. Osteopathy can be useful in pregnancy and after the birth, especially for backpain, sciatica, pelvic girdle pain and carpal tunnel syndrome. However, many people think that osteopaths deal only with musculoskeletal issues, but they can also treat many soft tissue problems such as heartburn, headaches, constipation and more. It can even encourage the onset of labour – particularly useful for those who wish to avoid medical induction. Osteopathy is safe in pregnancy – and for babies – and midwives, doulas and other maternity professionals can refer expectant parents to local osteopaths with confidence in their credibility and professionalism. For more information, see https://www.osteopathy.org.uk/home/

Of Pinard's and Pain

Denise recently saw a discussion on a midwifery FB page about Pinard's fetal stethoscopes going out of fashion. Here she remembers how it was when she was first a midwife in the 1970s. 

When I first started midwifery, there were no tick charts or technology to help us assess wellbeing and progress in pregnancy and birth - just our five senses. We assessed through sight, hearing, touch, smell and ... well, perhaps not taste - although we did employ a healthy dose of common sense, so perhaps that counts. In respect of the Pinard's fetal stethoscope, we had to have our hearing tested just to get into midwifery training - if you couldn't hear a fetal heart (or a blood pressure reading) with your own ears, you weren't accepted. Indeed, CTG machines were just emerging as I finished my training - and midwives and mothers were frightened to death of using them. I remember being chastised by a sister on the antenatal ward for not wanting to put a CTG on a woman, with the words "they're too expensive to leave them lying idle". Even later, when CTGs, became more widespread, Pinard's were still used as the main method of listening to the fetal heart.

in labour, there was little pain relief available except pethidine.There were no epidurals - instead, we offered inhalation pain relief in the form of Entonox or Trilene, the latter involving a rather strange and intricate piece of apparatus (Trilene was stopped in the mid 1970s as it was found to be potentially hazardous to babies). And as for Caesareans, these were extremely rare and warranted a postnatal stay of 14 days for recovery from major surgery. Of course, there were far fewer women with complex medical histories in those days, so operative delivery was really only used for major labour complications such as brow presentation. Induction of labour was very rare  (oh that it was still the case today!) Twin births were also relatively uncommon and warranted a whole group of student midwives and doctors being in the room to observe - a rather intrusive experience for the parents.

Masks, gowns, hats and gloves were worn routinely by midwives for all births -  requiring us to remove our uniform aprons, belts and caps before setting up the delivery trolley. Even the fathers had to wear masks when visiting their babies, who were all in a communal nursery until feeding time (as near to four hourly as possible). Women generally stayed in hospital for several days and were shown baby bathing, nappy changing, how to make up bottle feeds and sterilize equipment. The daily postnatal examination included physically measuring the descending height of the uterine fundus, using a wooden spatula marked off in inches. 

Home births remained popular despite the 1970 government move towards 100% hospital births. As community midwives, we attended these on our own and a second midwife was only called in an emergency. Women often gave birth in the left lateral position, which meant the midwife would rest the woman's raised right leg on her shoulder in order to support it and still be able to conduct the birth.

Midwifery postnatal care in the UK was the envy of the world. As a community midwife, I would visit twice a day up to day 3, including the evening of discharge from hospital, then daily to at least day 10, then weekly to 28 days, occasionally longer. Parents were not transferred to health visitor care until the umbilical cord had separated and healed and the mother's perineal sutures had either been removed or - later, when disposable sutures started to be used - had dissolved.health visitors generally visited on day 11.

What is Safe Complementary Therapy Practice in Midwifery Care?

The NMC Code emphasises the need for safe practice and the RCM believes “safety is intrinsic to maternity care and works as the golden thread in everything we do.” Current concerns about the maternity services focus largely on the risks of low staffing levels, but there is more to safe practice than having enough midwives. Research evidence is often used to attempt to underpin practice and to formulate NICE guidelines, but formal evidence is not the only requirement for safe practice. Midwives’ enthusiasm for using CTs is at an all-time high, perhaps to offset defensive interventionist obstetrics and paper over the cracks of the risk impact of overworked midwives. In my experience, midwives generally fall into one of five groups when it comes to CTs:

• outright sceptics with no knowledge, understanding or interest in CTs, who may use dismissive or even derogatory language to discourage parents from using them
• those who understand that their knowledge is lacking, who relinquish responsibility of advising parents by stating that they are unable to help and advising them to seek help elsewhere
• midwives with little knowledge and huge enthusiasm, who overstep the boundaries of NMC registration because of their desire to help parents, but who often provide inaccurate or incomplete information
• midwives who are qualified therapists, but whose knowledge is insufficient to enable them to apply its use in midwifery and in the NHS
• midwives appropriately trained to use CTs specifically in pregnancy and birth, who provide accurate, comprehensive advice and treatment within the parameters of their training, local clinical guidelines and their registration

However, midwifery managers and consultant midwives overseeing clinical midwives’ use of CTs seem to miss the point about how to ensure SAFETY, perhaps because many CTs are “nice” and aspects such as oil fragrances can enhance the birthing environment. SAFE practice requires midwives to be adequately and appropriately trained so they understand how to apply theory to practice, minimise risk and avoid safety incidents. It requires managers and senior midwives to understand safety issues such as indications, contraindications and precautions, and the laws pertaining to using CTs in maternity units and birth centres. Whilst they may acknowledge the safety issues of using acupuncture, the most significant issue, by far, is the use of aromatherapy, but even hypnosis practice is poorly monitored and often used without having any clinical guidelines to aid safe practice. It is inconceivable that managers in units previously under CQC scrutiny sometimes rush blindly into introducing CTs (usually aromatherapy) in a misguided attempt to improve matters, yet without the understanding of how to effect this change SAFELY. Unfortunately, it is also the case that CQC inspectors also have little or no appreciation of the SAFETY issues of CTs. It is all very well – indeed laudable – that managers wish to offer a more natural approach to birth in an attempt to reduce interventions, but they are treading on very thin ice unless they consider how best to ensure SAFETY of expectant and birthing parents, babies, visitors and staff.

What do you love?

As February is the month of love, let’s start it with a few words about my love of what I do!

This is Expectancy’s 20th year and I can honestly say I have loved every minute of watching my business grow and flourish; all the ups, downs and perseverance have contributed to a successful business with my ongoing quest for teaching and sharing a subject I feel so passionate about.

I could never go back to working for somebody else and I feel it’s the best thing I have done with my life.

It is very important to me to continue to increase awareness about complementary therapies in pregnancy and childbirth. It gives me great joy to watch my students and Licensed Consultants come into their own and to experience the satisfaction of a job well done!

Nasal Congestion in Pregnancy

Nasal congestion occurs in over 30% of pregnant women and the severity can range from simply being irritating to considerable discomfort and difficulty in breathing through the nose. It is caused by changing levels of the various pregnancy hormones that affect the nasal passages and can cause rhinitis, including a constantly dripping nose, and nosebleeds. In Chinese medicine, a blocked nose is thought to arise when there is stagnation of the internal energy (Qi) and if the condition becomes debilitating, acupuncture can offer a solution. Reflex zone therapy, a clinical form of reflexology, can also help - and a simple self-help strategy is to encourage expectant mothers to massage firmly around the joints of the thumbs - or better still, to ask someone to massage the tops of the big toes, particularly around the middle joints. These areas correspond to the face and working around the main joints of thumbs or big toes is, in effect, stimulating the nose area to encourage flow of the mucus in the nostrils. Inhalation of essential oils such as eucalyptus or frankincense may help but this should only be considered as a "quick sniff" solution and not as prolonged exposure to oils in a diffuser, which may actually worsen the condition. (and remember that small children and pets should not be exposed to oils containing eucalyptus).

In Japan

On Sunday, Denise gave a very successful conference presentation in Tokyo on “the challenges for clinical maternity aromatherapy” to obstetricians from the Japan Medical Association as well as midwives and aromatherapists. It was so well received that she received a further invitation to present to the whole Medical Association next year.

This was followed by a fascinating session on using aromatherapy for victims of child sexual abuse. A moving personal account of the benefits of aromatherapy after IVF pregnancy ending in a term stillbirth was a powerful persuader of the need to attend to emotional well-being, only recently an emerging concern in Japanese health care. Finally, her colleague talked about Japanese regulations on essential oil production and showed us photos of her wonderful fields and farms around Japan and overseas, from which her own brand is essential oils is produced. All in all, a very successful and enlightening conference.

Some Amazing Pregnancy and Birth Facts

Did you know that, between 1929 and 2023, only around 95 babies have been born on planes – and just three on British Airways flights? And did you know that, whilst the babies’ nationalities are usually taken from the country of origin of the airline, passports usually state the place of birth as “born at sea” (anywhere that is not on dry land).

The fastest recorded labour is TWO minutes – to an Australian woman who previous labours had only lasted 15 minutes each! And the longest labour was, apparently, 75 days for a woman in Poland in 2012!

Water births have been around for a long time – Egyptian pharaohs were said to have been born in shallow water – but the first recorded water birth was in France in 1505.

One of the highest rates of multiple pregnancy is to a tribal group in Africa where the staple ingredient of their diet is yams. Since yams contain a range of plant oestrogens that may aid fertility, they may aid maturation of multiple eggs, resulting in twin or higher multiple conceptions. 

The youngest female ever to give birth was a five-year-old girl in Peru in 1939. In the UK, an 11-year-old girl become pregnant in 2006.

And the Guiness Book of Records documents that a Russian woman conceived 27 pregnancies and gave birth to 69 – yes 69! – babies in the 18^th century. She had 16 sets of twins, seven sets of triplets and four sets of quadruplets!

In Japan

Denise is in Tokyo, Japan, teaching and speaking at a conference this week.

Denise had a fascinating day yesterday, treating six of her colleagues’ students with reflex zone therapy. It’s very different from general reflexology, especially Japanese reflex therapy which is more akin to foot massage.

They were amazed by what Denise was able to detect from their feet, including headaches due to dehydration, abdominal bloating due to a change in diet, uterine fibroids (visible on the uterus zone on the inner heel) and backache.

Today, (Saturday) Denise had a very interesting visit to the postnatal hospital at the royal Aiiku hospital in Tokyo central. Women transfer here after the birth and can use the facilities for up to one month. It’s like a hotel inside with beautiful en suite rooms. Midwives - note the full linen room! There’s also a section where women can pay to spend the day sleeping! They can bring the baby for a midwife to care for while the mother rests - part government funded, parents pay around £10 a day. Mind you, hospital parking for visitors is extortionate at around £100 a day (which pays for patient parking)! Postnatal classes are provided - they even include a “toy consultant”. Other services include counselling and lymphatic  drainage massage. Aromatherapy is provided by a team of staff led by Denise’s colleague, Azusa from ArtQ. Breastfeeding rates are about 30% - because the government does not promote it as they feel it’s too stressful for new mothers!!

What’s In A Name ? - Choosing appropriate names for your maternity related private practice.

Following our business training day for midwives wanting to set up private maternity complementary therapy practice, Denise has had several enquiries about individuals’ ideas for business names. Having a business name gives your business its own identify that enables potential clients to find you. choosing a name can be exciting and fun, but it is important to look at your long term plans before finalising your choice. You don’t want to choose a name that is too restrictive, for example, only relating to antenatal education when later you may want to include complementary therapies or tongue tie services. On the other hand, you don’t want a name that is too broad, and it is wise to avoid using solely your own name unless you already have a reputation that leads expectant parents to search specifically for you. Avoid using words that may mean something to you but which don’t pop up in search engine optimisation for those searching for pregnancy-related services.

It is essential to undertake an advanced internet search to see if any other businesses have the same name or similar. You must check with Companies House (UK) to find out if your chosen name has already been taken and is registered as a limited company, in which case you cannot have the same name. It is also wise to check if a name has been trademarked, in which case you cannot use the same name or logo. Use an online thesaurus search to see if you could use different words to make your business name more appealing. Denise undertook a an advanced Google search looking for names such as “holistic” and “midwifery” and found at least five different businesses with the same or similar names – this is not a good idea because if another business has better search engine optimisation or more popular social media postings, their business name will appear at the top of any list and you may find yourself further down, possibly even on another page.

Crucially, if you wish to use the word “midwife” or “midwifery” in your business name, you must consult the Nursing and Midwifery Council for permission to do so. This is because these words are protected in law – only a midwife or a doctor can claim to be practising “midwifery” and only those currently on the NMC register can claim to be a practising midwife and use “midwife” in their business title.

Less Is More: Complementary Therapies for Postdates Pregnancy

Many expectant parents become desperate to get labour started that they try many natural remedies and therapies to avoid induction.

One of the difficulties is that there are so many suggestions out there – Denise found at least 80 ways of initiating contractions from a simple Google search.  However, not all of these are appropriate, and some are unsafe, plus there is very little evidence to support many of the suggestions. More importantly, expectant parents should be advised NOT to combine all their chosen methods at one time – this simply overwhelms their physiology and is more likely to prolong labour than initiate i, and poses a significant risk that some herbal and aromatherapy remedies may interact and cause side effects. Less is always more – and midwives and birth workers should advise expectant parents to use any natural remedies cautiously AND to inform their caregivers.

Here is a summary of some of the popular remedies used to trigger labour:

• Foods thought to aid contraction of smooth muscle include aubergine, balsamic vinegar, bananas, capsicum (peppers), chilli, Chinese food containing monosodium glutamate (MSG), dates, green papaya, mangoes, pineapple, spicy food.
• Herbal remedies that are often used but which may be unsafe include aloe vera juice, basil, black cohosh, blue cohosh, evening primrose oil, goldenseal, motherwort, liquorice, squaw vine, raspberry leaf.
• Essential oils that are popular, but which are not appropriate for everyone include cinnamon, clary sage, fenugreek, frangipani, nutmeg, peppermint, thyme. 
• Other natural means of encouraging labour include laminaria tents (a type of seaweed), DIY enemas or stretch and sweep, various types of exercise especially those that cause movement such as yoga, Pilates, belly dancing, Tai Chi and, of course, sex.
• Complementary therapies with a reasonable evidence base: acupuncture, acupressure, some essential oils (aromatherapy), some herbal remedies, hypnosis, massage, osteopathy, chiropractic, reflexology, shiatsu.

Have You Set Your Professional Goals For 2024?

It’s a bit like a New Year’s resolution, but it’s important to review your professional practice and set some goals for the year. Denise will be off to present at a medical conference in Japan soon, but when she gets back, she’ll hit the ground running with no time for jetlag! There are various NHS courses arranged, our scheduled reflexology and hypnosis courses coming up and lots of webinars and discussion groups for our existing students and Licensed Consultants preparing for private practice. To celebrate Expectancy’s 20^th year, it’s time to invest in the business and plans are afoot for a revamp, with upgrades to our website, some eye-catching ads (look out for The Practising Midwife), new courses, a new marketing strategy and an uptick of our social media. 

We’d love to hear what your plans are. It might be as simple as ensuring you get ahead with your NMC revalidation documents, or it might be something new and exciting such as changing jobs, starting a Masters degree or deciding to have a complete change and work for yourself. Let us know what you’re doing in 2024!

Impact of Aromatherapy Oils on Midwives

A midwife recently asked me if prolonged exposure to clary sage oil during a long labour could have contributed to excessive abdominal cramps and vaginal bleeding even though she had a contraceptive implant in place and did not normally bleed. It’s impossible to say with certainty that inhaling clary sage oil continuously during a 12-hour shift caused her problem, it is certainly possible. Clary sage has also caused excessively heavy menstrual blood flow in many midwives, and even threatened miscarriage in a few in early pregnancy. Other oils that can adversely affect midwives, other staff and birth companions exposed to aromatherapy oil vapours for prolonged periods include hay-fever-type reactions and asthma attacks from flower oils such as lavender, geranium and rose; dizziness and fainting from the hypotensive effects of clary sage, ylang ylang and lavender; nausea and skin itching from citrus oils such as orange or grapefruit, especially in people sensitive to citrus fruit. It is as important to look after yourself in your clinical practice, as it is to be cautious with aromatherapy provided for individual women in labour (NMC Code),

Herbal Medicines Considered Unsafe For Use In Pregnancy

There are many herbal remedies that should be avoided in the preconception period, pregnancy, birth and breastfeeding.

Midwives should try to ask all those booking for antenatal care about their use of herbal and other natural remedies and document this in the notes. Some remedies may cause miscarriage, preterm labour or even birth defects; others interact with prescribed medication and some cause hepatic, renal or cardiovascular adverse effects. For example, many herbs contain chemicals that thin the blood, potentially causing bruising, bleeding or slow wound coagulation. Here are some of the herbal medicines that should be avoided:

Aloe vera (oral); basil; black cohosh; blue cohosh; clary sage; comfrey; dong quai; fennel; fenugreek; feverfew; ginseng; juniper berry; mugwort; nutmeg; parsley; pennyroyal; sage; St John’ wort. NB cautious use of herbal teas; herbs used in cooking in small amounts are acceptable.

Take Your Shoes Off !

Did you know that you should work barefoot when performing massage, reflexology or aromatherapy treatments? Have you ever felt exhausted when you’ve provided two or three manual treatments in a day? This is because of an energy transfer between clients and therapists. Treating several clients consecutively causes accumulation of the energy transfer from clients. It is vital to expel this accumulated negative energy and to find ways of protecting yourself when providing manual therapies. Working barefoot allows you to “ground” yourself and provides a conduit for the accumulated energy to be dispersed into the earth. For NHS midwives, working barefoot may contravene health and safety regulations, but keeping shoes on risks them experiencing adverse effects from repeatedly treating expectant or birthing parents and not providing an outlet for the negative energy. Adverse effects may be excessive tiredness, headaches, nausea, dehydration and an increased tendency to develop minor infections due to negative effects on the immune system. What are your thoughts about working barefoot, especially in the NHS? If you’re running an NHS complementary therapy service, for example, a postdates pregnancy clinic, how do you protect yourself from negative energies?

Pregnancy Sickness Causes 

It is interesting to see news of the recent research in which the growth-like hormone, GDF15, is implicated. Researchers suggest that this may pave the way to a treatment for pregnancy sickness in which those at risk are offered the hormone preconceptionally as a protection against debilitating sickness.  Denise says: For those who suffer extreme hyperemesis gravidarum, which often leads to hospital admission and even to some women to seek termination of pregnancy because they can endure it no longer, this new research could literally be a life saver. However, we must remember that pregnancy sickness is caused by various factors – from hormonal effects, nutritional deficiencies, musculoskeletal misalignment and other causes that are not acknowledged by the medical profession. Symptoms are often exacerbated by stress, tiredness and mental health issues and accompanied by headaches, bowel disturbances, heartburn and other symptoms. Indeed, whilst not wanting to minimise the severe nature of the illness for the 3-4% of women who suffer hyperemesis, it is often those with moderately severe sickness who struggle most. They are not ill enough to require medical care and are often left to find ways to reduce its effects by themselves. I have treated hundreds of women with moderately severe pregnancy sickness who report feeling isolated and uncared for by the maternity services. In addition, standard medical advice is limited to the ubiquitous ginger biscuits, dietary changes and rest, unless symptoms are severe enough to warrant medication, which often stops the vomiting but rarely the unremitting nausea. Those suffering pregnancy sickness should be fully and holistically assessed to determine the cause before being fobbed off with medication and the frequently incorrect and inappropriate advice to “try ginger”. If the cause of nausea and vomiting is a deficiency of vitamin B6 or magnesium, optimum treatment is to supplement these; it is it a history of whiplash injury that has caused musculoskeletal misalignment, chiropractic or osteopathy would be most effective.

More Criticism of Complementary Medicine

It’s only to be expected, of course, that the appointment of Dr Dixon, a GP with almost 50 years’ experience, would bring out the sceptics of complementary medicine once again. This truly eminent medical practitioner, with a distinguished career and an OBE for services to primary (conventional) healthcare, is being castigated by a belligerent press that believes the only way to provide healthcare is via the orthodoxy of conventional medicine, with its paternalistic, interventionist, chemically invasive approaches, preferably delivered within the NHS.

Outspoken in his criticism is retired Edzard Ernest, previously a professor of complementary medicine at the University of Exeter who became the "scourge of alternative medicine" in the late 1990s and early 2000s. Whilst his prolific research into complementary medicine undoubtedly added to the body of knowledge and evidence on different therapies, Ernst turned his back on his own medical training in Germany, where he had studied acupuncture, homeopathy, massage and other therapies. Throughout the 1990s he undertook hundreds of research studies in complementary medicine, most of which concluded that there was insufficient evidence to support its use or, indeed, that the therapies tested were “ineffective” or even “unsafe”. Like so many others, he attempted to evidence complementary modalities with “gold standard” randomised controlled research methodology, which does not fit with the individualised nature of complementary medicine. He gained a reputation as an anti-complementary medicine authority despite the title of his role at the time (Professor of Complementary Medicine). Of particular note is Ernst’s comments in the Guardian that “anyone who promotes homeopathy is undermining evidence-based medicine and rational thinking. The former weakens the NHS, the latter will cause harm to society.” This is not only grossly untrue and unfair, it is contrary to his own homeopathic qualifications and demonstrates more a desire to undermine complementary medicine evidence than offering any really critical appraisal of the failures of conventional medicine, particularly within the current NHS.

The press is vociferous in its deprecation of complementary medicine, yet there is no acknowledgement of personal choice – choice to decline conventional care, choice to choose “alternatives” - especially when the NHS has no other options to offer than drugs or surgery, coupled with excessively long waiting lists - and choice to pay for private care. In maternity care, this is particularly significant at present, with the anti-natural-childbirth lobby denigrating any practices of which it has little understanding and of which it does not approve, mainly for political reasons. Expectant and birthing parents do have choices yet find it difficult to search them out or combine with the medicalisation of maternity care. Complementary medicine is NOT about alternatives, it is about using different modalities in combination with conventional healthcare practices. It is to be hoped that the appointment of Dr Dixon will produce a new surge of interest in and enthusiasm for complementary medicine so that it can be integrated within conventional healthcare.

Expectancy Welcomes Appointment of Royal Doctor Who is Pro- Complementary Medicine

Denise is delighted to see that Dr Michael Dixon has been appointed to the Royal Household. A GP with an interest in complementary approaches to health and wellbeing, Dr Dixon has long championed the use of modalities such as herbal medicine, which works the same way as drugs, homeopathy, a gentle method of treating like with like, and relaxation therapies. Denise says:

It is so refreshing to see royal support for a doctor who advocates healthcare that is more individualised, less invasive and more focused on the whole person than conventional medicine. Whilst the mainstream press once again denigrates something about which they know very little, and which they claim to be a negative factor for the NHS, King Charles' renewed support could be a powerful motivator for the complementary medical field.

Doubtless the public media will use this move to argue that complementary therapies are ineffective, unsafe and poorly evidenced, but don't believe everything you read. I see this as a very positive move especially for maternity care at a time when childbirth is ever more interventionist, unsatisfying for parents and professionals alike and increasingly downright dangerous for many reasons. Congratulations Dr Dixon and well done Your Majesty.

Reflexology in Pregnancy and Birth: The Power of The Pituitary Gland

“Reflexology” is a generic term for a range of different therapies which are all based on the principle that one small part of the body (normally the feet and hands) reflects the whole. Denise teaches a German clinical style, reflex zone therapy, (RZT) devised by the midwife Hanne Marquardt, which is used by many midwives in northern Europe. Midwives on our courses learn the “map” of the feet and how to perform a relaxation treatment – but RZT offers so much more than relaxation effects. 

RZT can be used to treat many of the physiological discomforts in pregnancy and is particularly effective in facilitating the onset and progress of labour through stimulation of two pressure points on the big toes which refer to the pituitary gland reflex zones and can therefore initiate oxytocin release to encourage contractions. We have much discussion during our courses on the precise location of these points because different styles of reflexology locate it in different positions on the toes. When she was at the University of Greenwich, Denise worked on clarifying these points in a research study on predictions within the female menstrual cycle, which appeared to show the pituitary gland points in very different locations from any other style of reflexology. She also identified which toe relates to the anterior part of the pituitary gland and which relates to the posterior pituitary – which, in fact, differed from what she had been taught when training in the late 1980s. 

Understanding the most effective locations for the pituitary gland reflex zones can enable midwives to use RZT effectively for postdates pregnancy, labour acceleration, retained placenta and lactation support, all of which require pituitary hormone release. If you’d like to learn how to use RZT in your midwifery practice, we have two places left on our next course, commencing in January and currently available at the special discounted rate of £1800 (normally £2376). Contact info@expectancy.co.uk by 20^th December for more information.

Differences Between Midwifery Training Standards in The 1970s and Today

Denise has been reflecting on the differences between training as a nurse and midwife in the mid-1970s and training in the 21^st century. When she first started training in 1975, standards were very strict. Most students were young, often school leavers going straight into training and tutors acted in loco parentis. Almost all were unmarried – and encouraged to remain so until qualified. All students were addressed as “nurse” and their surname: first names were not permitted to be used on the wards or even in the classroom! Uniform standards were very high – students had their hair length measured to ensure hair did not touch the uniform collar; nail length was checked, and no bracelets, watches or rings were permitted apart from an approved fob watch. Only very light make-up was allowed – and absolutely no perfume in case it caused nausea in some patients. Tights were not allowed to have ladders in them and had to be changed if any occurred on duty. Aprons had to be removed when going to the dining room for a break. No drinks were officially sanctioned to be consumed in clinical areas although it was easer on night duty to grab something quickly in the ward kitchens. Every nurse and midwife was encouraged to take a break during each shift and were reprimanded if the workload prevented this – it was seen to be the fault of the individual in not organising their work efficiently enough!

Classes were very formal, and teaching was largely didactic (straightforward information-giving). The amount of detail taught was phenomenal – and students were expected to “know” it all. Students would never have dared to ask “how much do we need to know? (a common question asked by students today, simply to pass an exam). Anatomy and physiology was the backbone of the entire course – and wo betide any student who could not explain clinical situations in terms of A&P. Denise says she finds this the most concerning aspect of contemporary midwifery education, with many midwives unable to apply A&P theory to practice. Obstetricians and other eminent doctors were brought in to teach some aspects of the course – although most of them couldn’t teach at all! Research was not considered – in fact, one of the first midwifery research projects was only undertaken in the late 1970s after Denise qualified (an investigation about the routine use of enemas in labour). Assessments were almost entirely by exams in large formal halls – Denise remembers her final exams being a whole day with two 3-hour papers followed by a practical exam the following day. There was then the trauma of having to go to the Central Midwives’ Board (CMB which was eventually replaced by the NMC) for a viva voce (oral exam) with a midwifery tutor and an obstetrician. The CMB was in Kensington in London in a very old building and the door to the room in which the vivas were held had a carved banner over the door stating “Abandon Hope All Ye Who Enter Here”!

As a midwifery educator in the 1980s, Denise and her colleagues had their own “set” of students and were expected to teach the entire curriculum to their own group, as well as work with them on the wards. Indeed, every lecturer was expected to spend 20% of their week in clinical practice. The only aspect that was taught by a different lecturer on a rotational basis was the community element, with all students having a 3-month placement in the community. In the southeast London school of midwifery where Denise taught (Greenwich and Bexley), students were also sent to a second hospital for three months to gain different experience.

Does she miss those days? Yes, she does. It was hard work, but it was also fun, believe it or not. Students were proud of their training and their qualifications and went into practice well mentored. There were no clinical guidelines to constrain practice and innovation, no real shortage of staff and there was a supportive culture for everyone working in the health service. Would she go back into direct clinical practice now? Absolutely not, she states emphatically! Denise feels she has been very lucky to find her niche in midwifery, specialising in complementary therapies and teaching it to other midwives since 1984 – it will be 40 years next year!

Midwifery Aromatherapy Under Scrutiny

MIDWIFERY AROMATHERAPY UNDER SCRUTINY: LET’S GET THE MESSAGE OUT THERE - PLEASE SHARE THIS POST WITH ALL YOUR COLLEAGUES.

Midwifery aromatherapy is currently under immense national public and professional scrutiny, but still Denise is consulted by midwives facing safety issues in their units. She recently heard from a midwife whose manager wanted to introduce oil diffusers using a few oils, with laminated cards in birth rooms to inform midwives how to use them (without any training). Other examples, often repeated, include managers asking midwives who have studied a few days of aromatherapy to write clinical guidelines, diffusers being use in the antenatal ward or triage areas, or the constant injudicious and unsafe use of clary sage oil in well-established labour.

Aromatherapy – the use of aromatic oils and massage – provides a wonderfully relaxing adjunct to labour care, easing pain and aiding progress. There is evidence to demonstrate the benefits of using aromatherapy – when it is used appropriately, by midwives with comprehensive knowledge and understanding of the potential safety issues AND how to minimise the risks. Aromatherapy is NOT just about acquiring the skills of massage and how to blend a few oils together.

Midwives who study aromatherapy with Expectancy explore the positive and possible negative pharmacological effects of the oils, the health and safety issues of using them in maternity units, their application to medicines management principles and their legal, ethical and professional responsibilities to all parents, babies, visitors and staff exposed to the chemically active aromatic vapours. It is of grave concern that midwifery managers permit their staff to implement aromatherapy without themselves having any knowledge of the subject and how to monitor midwives’ practice to ensure it is safe. Midwifery managers themselves need to understand the risks of essential oil use in pregnancy and labour so that they can take steps towards minimising those risks and developing an aromatherapy service for birthing parents that is safe, as well as effective, cost effective and equitable.

Denise will be running a series of FREE WEBINARS specifically for managers and consultant midwives to help them appreciate safe use of aromatherapy in midwifery practice. NB These 90-minute webinars aim to provide information, answer your questions and encourage discussion and will not be recorded.

BOOK YOUR PLACE: Thursday 11^thJanuary at 1000 hrs; Wednesday 17^thJanuary at 1900 hrs; Tuesday 23^rdJanuary at 1400 hrs. CONTACT info@expectancy.co.uk for Zoom link.

A Conundrum ?

Conflicts of interest for midwives offering private services whilst still employed by the NHS :

Increasing numbers of midwives undertake some private work such as antenatal education, pregnancy yoga classes,complementary therapies, tongue tie division or other services. However, it can be difficult to maintain the boundaries between being self-employed if you also continue working in the NHS – you should inform your NHS manager of your private work and ensure there is no crossover with local NHS services. An example of this would be providing private services for postdates pregnancy when there is already a similar NHS service. Another area that can cause difficulty is antagonism from colleagues who are committed to free-at-the-point-of-access care as with the NHS, and who do not agree with charging for your services. Knowing how to market yourself without overstepping the boundaries of the NMC Code can be problematic and requires sound business knowledge so that you can promote your services professionally. You are not, of course, permitted to promote your services during your NHS work (nor do anything related to your private practice whilst on NHS duty time – not even taking a ‘phone call). Knowing the limitations of your personal indemnity insurance will help to avoid the pitfalls between working as a therapist, antenatal teacher, yoga instructor etc, and providing midwifery-specific care.

Postdates Pregnancy

Did you know that raspberry leaf tea is a third trimester BIRTH PREPARATION remedy and NOT a remedy to bring on labour? See Denise's latest book Complementary Therapies for Postdates Pregnancy for more information. 

Denise and Amanda’s Week

This week, Denise and Amanda have been teaching our popular online Aromatherapy and Acupressure for Postdates Pregnancy course, with over 40 midwives.

On the first day we explored the theoretical background to aromatherapy and the safe use of essential oils in pregnancy and birth.

On day 2 we applied the principles of aromatherapy to midwifery practice, considering ways of administering essential oils for expectant and birthing parents. This involved group work and experimenting with selecting oils for both their clinical effectiveness and their aromas.

Day 3 saw midwives practising acupressure points that have been shown to be effective for aiding labour onset.

We concluded by discussing the implementation of aromatherapy and development of a postdates pregnancy service in the NHS or private practice.

Did You Know That Herbal Remedies And Drugs Should Not Be Combined?

Many people view herbal remedies as natural - and therefore safe, but this is not the case. All herbal remedies work in exactly the same way as drugs and can cause similar side effects, which may be precipitated by combining them with prescribed or recreational drugs. This is particularly significant when women at term resort to natural ways to try and start labour. Taking herbal remedies such as raspberry leaf, castor oil, black cohosh, ginger, evening primrose oil and others alongside medical drugs to induce or increase contractions can lead to serious hyperactivity of the uterus and fetal distress. Midwives and other birth workers should advise parents not to combine herbal remedies with prostin, Propess™ or syntocinon. In pregnancy, taking herbal medicines frequently, even prophylactically, can cause problems such as changes in blood sugar, liver overload and, notably, blood thinning.

Why Do Expectant And Birthing Parents Turn To Complementary Therapies?

Complementary therapies (CTs) are not part of standard antenatal care but are increasingly used in labour. There are many types of CTs, including massage, aromatherapy and reflexology, acupuncture, moxibustion, herbal medicine and homeopathy and hypnosis. Osteopathy and chiropractic are not now classified as “complementary” but are statutorily regulated as “supplementaryprofessions”. In pregnancy and birth all these therapies should be complementary options – not alternative to standard maternity care and it is important that midwives ask expectant parents about their use of CTs and natural remedies.

Expectant parents turn to CTs to resolve pregnancy issues such as sickness and back pain, for which they are generally discouraged from taking conventional medicines. Many use them for relaxation and preparation for birth. Perhaps the commonest reason for CTs use is to avoid induction of labour, closely followed by pain relief in labour. It has been shown that CTs are less commonly used after the baby’s birth although some women use them to aid recovery, ease discomforts and stimulate lactation.

Did You Know That The Sense Of Smell Increases During Pregnancy?

Expectant parents often tell us that their sense of smell has changed, sometimes to the extent that they cannot tolerate certain odours. This heightened sensitivity to aromas is called hyperosmia. It is thought that this is due to the impact of increased ghrelin, a hormone found mainly in the stomach, and is often called the “hunger hormone” as it triggers the urge to eat. In pregnancy, it is also produced by the placenta in association with growth hormone, peaking in the second trimester and declining towards term. Reports of going off the smell of meat, milk orcooking/cooked food are common, but sometimes, a woman will tell you that her sense of smell is so sensitive that she cannot even bear the smell of her partner. When Denise was a student midwife in the 1970s, it was forbidden to wear perfume to work (in nursing too) as the aroma could have negative effects on expectant parents (and patients).

It is worth remembering this hyperosmia when working with expectant parents, especially in maternity units where aromatherapy is offered for labour. Essential oils should never be used simply to fragrance the environment in a birth centre or maternity unit, partly because of the potential for some people (not just parents, but also staff) may dislike certain aromas, but also because of the chemical impact on individuals inhaling the vapours.

Surreal conversation

Surreal conversation during our midwifery aromatherapy course recently:

Denise: all opened bottles of essential oils must be kept in the fridge

Midwife 1: can we keep our full carry case of oils in there?

Midwife 2: I can't do that, I wouldn't have space for my tortoise!

Midwife 1: why would you keep a tortoise in the fridge?

Midwife 2: to prepare him for hibernation

Denise: even without a tortoise you have to be careful to keep the oils insulated otherwise they can make your eggs smell - wrap the oil container in silver foil

Midwife 3: can the oils make the tortoise smell as well?

Midwife2: if so, should we wrap the tortoise in foil to protect him too?

Denise: actually you have to be careful about using essential oils around animals and you should avoid specifically oils such as eucalyptus and tea tree around tortoises.

NICE Persists in Inaccurately Classifying Aromatherapy as “Non-Pharmacological”

Having been away for a while, Denise has just caught up with the latest revision of the National Institute for Health and Care Excellence (NICE) on care in labour (NICE guideline NG235 published 29 September 2023). As expected, very little has changed in respect of pain relief in labour, particularly relating to complementary therapies. In a continuation from previous versions, maternity professionals are still directed not to offer or advise parents on aromatherapy, yoga, hypnosis, acupuncture or acupressure in the latent or first stages of labour – but suggests we should support her choice if she wishes to use them. They are “kind” enough to suggest that women wishing to receive massage “that has been taught to birth companions” should be able to receive it, but then discourage the use of massage, acupressure or hypnosis by professionals. This is ridiculous, since therapy performed by professionally taught midwives or doulas is likely to be more effective than that performed by partners. Either massage, acupressure and hypnosis are safe in labour – or they are not - in which case birth companions should be discouraged from using them as well. You can’t have it both ways. Further, women wishing to receive acupuncture are extremely unlikely to self-administer this or ask their partners to perform it: acupuncture needs to be administered by visiting acupuncturists or appropriately trained midwives or doctors. By advising that it should not be offered deprives women of a choice they may prefer to conventional pain relief – and one that is as effective and potentially safer than pethidine, morphine or epidural anaesthesia.

Crucially, despite several previous editions of the intrapartum guideline having been challenged by Denise and others, NICE persists in classifying aromatherapy as “non-pharmacological”. Essential oils used in aromatherapy most certainly DO work like drugs, being absorbed, distributed, metabolised and excreted by exactly the same physiological mechanisms. NICE incorrectly and simplistically classifies aromatherapy with other relaxation therapies with its dismissive and potentially harmful attitude. Indeed, the vast number of expectant and birthing parents using aromatherapy means that many are completely unaware of the possible risks of inappropriate use, seeing them simply as pleasant smells to enhance massage. Further, NICE sets its guidelines on the basis of the available evidence – and assumes (incorrectly) that there is insufficient evidence on complementary therapies to support their use.

Conversely, the revised antenatal care guideline (NG201 published 2021) advises maternity staff to record at booking the use of herbal remedies and to offer advice on herbal and other remedies during antenatal appointments, as well as commending the value of both acupressure and (inappropriately) the ubiquitous ginger for all women with nausea and vomiting in pregnancy. These are more examples of the lack of knowledge and understanding of complementary therapies and natural remedies by members of the NICE guideline teams, who seem out of touch with reality and the trends in self-administered natural remedies. Even if the team members do not understand this subject and cannot find sufficient randomised controlled trials to advocate for the use of complementary therapies in pregnancy and birth, they should, at the very least, ensure that the information in the guidelines is accurate – and the word “non-pharmacological” is not accurate when referrring to aromatherapy.

Licorice In Pregnancy

Licorice (Glycyrrhiza glabra) is a herbal remedy that is sometimes used by expectant parents to try to trigger labour. However, it should not be used in therapeutic doses – in the first and second trimesters it may cause miscarriage or preterm labour, or excessive contractions at term. Importantly, its high salt content means it should not be used by those with hypertension or oedema. Babies of women who have consumed a lot of licorice may have raised cortisol levels and exhibit signs of stress. Licorice should be avoided with gestational or pre-existing diabetes, renal conditions or hormone sensitive conditions. It has the potential to interact with many drugs, particularly antihypertensives, non-steroidal anti-inflammatories eg diclofenac, ibuprofen; some anti-diabetic medication andanticoagulants such as heparin, warfarin, aspirin, nifedipine, enoxaparin.

Childbirth In Africa: Still A Dangerous Event

Maternal deaths continue to be largely concentrated in the poorest regions of the world and in countries affected by conflict. In 2020, approximately 70% of all maternal deaths were in sub-Saharan Africa. In nine countries facing severe humanitarian crises, maternal mortality rates were more than double the world average (551 maternal deaths per 100 000 live births, compared to 223 globally). South Sudan has the worst statistics in the world, with a maternal mortality rate of 1223 per 1000,000 live births. Life threatening haemorrhage, hypertension and eclampsia, pregnancy-related infections, complications from unsafe terminations, as well as HIV/AIDS and malaria are the leading causes of maternal deaths. These are all largely preventable and treatable with access to high quality maternity care.

Effects Of The Full Moon On Women’s Health

Many people claim that the full moon affects their wellbeing. It is thought that menstrual cycles amongst groups of women become synchronised during the phase of the full moon, possibly due to the gravitational pull of the moon. It is claimed that a full moon affects mental health and wellbeing, although formal research studies have failed to confirm this.

A large French study of over 38 million births found a small but significant increase in labour onset during the full moon. (Chambat et al 2021).

African Medicinal Plants For Childbirth

Over 5500 plants growing in Africa are used in traditional medicines, although around 90% of these have not been studied, researched or classified for safety.

Many of the commonly used plants are the same as those used in first world westernised countries, such as ginger and peppermint for sickness and fennel and fenugreek for lactation, but others are rare or obscure plants– that may not always be safe.

Natural plant medicine in African countries is entwined with traditional sociocultural practices and spiritual beliefs and they are often shrouded in mystery such as when they are prescribed by the local sangoma (witch doctor).

One Zulu remedy in preparation for childbirth, called Isihlambezo, is a concoction of over 50 different plants, many of which in scientific medicine are not considered safe in pregnancy.

World Reflexology Week

This week, 18^th to 24^th September is World Reflexology Week. Reflexology is a general term for a wide range of therapies based on the principle of one small part of the body representing a map of the whole body. Some styles of reflexology are simply adapted foot massages incorporating pressure point work. Reflexology in the Far East uses Chinese medicine meridians (energy lines) and there are some European styles that are similar. Reflex zone therapy, which is taught by Expectancy, is based on anatomical and physiological principles and fits well with midwifery practice. We offer a full six month Certificate programme in Midwifery Reflex Zone Therapy commencing on 3^rd January 2024. If you’d like to join us to learn about this fascinating therapy, contact info@expectancy.co.uk

Complementary Therapies To Reduce Intervention In Childbirth

The growing number of birthing parents with complex medical, psychological or social needs, means that the focus of NHS midwifery is primarily on the pathological elements of complicated pregnancies and births. Since Denise started midwifery in the mid-1970s, childbirth seem to have changed out of all recognition and midwifery has become an extension of nursing practice, with greater medical intervention. This has led to a reduction in midwives’ experience of physiological birth – and their ability to help women whose births could remain physiological if only midwives had the confidence to help with them.

Using complementary therapies (CTs) can contribute to reduced stress in expectant and birthing parents which has a knock-on effect of increasing oxytocin and endorphins. Several units using aromatherapy for pain relief in labour or acupressure for postdates pregnancy have found a reduction in the need for epidurals, induction or acceleration of labour and Caesarean sections. Despite a national backlash against the use of CTs in midwifery from some quarters, there is no doubt that having birthing parents who are more relaxed contributes to greater levels of physiological birth, so long as there are no other complications or deviations from expected physiological progress. 

How Do You Know If An Aromatherapy Course Is Appropriate For Midwifery Practice?

Aromatherapy has become the most popular complementary therapy amongst birthing parents and is an effective tool for midwives to use. However, if you want to introduce aromatherapy for birth into your midwifery practice, it is essential to ensure that you choose the most appropriate training course. It is not necessary to be a fully qualified aromatherapist in order to use aromatherapy within midwifery practice, but midwives must undertake courses applicable to midwifery. Here are some questions you should ask to ensure that the course you want to attend is appropriate for midwives:

• are all the course facilitators qualified midwifery educators, fully qualified in aromatherapy? do they have experience of implementing aromatherapy into midwifery practice in the NHS? 
• is the course accredited by a reputable organisation: (NB any course claiming to be RCM accredited is out of date – RCM has not accredited courses since 2020)
• how long is the course and what do the facilitators claim you are able to do at the end of the course? Is it appropriate for CPD and revalidation?
• does the course content provide a balance between theoretical and practical learning?
• is the theory taught at academic level 6, in which you are encouraged to apply principles to practice – or is it merely a level 3 or 4 course, which offers enjoyable practical work with little academic content?
• does the way the course is taught test your understanding of pregnancy and birth physiology and how it relates to aromatherapy – or is the teaching didactic?
• does the course content include chemistry, NMC parameters, institutional health and safety laws, research evidence and regulations pertaining to aromatherapy?
• are participants assessed for competence and knowledge of aromatherapy? if so, is the assessment process robust and validated by an external academic organisation?
• Do the introductory courses offer opportunities for further learning on advanced aromatherapy and massage, as well as preparing you for both NHS and private practice?

Expectancy aromatherapy courses provide you with all of this! 

What Is Your USP? 

Midwives who’ve joined our Expectancy Licensed Consultancy have taken the plunge to work freelance so they can offer services for expectant and newly birthed parents that are not generally available on the NHS. We always advise our LCs to focus on their USP – their unique selling point – which is the fact that they are MIDWIVES and have undertaken specialist training with Expectancy on midwifery complementary therapies (CTs). Expectant parents like the fact that their appointments allow them time to ask the midwife any questions they may feel they can’t ask in a busy NHS clinic. We advise the midwives to market (advertise) their services in terms of offering SOLUTIONS TO PROBLEMS, rather than the process (the treatment). For example, rather than stating on their websites and social media that they offer reflexology, aromatherapy or hypnosis etc, we suggest midwives focus their adverts on being able to help relieve pregnancy sickness or backache or CTs treatments for those wanting to avoid induction for postdates pregnancy. Expectancy’s Licensed Consultancy offers full business training alongside your chosen complementary therapy programme, with support to establish and start your private practice and develop it further once you have started trading. 

Don’t Stretch The Boundaries Beyond Your Training 

Denise was recently contacted by a midwife from a unit where aromatherapy has been available for some time. She asked whether it is possible to use polysorbate 20 rather than carrier oils when midwives provide aromatherapy in pregnancy or birth. Polysorbate 20 is a non-ionic surfactant and emulsifier substance derived from oleic acid and is soluble in water. The surfactant contains ethylene oxide produced from sorbitol through various industrial processes, so polysorbates are not natural products - they have been chemically altered.

There are several reasons why polysorbate 20 should not be used by midwives offering aromatherapy:

• it is an artificially produced chemical substance whereas only natural essential and carrier oils should be used in aromatherapy
• oleic acid is contraindicated for massage as it can actually dry the skin – it is also the reason why olive oil should not be used in massage
• concerns have been expressed about the potential allergenicity, reproductive toxicity and carcinogenic effects of polysorbate 20 (due to ethylene oxide content).

More importantly for midwives, the NMC Code 2018 requires midwives to:

• work within the limits of knowledge and training
• act in the best interests of people in their care and in line with available evidence for safe practice
• have a clinical guideline that states clearly the parameters of practice – so if carrier oil is specified and polysorbate is not, then it should not be used  
• take account of their own safety and that of others
• work in line with the principles of medicines management
• reduce potential for harm associated with practice

Midwives need to be more careful than ever before, with so many challenges to midwifery complementary therapies (CTs), especially aromatherapy.

This requires them to be updated and to work within the very strict criteria laid down by the NMC, the RCM position statement 2020 and the forthcoming RCM Guideline for midwives using CTs (2023).

Home Birth or Hospital Birth ?

Denise was chatting with a midwife the other day, acting as her confirmer for NMC revalidation. The midwife explored a situation in which she was caring for a woman who had an undiagnosed breech presentation in the second stage of labour and commented on the reassurance that having another midwife present gave her. Denise then reflected on her own experiences as a community midwife in the late 1970s and early 1980s, when home births were generally conducted with only one midwife present. Midwives today work in a maternity culture in which, rather than focusing on appreciating physiological parameters, emphasises the need to avoid complications - and possible litigation when things go wrong. However, in the 1970s and ‘80s, midwives understood physiological birth so well that they had confidence in women’s bodies to labour and birth their babies spontaneously – and the parents had confidence in their midwives. Understanding physiological parameters meant that midwives were able to detect when deviations from normal progress were developing and the stage at which obstetric support should be summoned. The spectrum of “normality” was much wider than it is today – but then many parents still chose home birth, despite the move to encourage hospital birth. How confident would you feel in assisting parents without a second midwife present, especially at a home birth?

Most Commonly Used Herbs for Pregnancy and Birth

Did you know that the most commonly used herbal medicines during pregnancy include ginger (for nausea), raspberry leaf (for birth preparation, not induction), peppermint (for sickness), chamomile (to aid sleep), cranberry (for urinary infections - UTI), fennel or fenugreek (for lactation) and clary sage, black cohosh, blue cohosh and evening primrose oil (to aid labour onset). However, you may not know that all herbal medicines must be used with caution as they act in exactly the same way as drugs and can interact with some. Whilst most of these herbal remedies are safe enough in pregnancy and birth when used appropriately, some – particularly blue cohosh – should not be used at all. Others, including clary sage oil should be avoided until at least 37 weeks of pregnancy and only used when there are no complications. There are specific issues to consider depending on the remedy used, for example cranberry juice to prevent or treat UTI should always be sugar-free; chamomile should not be consumed to excess as it will then act as a stimulant rather than a sedative, and fenugreek taken in late pregnancy can cause the baby to be born with an unusual body odour, similar to maple syrup urine disease. 

WATCH OUT!

It’s essential for both the pregnant or birthing parent receiving complementary therapies (CTs) and the midwife, doula or therapist providing treatment, to remove their watches during the session. This is not only to avoid scratching the client (from a wristwatch), but more importantly because a watch can have an impact on the success of the treatment. CTs work on balancing energy levels to restore homeostasis. However, a watch (fob watches too) or any other source of magnetic or electrical energy, increases heat transfer which increases stress hormones and can adversely affect the success of the therapy. This also applies to other equipment, for example, CTG machines in the birthing room, which are an unpleasant source of heat that are counter-productive to physiological birth progress. The concept of energy is explored on our scientific basis of CTs, an essential study day for midwives on our Diploma in Midwifery CTs and our acupuncture programme. 

Promoting Physiological Birth

Did you know that research supports the use of complementary therapies (CTs) in pregnancy and birth, with several studies showing a decrease in stress hormones. Massage, acupuncture and reflexology have all been shown to reduce cortisol and increase feel-good endorphins and encephalins. As we know, reduced stress hormones has a knock-on effect by increasing oxytocin to aid progress in pregnancy and especially during labour. Let’s return to nurturing birthing parents by using relaxing CTs during the first stage. Promoting physiological birth reduces the need for medical intervention – but does not preclude it if it becomes essential.

IT ONLY TAKES ONE ….

The number of allergic reactions has doubled in the last two decades, with over 25,000 people requiring hospital admission (this does not account for those who attended A&E but who were not admitted).

Whilst the main culprits are foods such as nuts, kiwi fruit and chickpeas, dairy and wheat products, people also react to chemicals in the atmosphere, from fuels and industrial use. Others react adversely to certain trees, for example, the increasing plantation of birch trees. Perfumes, bath products and household cleaning agents are also high on the list of allergens. This includes aromatherapy essential oils, which each contain up to 300 chemical constituents.

Denise has seen some extremely severe reactions to aromatherapy oils, with more reactions amongst students in the past ten years than in the previous 30 years working in the complementary therapy field. It only takes ONE single chemical to aggravate the nasal smell receptors, stimulating the olfactory nerve and passing to neurotransmitters in the brain which impact on various other nerves to produce respiratory, dermal, cardiovascular or other adverse reactions.  Why then, is it so difficult to get this message across to midwives using aromatherapy in their practice? Essential oils act like drugs and can be very effective in relaxing pregnant and birthing parents, easing labour pain and nausea, fighting infection and lowering blood pressure. Conversely, if they have the power to do good, they also have the potential to do harm when not used appropriately. Midwives need to get past the belief that essential oils are just “pleasant smells” and take on board that they may cause allergic reactions – in expectant and birthing parents and babies, themselves and anyone else wo comes into contact with the chemical vapours (aromas). The issue is often that “aromatherapy” is taught as a skills-based “tool” to add to midwives’ options for care, without adequate theory to help them understand the therapy and its mechanism of action, contraindications and precautions.

Expectancy is currently developing a full implementation project for NHS trusts wishing to introduce or review aromatherapy services or to establish clinics for postdates pregnancy using essential oils and acupressure. Denise’s philosophy has always been “safety, accountability and evidence-based practice” – and this includes ensuring that midwives fully understand both the benefits and the risks of using essential oils in their care of pregnant and birthing parents – and that they know how to minimise those risks. Midwives should also acknowledge that they are “cherry picking” a small amount of someone else’s profession to add to their own. We would not expect aromatherapists to undertake a couple of days of skills based training on how to help someone give birth - and then expect to practise “midwifery” – so why do midwives assume that they can do so with aromatherapy?

Safety, Accountability and Evidence-Based Practice

There is much national scrutiny of midwifery complementary therapies at present - from people who know nothing about the subject but who have an axe to grind against the natural childbirth lobby and, indeed, against the midwifery profession. They argue that the NHS should not "waste" money on "unproven quackery" yet, conversely, want greater medical intervention to avoid the so-called risks of allowing women's bodies to do the fundamental job of giving birth. 

Complementary therapies (CTs) should be just that - a complement to other midwifery care - offered as an aid to relaxation and a means of facilitating physiological progress of pregnancy and birth. Despite the sceptics' claims that it is unproven, there IS a considerable amount of evidence to support therapies such as massage, aromatherapy, acupuncture and others. 

And what does this scepticism and antagonism do for expectant and birthing parents' choices? The fact that over three quarters may be using some aspect of CTs or natural remedies indicates the popularity of less invasive options particularly for pain relief in labour or as a means of avoiding induction.

At Expectancy, our courses aim to help midwives use CTs safely. Indeed, our philosophy is "safety, accountability and evidence based practice". Midwives on our courses not only learn the skills but acquire an in-depth understanding of the therapies, how they work and how to use them safely. Assignments are based around a critical understanding of the evidence and the professional,.legal, ethical and health and safety parameters required for implementing CTs into midwifery practice. Midwives complete a year-long academic programme designed to prepare them to defend CTs and to use them appropriately and safely.

Bring Back Massage in Midwifery !

Denise has been having some very interesting conversations with midwives on her courses recently. One group was reflecting on the power of touch and the benefits of massage, especially during labour. Massage, with fragrant herbs and oils has been part of midwifery care for childbirth since time immemorial. However, it seems that the skills and - importantly - the intuition to use touch may be being lost, unless we take steps to remedy the situation.

Student and newly qualified midwives seem hardly ever to witness their mentors touching expectant and birthing parents in anything other than a functional way, doing things TO them rather than FOR them. This may be due to lack of time, a fear of misunderstanding of intent or a worry that spending time with one woman denies others, thus making the service inequitable. 

Touch and massage are fundamental to the nurturing of midwifery yet if we don't work hard to incorporate it into our care, it will be lost altogether. The changing nature of maternity care, the medicalisation of birth, the pressures on staff and the political correctness of modern day society all conspire to discourage many health professionals from providing anything more than the basic care to enable expectant parents to give birth to their babies.

On the other hand, massage is immensely powerful in its own right. It is well researched and demonstrates that touch reduces stress hormones such as cortisol and increases the feel-good endorphins and encephalins,with a corresponding increase in oxytocin and other birth hormones. Receiving regular massage (and other touch therapies) in the last few weeks of pregnancy has been shown to facilitate the spontaneous onset and physiological progress of birth. It enhances the birthing experience, promotes the infant-parent relationship, improves the immune system to aid recovery from birth and reduces the long-term physical and emotional negative effects of birth. This in turn reduces the long-term financial and logistical impact on the health services, particularly gynaecology and mental health services.

Student midwives need to be helped to develop a better intuitive approach to pregnancy and birth through pre-registration programmes that focus on holistic approaches. Newly qualified midwives need to lose the fear of punitive criticism for "wasting time" CARING for expectant and birthing parents. Midwives who have been in practice for some time need help to rekindle their joy of helping families at this most significant time of their lives. Managers need to factor in time and cost of caring as opposed to ticking boxes in pointless time wasting statistics gathering exercises. And society needs to embrace the value of birth as perhaps the most important human achievement of all. 

An Extract From Her Latest Book, Complementary Therapies for Postdates Pregnancy....

Denise explains how she came to be involved in – and enthused by – complementary therapies. Now acknowledged as one of the world’s authorities on midwifery complementary therapies, Denise has spent 40 years developing the specialism, including practising, teaching, researching and publishing on the subject. 

In the early 1980s, when I first became involved in this emerging field of healthcare, most therapies were viewed very much as “alternative” or “fringe medicine” (or even witchcraft!). I first become interested in complementary therapies (CTs) after completing a massage course, then decided to train in reflexology, which I loved. At the time, I had returned to my midwifery teaching role but was still breastfeeding my nine-month-old son. Whilst on the reflex zone therapy (RZT) course (a specific German clinical style of reflexology), I started to produce copious amounts of extra breastmilk, which my tutor informed me was due to slight over-stimulation of the foot reflex point for the pituitary gland during the previous day’s practical work. This caused me to consider the possible application of RZT to midwifery practice – indeed, it was my “aha” moment that was the driver for everything else I have done since. RZT became my primary tool in clinical practice and is still my preferred therapy today. Next, I attended an aromatherapy course which fuelled my interest in using essential oils for pregnancy and birth, but although I now teach more aromatherapy to midwives than any other therapy, I use it less in my own clinical practice than RZT. I have a serious interest in the need for professionals to use aromatherapy with extreme caution in pregnancy, especially when it is incorporated into midwifery practice and have recently completed guidelines for other midwives using CTs for the Royal College of Midwives (due to be published shortly). Over the next few years, I studied herbal and homeopathic medicine and later maternity acupuncture and clinical hypnosis. In the late 1980s, schools of midwifery and nursing in the UK were just being incorporated into the university system and the school of midwifery where I worked in southeast London became part of the University of Greenwich. I was appointed to lead the post-registration education provision and was given the opportunity to develop a Diploma of Higher Education in CTs and later a unique Bachelor of Science Honours degree in CTs. I also established, as part of this work, a CTs teaching clinic at one of the local maternity units where student midwives undertook their clinical placements. I spent one day a week in the clinic for the next ten years and treated almost 6000 expectant women with a variety of pregnancy discomforts and anxieties. As a midwife, I think I was initially seen as the “resident witch” particularly when it came to weird techniques such as burning sticks to turn a breech (moxibustion) or claiming that pressing points on the feet could impact on uterine action (RZT) or advocating natural remedies that contained “nothing” (highly diluted homeopathic remedies transformed from pharmacological chemical substances into energetic medicines). However, as time went by and the midwives and obstetricians witnessed the successes I achieved, they became increasingly more accepting of what was on offer, sometimes even attending themselves to experience a treatment session – a very good way of convincing them of the effectiveness of complementary therapies. At one point, having successfully relieved pregnancy sickness and hyper-salivation for one of the obstetric registrars, who later recounted her experience in theatre over a Caesarean section, I then had several anaesthetists with similar problems queuing up for treatment! One of the initiatives I introduced, with the help of other midwives I had trained in the unit, was a postdates pregnancy clinic, the first of its kind in the UK. We used acupressure, aromatherapy and reflex zone therapy as a package of treatment and had significant success in facilitating labour onset.  I also undertook several research studies relating to CTs, including assisting a local maternity unit with research on using acupressure for postdates pregnancy. Postdates pregnancy has always been a specific interest of mine and no more so than now, when it is one of the most provocative debates in maternity care. In 2004, I left the University of Greenwich to set up my own education company, Expectancy, and have been training midwives in the UK and overseas on a variety of CTs ever since, together with continuing to write textbooks on the subject, an activity that began in 1992.

Yoga as Preparation for Birth

Yoga can be a very pleasant way of preparing for birth, although some authorities advise that the style of yoga should be one that is largely sedentary rather than the excessive exercise of “hot” yoga which would raise the woman’s temperature excessively. In general, yoga can have a positive physical and mental effect, reducing stress in pregnancy, which contributes to a positive approach to labour and has even been found to reduce depression in some women. Yoga may contribute to reduced intervention, shorter first stage labour and alter the perception of pain, thereby reducing the amount of pharmacological pain relief required.  This is likely to be due to the generalised impact on stress and biomarkers such as cortisol, salivary amylase and immunoglobulins.

Midwifery Aromatherapy: Is It Safe? 

The use of aromatherapy by midwives in the UK has been under intense national scrutiny in the past few months, from the CQC, Ockenden review teams and national newspapers and radio. The media frenzy in particular has arisen from problems in some maternity units where midwives offer labour aromatherapy. Whilst there is not always a direct correlation between obstetric/neonatal complications and aromatherapy when midwives use it cautiously, there is bound to be some antagonism from sceptical colleagues when things go wrong. Similarly, parents experiencing traumatic birth or loss look for reasons and could potentially blame the use of aromatherapy in the absence of any known evidence for its safety.

So, is it safe to use aromatherapy in pregnancy and birth? The short answer is YES – when those using it understand how it works and when - and when not - to use essential oils. This includes ensuring that expectant and birthing parents appreciate that the oils act like drugs and are not always safe to use.  And - is it safe for midwives to incorporate aromatherapy into their practice? YES - when midwives and managers apply the principles of aromatherapy to its use within a maternity unit or birth centre. This requires them not only to know how to select and blend appropriate oils and to administer them, but also to appreciate issues around health and safety, the law and the midwifery Code and the impact on everyone exposed to the oil vapours. 

And – the crux of the matter – is aromatherapy use in midwifery currently safe? The answer here is - NOT ALWAYS. Many midwives ARE using essential oils judiciously and practice, monitored by managers who understand the subject, is based on contemporary evidence and safety principles intended to protect families and professionals. However, there are some maternity services where midwives’ use of aromatherapy is based on training undertaken years ago or, which has been provided by teachers who themselves do not understand the context in which they need to set maternity aromatherapy. These midwives’ practice is considerably out of date, both in terms of aromatherapy practice and NHS developments. It is not evidence-based and is not in keeping with contemporary maternity care, the parameters of institutional use and the NHS culture.

Do I think that midwives should learn about aromatherapy in their training? YES, absolutely. I have been campaigning for an introduction to the vast subject of complementary therapies to be included in pre-registration midwifery education for many years. This is not because I believe that all midwives, at the point of registration, should be involved in offering aromatherapy in practice, but because they should all be able to provide basic safe information to expectant and birthing parents who ask about it – and to advise on safety for those who don’t ask but who wish to use their own oils, particularly to aid the onset and progress of labour.

My professional philosophy, over 40 years of teaching complementary therapies in midwifery, has always been SAFETY, accountability and evidence-based practice. It was this philosophy that motivated me to establish myself as a freelance lecturer via my own company, Expectancy, almost 19 years ago after running a BSc(Hons) degree on the subject at the University of Greenwich for many years. It is the reason I am still working long after many of my colleagues have retired, and the reason I intend to continue hammering out the same message of safe practice as I pass on the baton to other colleagues.

For NHS trusts wanting to introduce or review current aromatherapy services or to establish complementary therapy services for postdates pregnancy, I can help you provide a safe, effective, cost effective, equitable, timely and evidence-based service. For those increasing numbers of UK midwives wanting to offer private pregnancy aromatherapy, I can help you avoid the pitfalls of “going it alone” and ensure that you can offer a safe, effective, marketable and profitable service. For midwives overseas, I can provide face to face or online courses to enable you to use aromatherapy appropriately and safely. Contact me now for more information – info@expectancy.co.uk

The Professionalism of Reflexologists

I am once again concerned to see several posts on Facebook from reflexologists asking questions that should not be asked in such a public domain. The most worrying post was from someone asking if it was OK to provide reflexology for someone who had had "brain surgery"  two weeks ago, with no other information given. Some responses suggested this was acceptable, which I would truly challenge. If a reflexologist has to ask such a fundamental question, then they should not be providing treatment for people with complex medical conditions before further training. Moreover, if they do not recognise the boundaries of their own practice, perhaps they should not be practising at all. 

Other posts pose similar questions based on what colleagues can see on photos of clients' feet, (only occasionally with a "posted with permission" comment). Whilst viewing photos in a formal training session can be a useful aid to learning, it is highly inappropriate to post these publicly and to ask for comments from colleagues who do not have the clients' full medical histories. Doctors would not post photos of  patients' organs with a general "what would you do?" question to all and sundry, so why do some reflexologists feel it is acceptable?

One issue that raises its head in relation to pregnancy reflexology is that of helping to "induce" labour when women are approaching term and want to avoid induction. Whilst reflexology can be very useful in aiding relaxation, which encourages oxytocin, and even, when performed by appropriately trained midwives, facilitate the onset of contractions, I have come across several reflexologists claiming to offer an ™induction" service. This is most certainly not their role -especially when they do not know or understand the obstetric history or - in the case of one practitioner I met many years ago - even consider the need to take a history.

So why do some reflexologists feel these practices are acceptable? Is it a genuine interest in sharing of knowledge? I suspect this is what they would say. Is it a lack of availability of professional development opportunities to ask these questions in a formal setting? Perhaps there is a need for reflexology educators to provide a regular forum for reflection and further learning through case discussions, as we do regularly in midwifery. Or is it because some reflexologists are "wannabee" medical practitioners who see fit to stretch the boundaries of their practice because it gives them a sense of self-importance?I

Of course, these issues apply to only a very few therapists and most reflexologists are highly trained practitioners. However, in a health discipline that still draws scepticism from many conventional  medical practitioners, it is these few who detract from the professionalism of the majority. Perhaps it is time for the reflexology regulators and training organisations to address how they identify and deal with these few mavericks.

Reflexology For Pain Relief In Labour: Research Problems    

Several research studies have been undertaken to determine its effect on labour pain and duration. Most of the more recent studies have been done in countries such as Turkey and Iran. There is no doubt that manual therapies such as reflexology and massage can be effective in relaxing women during labour, reducing their stress hormones and increasing birth hormones to aid comfort and progress. Denise has treated hundreds of expectant and birthing parents with reflex zone therapy, a German clinical style of the therapy that lends itself very well to midwifery practice 9and was developed by a German midwife, Hanne Marquardt).

Marhan, Varghese 2021 Unfortunately, the research is not as clear cut as it could be and does not give us the best evidence of effectiveness. There are several reasons for this. Most studies fail to define what type of reflexology is used, which precise reflex points on the feet are palpated, which techniques are used or even to differentiate between reflexology and foot massage. This makes it difficult to determine whether the effects are from reflex point stimulation specifically or from touch and massage more generally. Studies also need to be set in the context of the maternity care provided in the different countries: where care is very medicalised, with frequent vaginal examinations or other interventions, any nurturing in the form of touch therapies is bound to enhance the experience for birthing parents, irrespective of what type it is. There is no acknowledgement in most studies of the contraindications and precautions to using reflexology – this is particularly so when treatment is provided by midwives who have learned a few reflexology (or foot massage) techniques but whose knowledge and understanding of the therapy is limited. Indeed, there is no evidence for either the safety or risk aspects of reflexology in pregnancy, so practitioners need to determine for themselves whether or not it is safe to treat a woman by applying reflexology theory to the midwifery/obstetric condition of the individual. Reflexology is one of the most difficult therapies to fit into a randomised controlled trial methodology, because the foot points vary from one system to another – reflexology is not a single therapy but a wide range of different “reflex” related therapies which different mechanisms of action, different point locations and different techniques. Further, there are several studies where reflexology has either been compared to other therapies or interventions for pain relief, or have been used in combination with strategies such as massage, music or breathing exercises.

Healing Reactions and Adverse Effects of Complementary Therapies

Complementary therapies (CTs) generally aim to work from the inside out, considering the physical, psychological and spiritual factors that contribute to health and wellbeing. This differs from conventional medical treatment which focuses on working with individual body systems and the relief of symptoms. In the case of pregnancy, obstetrics focuses on the reproductive system, its symptoms and effects on other systems, and rarely considers the impact of lifestyle or psychosocial factors that may impact on pregnancy wellbeing.

Most people experience effects from CTs treatments as the body starts to heal itself. Some of these effects are positive, for example an improvement in unpleasant symptoms such as sickness or backache. Other effects of treatment can appear to be negative, but in fact are a positive sign that the treatment is working, encouraging toxins to be eliminated as the body responds. This is called a healing reaction and people may experience headaches, increased urine output or perspiration, thirst or other signs of toxin release such as spots appearing on the face. Healing reactions generally occur within 24-36 hours of CTs treatment, usually being more dynamic after the first treatment.

Conversely, more significant advere reactions can occur, in the event of inappropriate ue of CTs, such as prolonged or excessive administration. Sometimes these effects can be relatively minor and may include symptoms similar to healing reactions although they may last longer than 24 hours. More often, and dependent on the doses and duration of misuse, some adveres reactions can be severe and occasionally even life-threatening. This is particularly so with inappropriate use of herbal medicines that have a systemic effect and can affect the liver, kidneys or brain.

Added to this is the need to be mindful that some symptoms may be unrelated to the CTs treatment but may be a normal physiological symptom of pregnancy, or herald the onset of a pregnancy complication. For example, headache may be a healing reaction to an appropriately used therapy or an adverse reaction to an inappropriately used therapy, Conversely, it may be unrelated to the CTs, but be a normal symptom of pregnancy, tiredness or stress, or it may be the start of impending fulminating pre-eclampsia. When midwives use CTs in pregnancy, birth or the postnatal period, it is vital to distinguish between normal healing reactions, common physiological symptoms, abnormal adverse reactions to CTs and the onset of clinical complications.

What’s in a Name?

Did you know that the name of Denise’s company, Expectancy, is a mnemonic derived from the somewhat wordy title, “Expectant Parents’ Complementary Therapies Consultancy”? This was how Expectancy started back in 2004, when services were initially aimed more at expectant parentsrather than professionals. However, as a midwifery lecturer and international authority on the subject of complementary therapies (CTs), Denise soon realised that her forte was more in teaching other midwives to offer CTs for pregnancy, birth and the postnatal period, especially as this was at a time when many midwives were just becoming interested in learning more about this emerging specialist field.

Did you also know that Expectancy is the ONLY organisation, world-wide, offering this wide range of CTs courses specifically related to maternity care? Denise and her team teach in London, around the UK for various NHS trusts and Denise frequently teaches overseas, with courses for midwives and doulas wanting to learn about the therapies, and for therapists wanting to specialise in working with pregnant clients. Contact info@expectancy.co.uk for a prospectus.

Complementary Therapies for Mental Wellbeing in Pregnancy

Lets explore how complementary therapies can be helpful for sustaining mental and emotional wellbeing in pregnancy. We know that pregnancy and early parenthood can be a very stressful time for many expectant and new parents. Despite most babies being anticipated eagerly, physical, emotional, occupational and societal pressures combine to cause anxiety, stress and fear to a greater or lesser extent in most expectant parents. For some, the pressures are even greater, leading to both antenatal and postnatal depression – sometimes in both parents. We know that a large proportion of the population already experience mental health issues, with many taking antidepressants before and during pregnancy.

Therapies such as massage, reflexology and aromatherapy are known to be very relaxing and have been shown in various studies to reduce stress hormones (cortisol) and increase feel-good hormones (endorphins). A course of relaxation treatment during pregnancy, perhaps monthly or even more frequently, can be very effective in keeping stress and anxiety at bay, with an accumulative effect over the weeks. Reduced stress enhances expectant parents’ coping abilities when faced with the many discomforts of pregnancy, and aids growth and development of the fetus. Indeed, regular massage or reflexology has been found to make it more likely that labour will commence within expected time limits and progress will be good, resulting in a reduced need for intervention such as induction. Essential oils used in aromatherapy contain chemicals known to be relaxing, even sedating, and some can be useful in dealing with the physical symptoms that accompany mental ill health, such as headaches, insomnia and tension-induced muscular aches and pains.

Acupuncture is not usually the first therapy which comes to mind for relaxation, but studies have shown significant changes in stress hormones during and after receiving acupuncture for other conditions. This is particularly helpful when couples seek treatment to for fertility issues, since stress can be a real barrier to balanced hormones and sub-fertility. Herbal medicines, such as dong quai, chasteberry, black cohosh, evening primrose oil, red clover and others, can also help in the preconception period, but are best prescribed by a qualified practitioner rather than self-selected and administered. Similarly, homeopathy offers a gentle, individualised means of preparing for pregnancy, dealing with antenatal aches and pains and facilitating physiological birth.

Clinical hypnosis can be especially helpful in general preparation for the birth, but it can also be effective for specific issues during pregnancy, such as smoking cessation, needle phobia or extreme fear of giving birth. A course of treatment may be best, but there are also some excellent digital versions of general relaxation sessions which may be suitable for many. Note – clinical hypnosis is more specific and individualised than “hypnobirthing” and safer when attempting to treat acknowledged mental health issues. Like “hypnobirthing”, it is contraindicated when there is a diagnosed clinical mental health disorder.

In labour, midwives offering complementary therapies such as aromatherapy or massage find that birthing parents are calmer and progress better than those who do not receive aromatherapy. This may be due to the closer relationship between the midwife and parents, with a greater sense of wellbeing arising from the feeling of being nurtured. Postnatally, too, complementary therapies contribute to an easier transition into parenthood and quicker recovery from the birth. Regular treatments of all sorts of therapies can keep parents calm, focused and less likely to develop clinical depression or to experience a worsening of an existing condition.

Midwives’ Knowledge of Natural Remedies in Pregnancy and Birth 

At our recent online study day on natural remedies, we discussed the difficulties facing midwives in helping parents to understand the safety aspects of herbs, homeopathy and other natural remedies. Unfortunately, there is no single source of information for maternity professionals and parents. In addition, it has been shown from research surveys that expectant parents primarily obtain their information about natural remedies from the internet, friends and family, none of which may be the most knowledgeable source. Furthermore, student midwives are not taught about natural remedies such as herbal raspberry leaf tea for birth preparation, ginger for nausea, castor oil to expedite labour onset, echinacea to prevent winter colds or any of the other popular remedies. There is also a misunderstanding that highly diluted energetic homeopathic remedies such as arnica (for stress and bruising) is not the same as pharmacologically active herbal arnica, which can be toxic in large doses This lack of knowledge and understanding amongst midwives is due to several reasons:

1) there are virtually no midwifery lecturers with the appropriate training on the indications, contraindications, precautions and side effects to teach students about safe use of natural remedies so they can advise parents accordingly;

2) there is insufficient time to include the subject in pre-registration training and

3) there is  no real acknowledgement at a national educational or clinical level (ie within the NMC) to appreciate the need for midwives to be able to provide this information for the people in their care, because “natural remedies” are classified under the same umbrella term as “complementary therapies” with its insinuation that CTs are solely for relaxation.

Where's The Evidence For Banning Aromatherapy Diffusers From Birth Centres?

Denise has written guidelines for midwives on why aromatherapy diffusers should not be used in maternity units and birth centres. Recently, a consultant midwife challenged these guidelines, asking "where's the evidence?" There is, of course, no "evidence" in terms of formal research. It would be unethical to test out diffuser safety in a randomised controlled study. However, "evidence" can be gathered from a variety of sources, particularly from the application of knowledge to practice and from experience. The diffuser guidelines are based on physiological, chemical, legal and health and safety knowledge and principles, and the application of aromatherapy knowledge to midwifery practice and NMC and NHS requirements.

Unfortunately, it's easy to think of aromatherapy as just pleasant, relaxing aromas - but anything that has the power to do good also has the potential to do harm when used inappropriately. It's also sad to think that a consultant midwife, so keen to include diffusers in the birth centre simply for their aromatic effects, fails to understand midwives' professional responsibilities to parents, visitors, other staff and themselves and their legal obligations to the institution in which they work. Or perhaps we've become so reliant on seeking the "evidence" that we've forgotten how to apply knowledge to practice and how to appreciate and apply empirical evidence?

Promoting Midwives Working in Private Practice – What Are The Rules?

I am often asked about whether midwives working in private practice can be promoted by their NHS colleagues to women in their care. There is a long-standing misconception that NHS midwives are not permitted to suggest named practitioners, but this is not true. Amongst our Licensed Consultants, there have been situations where NHS managers have forbidden all midwives to promote the services of an individual midwife offering private complementary therapies. The NMC does not state, anywhere in its documentation, that a midwife cannot provide the names of specific practitioners to people in their care – and surely it is better to advise someone to contact a known practitioner than to conduct on online search. The NMC Code 2018 requires all midwives to promote professionalism and trust and to uphold their position as a midwife. Midwives working part time in the NHS cannot promote their own private services, as this would be a conflict of interest. However, another midwife can suggest that person and even give out business cards, if they feel the private practitioner has credibility. Direct reference to advertisements requires midwives working in private practice to ensure that they are “accurate, responsible, ethical, do not mislead or exploit vulnerabilities and accurately reflect skills, experience and qualifications”. It is not acceptable to imply that being a midwife makes you a “better” acupuncture or reflexology practitioner than someone who is not a midwife.

If you have lots of questions about this and other aspects of working for yourself, why not consider our Licensed Consultancy scheme? Full business training, problem-solving sessions, webinars, personal guidance on setting up and growing your business and much more, alongside your chosen complementary therapy programme – acupuncture, aromatherapy, reflexology, hypnosis or our signature Diploma in Midwifery Complementary Therapies. Contact Denise on info@expectancy.co.uk

Exciting Business Developments and Teaching

Denise has a busy week ahead. She will be spending a lot of time with her laptop, offering webinars for current students on the mechanism of reflexology and literature searching to help with assignments. She also has a very exciting meeting to discuss our new project, offering a full aromatherapy implementation package to NHS trusts wanting to introduce aromatherapy into midwifery practice.

On Wednesday she has her business coaching meeting, to enable her to discuss the next stage of Expectancy’s services and a business networking lunch on Thursday. Having been teaching all of this last weekend, Denise will be taking a well-earned weekend off for the bank holiday.

Wooden Combs for Childbirth – How Do They Work?

The use of combs to activate pressure points has become very popular for use in childbirth. These combs are usually wooden, chunky and small enough to fit into the palm of the hand. When clutched during labour, especially during contractions, they can act as a diversion from the physiological but often intense sensations of uterine contractions – this is based on the gate control theory of pain. In fact, pressure applied by squeezing the comb teeth is focused over two acupuncture / acupressure points on the palm of the hand. These are called Pericardium 8 and Heart 8. In Chinese medicine, the Pericardium 8 acupoint is referred to as Lao Gong, meaning “the palace of toil or labour” and is particularly good for relieving anxiety, literally by helping to “push” the pain away. It is situated at the centre of the hand and can be found, when making a fist,  by bending the middle finger into the palm. The Heart 8 acupoint is located, when making a fist, at the point where the little (5^th) finger rests. It is thought to increase internal energy and ease reproductive pain. Both of these points are approximately along the main crease across the palm, where the teeth of the comb presses when squeezed. Our Senior Tutor for our Certificate in Midwifery Acupuncture, Amanda Redford, recommends the Wave com,  which was cleverly  developed by a woman who used designed a moulded, small version of the original combs but small enough to fit neatly into the palm.  See https://www.thewavecomb.co.uk/    If you are interested in applying for our acupuncture programme for midwives, commencing in September, please email info@expectancy.co.uk for more information.

Starbucks In The Firing Line For Drinks To Aid Labour Onset

click here for link to article

There seem to be no lengths to which expectant parents will not resort in their attempts to expedite labour and avoid medical induction. The latest fad seems to be to drink Passion Tango tea from Starbucks. This tea contains hibiscus, a herbal remedy sometimes used as a traditional remedy to aid labour onset. The article states that it is not advisable to drink the tea because there is some evidence to support its effect on smooth muscle. Yes, hibiscus, in a medicinally therapeutic dose, may possibly encourage the uterus to start contracting and it is not advisable to drink concentrated hibiscus tea in large quantities in earlier pregnancy. However, it is highly unlikely that a commercially prepared drink will contain anything approaching a medicinal dose of hibiscus. Apparently, women are also adding Starbucks’ “raspberry syrup” to the drink, presumably in the mistaken belief that it acts like raspberry leaf, which may also aid labour onset. However, the traditional remedy of drinking raspberry relates to the LEAF rather than the fruit. Adding raspberry syrup to a drink will have no impact on labour onset but its high sugar content may be a problem for women with diabetes. Some parents are also adding pineapple syrup or juice – because there is some evidence that the bromelain in the central core of pineapple may encourage contractions. However, the bromelain is destroyed by juicing or canning the pineapple, so it is also rather pointless to add the juice or syrup to the drink. This is yet another fad embraced by desperate expectant parents which has absolutely no foundation, although I would not advise consuming excessive amounts – of anything- to encourage labour. Certainly, Starbucks should not be pilloried for offering the drink as one of their products, a product which has been lauded as a possible answer by hordes of expectant parents desperate to get into labour.

Happy 900th Anniversary - Saint Bartholomew's Hospital, London!

Today marks the 900th anniversary of St Bartholomew's Hospital in London. Denise was interviewed for nurse training in the year of the 850th anniversary,1973, and started training in 1975. Situated in London, between St Paul's cathedral and the Barbican, and very close the the Smithfield meat market, it was wonderful to be part of the heritage of this prestigious hospital. Denise will be visiting on the annual View Day in May to explore the area and meet up with friends. 

NHS Information About Complementary Therapies in Pregnancy

The NHS generally does not support the use of complementary therapies (CTs), except for cancer patients. Its information relating to pregnancy is superficial and challenges the safety of CTs, stating that most CTs are not statutorily regulated (correct) and that CTs lack scientific evidence to support it (incorrect but based solely on studies using “gold standard” methodology). 

There are some sweeping statements that provide no real information for prospective users of CTs. For example, there is no explanation about any of the supportive therapies which are frequently used by expectant and birthing parents, including aromatherapy, massage, reflexology, moxibustion and hypnosis. There are links to additonal pages on acupuncture and homeopathy, yet there is an implied disparagement for traditional Chinese medicine as opposed to western medical acupuncture, and antagonism towards homeopathy since it is no longer approved for NHS use, despite the fact that many people continue to access homeopathy elsewhere. 

Conversely, there is the ironic and continuing inaccuracy advocating universal recommendation of ginger for pregnancy sickness, based on its proven anti-emetic effects, yet failing to caution that it is not safe for everyone. There is just a single statement about herbal medicines focusing on the risks of using blue cohosh (correct) but failing spectacularly – and irresponsibly, almost negligently  - to emphasise that ALL herbal medicines should be used with caution since they act in the same way as prescribed drugs.

https://www.nhs.uk/common-health-questions/pregnancy/are-complementary-therapies-safe-during-pregnancy/

Clinical and Business Issues for Midwives Working in Private Practice

Denise has had a very busy return to work, helping some of our Licensed Consultants (LCs) with both clinical and business queries. Our LCs have completed one of our complementary therapy (CTs) programmes alongside business training so they can work in private practice. As part of the LC benefits, they have the opportunity to discuss suitable treatments for their clients, and to ask busines-related questions. Sometimes, especially those still working part time in the NHS, midwives want to discuss how to resolve complementary therapy safety issues that arise in practice.

Some of the questions Denise has tackled today include: 

• Suitable treatment for a woman with severe pregnancy sickness, also expecting twins
• Whether it is safe to treat with CTs a woman with abdominal pain, possibly adhesions from diastasis recti in the last pregnancy
• Discussing the draft text for a business website
• Proof reading some parent information leaflets devised by one of the LCs
• Reassuring an LC who wanted to double check the location of some acupressure points for postdates pregnancy
• How to deal with a Head of Midwifery intent on introducing aromatherapy diffusers to labour ward, despite the midwife explaing it is not safe
• Considering a business proposal for an LC wanting to ask for a loan from the bank
• Advising an LC who has booked to exhibit at a local Baby fair

If you are considering setting up your own maternity complementary therapy business, contact Denise on info@expectancy.co.uk for information about our Licensed Consultancy programme commencing in September.

The Evidence Base for Complementary Therapies

It's an easy argument for sceptics of complementary therapies (CTs) to say there is no research to support their inclusion into conventional healthcare. The truth is that these antagonists do not know about the considerable body of evidence for many of the popular therapies, largely because they do not know where to find it. In addition, that old chestnut, the reliance on "gold standard" randomised controlled studies, is yet again trawled out as further fuel against using CTs as a complement to standard care. The issue here is that RCT research methodology is not appropriate for care that needs to be individualised to each person. However, there certainly is evidence out there if you know  where to find it. Some of it is poor but much of the research is increasingly of a good standard and provides evidence of effectiveness and safety.

Pregnancy presents an additional problem because it is not possible to test out CTs for safety on expectant and birthing parents. Sceptics conveniently forget that some aspects of general healthcare are introduced without adequate evidence of safety of effectiveness. Pharmaceutical research was introduced after the Thalidomide disaster in the 1960s, but still it is unethical to test new drugs for safety on pregnant women - so some drugs used in pregnancy are not actually licensed for such use.

There is very much a two tier system in play here, with acceptance that certain medical treatments, largely introduced by doctors into our paternalistic health service, are acceptable without always having exhaustive evidence prior to implementation, whilst caring strategies introduced by midwives have to prove themselves twice over in order to gain any semblance of acceptance.

Once again, I challenge these arguments put forward by people with personal agendas, who seek to denigrate CTs because it suits them to do so but who do not in any way have the expertise to use facts rather than supposition. I would always defer to the relevant authorities for correct, comprehensive, contemporary and evidence based facts on other clinical specialisms - so why can't those same "experts" have the respect for those of us who have worked for so long to make midwifery CTs an academic and professional specialism that involves years of practice, teaching, research and publication on the subject?

Integration of Complementary Therapies in Midwifery 

When midwives consider introducing any aspect of complementary therapy (CT) into their practice, they're governed by the Nursing and Midwifery Council Code of Practice, not by the regulatory organisations that would govern CT use outside midwifery or the NHS. 

CTs offered by midwives as part of standard maternity care must be: 

• Effective
• Safe 
• Cost effective
• Evidence-based
• Individualised
• Equitable
• Compatible with other treatment
• Set in the context of institutional use (NHS)
• Used in line with national laws and directives

The Cost Effectiveness of Complementary Therapies in Maternity Care

Money has raised its head as yet another argument against incorporating complementary therapies (CTs) into midwifery. Various Twitter comments theorise that CTs are an expensive waste of money and something that the NHS can ill afford to support. The truth, in fact, is very different. Introducing aromatherapy into labour care for women without complications costs no more that £1500 a year, even in large tertiary units. That is less than the cost of one unnecessary Caesarean section. The procedure of moxibustion to turn a breech baby to head-first costs as little as £15.  Even when a couple of hours of midwives' time is factored in, the whole process costs little more than £100 - if that saves a woman from having a Caesarean then the NHS has saved another £2000. Teaching parents to use acupressure points at home to encourage cervical ripening and contractions has been shown in several studies to reduce the need for medical induction with all its potential for a cascade of further intervention - and yet another risk of a £2000 Caesarean.

And let's not forget the cost of parental satisfaction and facilitating parents' choice. Medical staff, supported by NICE, seem hell bent on taking total control of pregnancy - and particularly labour onset and birth. We now have induction for "post dates pregnancy" recommended to be brought down to 41 week's gestation, despite no real evidence that this saves babies' lives. Indeed, what it does show is that women do not want to be coerced into labour before their bodies are ready - and they are not given sufficient information about the risks of induction to be able to make informed decisions about the procedure. Indeed, the forcing of labour onset, in itself, increases the risks of further intervention, complications - and ultimately of possible litigation when things go wrong - and that is the most expensive cost to the NHS obstetric specialism. 

Midwives Are Beleaguered Again About Complementary Therapies

Is there nothing that midwives or the maternity services can do right? Once again, the use of “unscientific” complementary therapies (CTs) in maternity care is being challenged by people who know nothing about the subject but who feel they have an axe to grind because they have had personal negative experiences of maternity care. In addition, I am being harangued as someone who should not be teaching midwives about “expensive” and “unproven”  alternatives. Yesterday, I had an email from a journalist preparing an article for a mainstream national newspaper (online) about CTs. She had obviously seen various posts on Twitter about courses for midwives and wanted me to tell her which trusts I had provided training for, and how much they were charged. I obviously refrained from giving her the confidential names of my clients (NHS trusts) but sent her the publicly available information in our Expectancy prospectus and the brochure that is sent to trusts enquiring about having training. I then ‘phoned her to find out what the article was going to cover, but she said it was in the planning stages and she didn’t yet know but that it would be “balanced”. I informed her verbally and in writing that I did not want my name associated with any negativity surrounding CTs, nor did I wish my reputation to be maligned. 

Much of the challenges are arising from patient safety groups associated with recent investigations of failing maternity services around the UK. I have no qualms about safety and practice being scrutinised – as those of you who know me will be aware, my whole focus for almost 40 years has been on the scientific basis of CTS. This requires not only acquiring the manual skills of a therapy but also developing an in-depth knowledge of the physiology, pharmacology, chemistry, philosophy and safety of each therapy, and especially its evidence-base and its application to midwifery practice. It is untrue to state that essential oils or other CTs are unsafe in pregnancy and birth because midwives who have been trained to use them should know how to use them judiciously. Where CTs are not used appropriately, there is of course a risk to both parents and babies, as well as staff. So it is not so much the therapies that are unsafe but possibly a few maverick midwives stretching the boundaries of practice without fully understanding the implications. 

Aromatherapy is by far the most challenged therapy because it is the most popular amongst parents and maternity professionals alike. Here I include my guide for midwives using essential oils, including some updated cautions as a result of changes in aromatherapy practice and in light of the various challenges to midwives using essential oils.  

Professional requirements relating to midwives’ use of essential oils:

• Midwives must complete the trust-approved training on safe use of essential oils (EOs) and update every two years; cascade training of colleagues is NOT permitted.

• The use of EOs by midwives is a clinical intervention only to be used in the absence of any medical or obstetric deviations from normal progress.

• Midwives must be able to justify their use of EOs which must, where possible, be based on contemporary research or authoritative discourse. 

• Midwifery responsibilities and the needs of the maternity servicestake priority. 

• Fully informed consent must be documented prior to use of EOs. Comprehensive records of EO use must be documented in the maternity records. 

• Clinical guidelines, regularly updated, must include indications, contraindications, precautions to use of EOs; specified EOs permitted for use in the trust; what to do in the event of adverse effects, spillages or other untoward situations relating to EO use.

• EOs are prohibited from use in the antenatal ward or main delivery suite; EOs used in the birth centre must be discontinued if a transfer to delivery suite is required.

• EOs must not be used for, or near, neonates; EO use in labour must be discontinued by the start of the second stage of labour, or preferably at transition, if known.

• EO use must be in accordance with the principles of medicines management (but should not be documented on the medicines prescription record).

• EOs must be individualised to each woman and used only whenclinically compatible with any other care or treatment, including other self-administered herbal medicines.

• The NMC Code 2018 requires midwives to take account of their own safety and that of others exposed to EOs. Under the Health and Safety at Work Act 1974 and Control of Substances Hazardous to Health (COSHH) Regulations 2002, midwives must minimise the risk of harm to themselves, colleagues, parents, babies and the public.

• The use of diffusers is completely contraindicated in any institutional setting – birth centre, main delivery suite, publicly accessible areas, including staff areas.

• Midwives who identify any digressions from the approved use of EOs, especially when safety is an issue, are required to escalate their concerns to an appropriate authority.

Essential oils – specific requirements 

• Stocks of unopened EOs must be stored in a cool, dark, locked refrigerator. Opened bottles must be stored in a locked refrigerator.

• The batch number of each opened bottle of EO must be recorded in a central register.

• The Cosmetics Regulations 2020 require midwives wishing to provide EOs for home use to undertake an initial face-to-face consultation, to give the first treatment and provide parents with the remainder of thesame blend with full written instructions.

• EOs aimed at aiding progress in labour, particularly clary sage, must NOT be used in well-established labour to avoid hyperpolarisation. Midwives must take steps to avoid hyperpolarisation, be able to recognise its effects and know what to do to reverse it.

• EOs must NOT be added to the water of the birthing pool, or to a bath if the woman has ruptured membranes.

• Midwives must be able to differentiate between adverse reactions to EOs, physiological symptoms of pregnancy and developing pathological complications.

Copyright © Expectancy ® 2023; All rights reserved

Holding Babies Has An Epigenetic Effect

Research at the University of British Columbia in Canada has shown that the amount of time babies and children up to the age of five are held and cuddled affects their "epigenetic age". Babies who are held less are found, at age 4.5 years, to have an epigenetic age lower than their actual age, making them more prone to illness throughout their lives. Lack of touch was shown adversely to affect gene expression at five specific DNA sites, including one affecting the immune system and one affecting metabolism. The University team plans to follow up with another study exploring the affect of cuddling on genes impacting on psychological wellbeing. 

The Pressure On Expectant Parents To Have A Perfect Birth

This article explores the mis-match between parents' expectations following birth preparation and the reality, particularly when the progress of birth deviates from that for which they were prepared. Yet again we have a journalist challenging antenatal classes such as "hypnobirthing"and complementary therapies including massage or acupuncture as methods of birth preparation . There is truth in the fact that many women may not achieve the birth for which they planned, but a blanket criticism of birth preparation is inappropriate, unhelpful and only part of the picture. 

I agree that some who attend "hypnobirthing" classes may come away with an idealised vision of what the birth may be like, and may be left feeling disillusioned and with a sense of grief and failure if they do not "achieve" the birth they planned. Yet this is not about the classes per se; it is about the slant put on the subject by the person presenting the classes. As was the case with the NCT in the 1970s and 80s, an emphasis on battling the system for a natural birth can be seen in the approach used by some "hypnobirthing" facilitators who idealise birth and who direct the blame for not achieving a spontaneous vaginal birth onto the "system".

However, disillusionment with birth experiences is not just about ill-directed birth preparation. It is a complex issue in which the whole of modern society is complicit. The medicalisation of birth and the attempt by doctors to control it, the apathy amongst many NHS midwives to challenge the status quo (except those who leave), the expectation of parents that they can conceive and birth a baby whilst continuing their high stress lifestyles and the pressure of society as a whole to control every element of life from birth to death contribute to highly emotive attitudes that can leave some parents with post traumatic stress after giving birth.

Part of the solution requires a radical overhaul of the maternity services which are, like the rest of the NHS, no longer fit for purpose. On the other hand, expectant parents who choose to appoint an independent midwife for their care through pregnancy, birth and the early postnatal period rarely experience dissonance between expectation and reality. This is because care is totally individualised, with plenty of time allocated to discussing desires and fears for the birth, and adaptations to care according to clinical need being made by mutual agreement. 

Continuity of carer has been shown to be an effective model but does not work well in the over-stretched NHS. Expectant and birthing parents need individualised care provided by a system that puts them first, and one in which intervention is justified and accepted as a possibility for some. When it is required, we can still take steps to ensure the event is as near as possible to what was envisaged and to help parents to see that they have not "failed" if birth progress is different in one person from another.

Healthcare in Japan

On her recent visit to Japan, Denise and her colleague Azusa, discussed the perilous state of the NHS and how Japan differs in its provision of healthcare. Japanese people find it difficult to understand how healthcare can be free at the point of access in the UK, when they pay so much for it. In both countries income tax contributes to healthcare services, as well as education, policing, roads etc. However, in Japan, this covers only basic health services. Everyone is required to pay for individual health insurance which covers the secondary and some tertiary healthcare, but not major issues such as cancer, ongoing disability or life limiting conditions - these are paid for through life insurance policies. Road accidents that necessitate hospital admission are covered by vehicle insurance. All-in-all, these equate to about 40% of the individual's salary. A small state pension is paid from income tax, but most people also take out private pensions if they can afford them. Given that the majority of families rent their homes, this means that they have nothing to sell to fund their retirement so tend to take out other insurance policies to cover old age, although the state does contribute to elderly care after the age of 75, which is the pensionable age.

There are also some cultural differences between people's expectations of healthcare provision. Unlike the UK public's expectation that the paternalistic  NHS will "pick up the pieces" when people are ill, Japanese people take greater individual responsibility for managing minor illnesses and health conditions. There are no GPs, but they consult pharmacists for self-treatment advice or private specialists for more serious illnesses. However, the national deference to authority means that people generally accept without question the medical advice and treatment offered. There is less abuse of the system and more appreciation of, and gratitude for the care, advice and treatment available.

An Interesting Discovery

Denise is teaching in Japan at the moment. In her Tokyo clinic she treated a student whose baby was just two months old, which was lovely. However the interesting part of this treatment was what Denise noticed on the woman’s feet. On the outer heels where the reflex zones for the ovaries are found, there was a noticeable difference in the location on one foot compared to the other.

Normally this reflex point is central to the heel as seen on the left foot here, but on this lady the ovary zone on the right foot was much higher. This led Denise to ask the woman if she had any misalignment in her spine and the client revealed that she had scoliosis, making her right leg shorter than her left. Fascinating!

Photo with permission.

Did you know ?

Did you know that homeopathic remedies and aromatherapy oils should not be used together? If someone in labour wants to use their own homeopathic medicines to aid progess, midwives should not offer aromatherapy at the same time. Homeopathy is an energetic medicine and is chemically dilute and fragile, so the remedies are easily inactivated by strong smells from chemically active essential oils and some drugs, as well as moxibustion sticks and electrical equipment such as mobile 'phones and monitoring machines used in labour (CTG). Always ask birthing people if they are using other natural remedies before offering aromatherapy in labour.

Natural Remedy Safety in Pregnancy and Birth – Guidelines for Midwives and Birth Workers 

• NRs include herbal remedies and aromatherapy oils (pharmacological), homeopathic medicines (energetic) and traditional remedies from different cultures, which may derive from plants, minerals or animals.

• All natural remedies (NRs) should be treated with the same respect as that given to pharmaceutical drugs.

• “Natural” does not mean that all NRs are safe, or safe for all.

• No NR should be used routinely for prolonged periods of time.

• Natural remedies should never be used as a replacement for proven medical treatment, especially in the event of an emergency.

• Expectant parents should be advised to avoid ALL NRs before and during pregnancy, labour and breastfeeding unless under the supervision of an appropriately qualified, insured professional.

• Expectant parents should be asked at their first antenatal appointment if they are using any NRs. They should be asked again in the third trimester as they prepare for the birth, and in early labour, to ascertain if they are using any remedies that may compromise maternal or fetal wellbeing or progress.

• In labour, any self-administration of NRs should be documented and correlated with standard monitoring eg CTG.

• Expectant parents should be informed that not all NRs are approved, regulated or evidence based. NRs obtained from the Internet may be falsely labelled, contaminated with chemical impurities or contain banned or toxic ingredients.

• Pregnant women should be informed about the possible risks of taking pharmacologically active herbal remedies or using essential oils, including adverse effects such as allergies and interactions with other prescribed drugs. 

• There is no place for the use of NRS when complications arise in pregnancy or birth. Midwives should be mindful that deviations from normal progress may be linked with undisclosed self-administration of NRs.

• Women admitted to the antenatal ward have, by definition, pathological complications requiring medical attention; they must be asked directly if they are self-administering NRs. It is not appropriate for midwives and other maternity professionals to advocate NRs for these women or to use essential oils for aromatherapy in the antenatal ward area.

Indoor Pollutants Harmful To The Fetus

Everyone is aware of the dangers of passive smoking and general air pollution, especially before and during pregnancy. Minute particles of toxic substances have been found in the lungs, brains and livers of fetuses, even when the mothers do not smoke. A new study at the University of Swansea is now examining the impact of indoor pollutants on the fetuses and children of women exposed to their chemicals, including those from cleaning products and cooking. Indoor pollution can be up to ten times higher than when the same substances are used outdoors. Products that may cause adverse effects include paints, solvents, glues, wood preservatives, dry cleaned clothing, pesticides, office chemicals such as printer inks and correction fluids, burning materials and furnishings. Use of paint stripper agents in the home has been shown to produce high levels of harmful chemicals which can persist for several hours. Added to these, are the adverse effects of aerosol air fresheners, essential oil diffusers and burning incense sticks. ANY inhaled chemicals, including those which produce a fragrance - whether pleasant or not - can affect people trying to conceive, those who are pregnant and new parents and their babies. Any small children, elderly or unwell relatives or friends exposed to the chemicals, even pets, can also be adversely affected.

Essential plant oils used in aromatherapy release volatile organic compounds into the air. When these VOCs combine with ozone in the air, minute by-products are produced,which are inhaled and may cause respiratory difficulties, as well as eye, nose and throat irritation, nosebleeds, headaches, nausea, lethargy and loss of coordination. Excessive or long-term exposure can lead to liver disease, cerebral effects and even cancers.

Beauty spas are notorious for using aromatic substances to fragrance the environment, yet some clients may be allergic – or simply dislike – the aromas. Chemicals in nail varnishes and gels and their removal agents are particularly significant and expectant mothers should avoid exposure to them. Taiwanese researchers found high levels of indoor pollutants in spas, which varied according to the efficiency of their ventilation systems and the layout of the area. Certain high street stores pride themselves in aerating the atmosphere for the “pleasure” of the purchasing public – yet often so heavily that the smell is overpowering that it spills into public walkways outside the shops.

In pregnancy and birth, midwives and birth workers must remember that aromatherapy is used as a tool to enhance expectant and birthing parents’ physical and emotional wellbeing, and NOT as a means of fragrancing the environment. ALL exposure to essential oil chemicals must be individualised, taking into account the wellbeing of not only the mother but also the partner, staff and other people present who are inhaling the aromas.

The Concept of Energy and Complementary Therapies

Midwives on Expectancy’s Diploma explore the concept of energy and its relationship with complementary therapies. Work by the scientist, Winifred Otto Schumann in the 1950s revealed that the earth’s energy vibrates at a particular energetic frequency and that the energetic level of humans (and animals) in optimum health is exactly the same as that of the earth. This is measured as 7.83 Hz. Any compromised wellbeing alters the energy frequency measurement, leading to ill health or disease. Other sources of energy (heat) can adversely affect wellbeing, also potentially leading to ill health. Electrical equipment such as TVs, mobile ‘phones, X-rays, microwaves, medical monitors such as CTG machines and more can interfere with the optimum 7.83 Hz energy of an individual. Stress hormones act as a vibrational heat source to agitate the brain (“hot tempered”) and blood (increased risk of clumping of platelets). Adverse energies can also arise from changes in geopathic stress – volcanoes, earthquakes and global warming – leading to issues such as sick building syndrome and adversely affecting human and animal health. 

During complementary therapy, the practitioner acts as a conduit to channel positive energy to aid a return to homeostatic balance – which is why it is vital that therapists are in good health when they are treating clients. This applies whether the therapy is manual, as with massage or reflexology, psychological, for example, Hypnotherapy, or energetic such as homeopathy or reiki. Midwives providing massage or aromatherapy in labour should not be stressed, busy or tired since their increasing negative energy levels can be transmitted to the birthing person, potentially adding to any negative energies arising from equipment, stress levels, noise, movement and light. This is why a quiet, secluded birthing environment is so important for both mother and baby.

NHS Trusts Accused Of Pseudoscience - Putting Expectant Parents At Risk With Alternative Therapies

Yet again, mainstream media has sensationalised what they perceive as “witchcraft” – the use of “alternative” therapies by midwives. The Sunday Times has now waded into the melee, castigating midwives’ use of aromatherapy, acupuncture, reflexology and “burning herbs to turn a breech baby” (moxibustion).

The article by Health Editor Shaun Lintern also denigrates practices which are not classified as complementary therapies, such as water injections for pain relief, hypnobirthing for birth preparation and counselling sessions following traumatic birth. Some of the accusations focus on their (inaccurate) statement about the lack of complementary therapy research, whilst others deplore trusts charging for some of these services.

A letter to the Chief Executive of the NHS has been sent by a group of families whose babies have died in maternity units that have now come under scrutiny from the Care Quality Commission and the Ockenden team. Amongst those spearheading this group is a consultant physician whose baby died during birth (unrelated to complementary therapies) and who has taken it on himself to challenge the NHS on all matters pertaining to safety in maternity care. That is admirable – safety is paramount – but it is obvious neither he, nor the author of this latest article, knows anything at all about the vast subject of complementary therapies in pregnancy and birth.

The article is padded out with (incorrect) statistics about midwives’ use of complementary therapies, coupled with several pleas for the NHS to ban care that they say (incorrectly) is not evidence-based and which contravene NICE guidelines (the relevant word here being guidelines, not directives). The article is biased and, to my knowledge, no authority on the subject has been consulted to provide a balanced view (the Royal College of Midwives offered a generic response but did not consult me, despite being appointed a Fellow of the RCM specifically for my 40 years’ expertise in this subject).

I would be the first to emphasise that complementary therapies must be safe and, where possible, evidence-based, and I am well aware that there have been situations where midwives have overstepped the boundaries of safety in respect of therapies such as aromatherapy. However, I have not spent almost my entire career educating midwives (not just providing skills training) and emphasising that complementary therapy use must be based on a comprehensive theoretical understanding, to have it snatched away because of a few ill-informed campaigners intent on medicalising pregnancy and birth even further than it is already.

For well-respected broadsheets to publish such inaccurate and biased sensationalism only serves to highlight the problems of the British media and the ways in which it influences public opinion with untruths and poorly informed reporting.

Chamomile In Pregnancy

Chamomile has many medicinal uses. As a tea, it can aid wound healing, promote relaxation and sleep, encourage intestinal balance (relieve constipation or diarrhoea).

The essential oil, applied topically, can be effective for labour, reducing pain and aiding contractions; in pregnancy, it eases sickness (in some), aids relaxation and even ease haemorrhoids.

In pregnancy, however, it should be used with caution – excessive consumption of the tea as a night-time relaxant can have the opposite effect, overstimulating the brain and preventing sleep. The essential oil (and tea) should come from Roman chamomile (Anthemis nobilis) rather than German chamomile as this is considered safer in pregnancy.

Small doses of the oil, of no more than 1.5%, should be used for aromatherapy in pregnancy to avoid any possible risk of threatened miscarriage. In large doses, both the oil and excessive consumption of the tea could lead to bleeding problems, so it is best avoided by anyone with a bleeding condition or on anticoagulants. The oil can cause skin irritation in some people (including the practitioner when applying it in a massage blend).

Vigorous Massage Of The Inner Heels In Labour Should Be Avoided

Many women enjoy foot massage or reflexology for relaxation during labour. However, vigorous massage of the inner heels can interfere with the progress of birth because, in reflexology, this area represents the link with uterus and reproductive tract. Some reflexologists mistakenly believe that stimulation of the uterus reflex points encourages contractions but it is more likely to disrupt the natural rhythm of contractions. If labour progress needs a helping hand, careful stimulation of the reflex points for the pituitary gland - which is on the side of the big toes - may help increase the frequency and length of contractions. This should only be done when the midwife has confirmed there is no clinical reason for delay in labour such as obstruction.

Discontinue Aromatherapy By The Start Of The Second Stage Of Labour

The use of essential oils and massage is wonderfully relaxing for birthing parents during the first stage of labour and can ease pain and aid progress. However, to protect the baby from inhaling the aromas - and therefore the chemicals - aromatherapy should be discontinued once the mother reaches the second stage and is about to give birth (or preferably stopped once she is in the transition stage if this is recognised). Babies should not inhale the vapours / chemicals of essential oils because they can cause cerebral irritation, may mask the baby's ability to recognise its mother through smell and can compromise the immature liver (oils are metabolized via the liver)

Moving Into Private Practice Is Not A Way Of Working Less – But It Does Provide A Way Of Working Better

We all know the difficulties currently being faced by the maternity services, but the situation is too complex and longstanding to be resolved easily. However, one effect of those difficulties is that midwives appear to be leaving the NHS in droves, looking for a better work-life balance.

At the recent RCM conference, CEO Gill Walton advised that anyone thinking of leaving the profession should consider all the pros and cons before taking that step. In fact, many midwives are not leaving the midwifery profession, they are leaving their current employer, ie the NHS.

A midwifery registration with the Nursing and Midwifery Council provides a licence for midwives to practise midwifery in any setting in any country (subject to national regulations overseas). Registration is not a noose that ties you to the NHS. Of course, the NHS is the main employer of midwives in the UK, but some midwives work in private maternity or related clinical services. Others choose to go down the independent midwifery route, contracting directly with expectant parents to provide alternative options to NHS care. Still more are moving into business offering services such as antenatal classes, exercise and yoga, complementary therapies and pregnancy coaching.

It is an interesting concept that, until recently, most midwives did not realise that they can go it alone. Yet, outside the UK, there are models that facilitate midwives to work independently of the nationally provided maternity services, or perhaps in conjunction with them. In Iceland, for example, the state provides standard, safe antenatal and birth care, but state-paid midwives are also permitted to offer private services alongside this. They offer antenatal classes, acupuncture, aromatherapy, aspects of postnatal care and much more – and they offer paid-for services to the very same parents who are receiving nationally-funded maternity care. It is the accepted way for the country to deliver maternity services for expectant, labouring and newly birthed parents and the population appreciates this as normal.

There is much discussion in the UK maternity services about CHOICE (or lack of) for users and the quality of parents’ EXPERIENCES, yet so much antagonism when UK midwives choose to offer their services in a different way to the majority. Providing services in different ways offers expectant parents more choice as to how they experience their pregnancy, birth and new parenthood. They are prepared to pay for what they want at this most special time in their lives – and, increasingly, midwives are prepared to provide them. Moving into private practice, whether full or part-time, also offers midwives choice in the way they want to work. They feel valued, in control and able to provide care in ways they were originally trained to do.

Moving into the commercial sector is not for the faint-hearted and is not a way of working less – but it does provide a way of working better. It is a huge leap that requires good preparation, and enthusiasm to be your own boss does not mean that the move can be rushed. Some midwives have paid costly financial, professional and legal errors in their business through lack of knowledge and preparation.

Enthusiasm Over Safety

Denise recently heard about a maternity unit in which the obstetric registrars intend to “cascade train” midwives to provide moxibustion treatments for women with breech presentation, even though the doctors are not qualified acupuncturists. This is yet another example of enthusiasm overtaking professional integrity and safety. It is all very well to add complementary therapy services that may be of value, in this case potentially reducing the number of Caesareans for breech presentation, but not at the expense of having poorly trained staff. There is so much more to moxibustion than simply directing the moxa heat at acupoints on the feet – midwives and obstetricians need the underpinning knowledge in order to understand the contraindications and precautions and to be able to recognise side effects.

Similarly, a midwifery manager contacted Denise to arrange for an aromatherapy course to be taught in the unit. When it was explained that the course is for two days, the manager wanted it reduced to a single day, repeated the next day, so the unit could get as many midwives as possible through the course so they could start using aromatherapy in the birth centre. Denise explained that a single day was not educationally appropriate, as it did not give enough time for midwives to absorb the in-depth theoretical information that is crucial to critical learning and safe practice. It is really worrying that midwifery managers seem to care more about implementing a new service than about safety.

When the NHS maternity services are in dire straits, why are midwives and doctors trying to “improve” matters by introducing complementary therapies in a haphazard manner that risks safety through ill-informed staff? And why are managers, budget holders and those responsible for monitoring safety not considering the potential issues that this may bring to an NHS that is already under the spotlight? To join our online moxibustion for breech presentation study day on 1st December, contact info@expectancy.co.uk

Fenugreek To Aid Lactation

Some research studies suggest that almost 60% of breastfeeding parents used herbal remedies, with fenugreek seed tea - (Trigonella foenum-graecum) being one of the most popular, with some apparent success. Fenugreek is thought to work through the stimulation of dopamine receptors that stimulate prolactin production; it may also contribute, indirectly. to infant weight gain,presumably because of the increase in available breast milk. However, adverse reactions can occur with maternal ingestion of fenugreek. The babies of women who consume fenugreek tea, either in late pregnancy or during breastfeeding, may develop an unusual body odour similar to that of maple syrup urine disease.

Clary Sage Oil - Nature’s Syntocinon

Did you know that clary sage oil should not be used once labour is well established? This would be like putting up an intravenous infusion of syntocinon and is more likely to cause excessively strong contractions and possibly fetal distress than to aid the progress of labour. Similarly, when someone is in the physiologically normal early (latent) phase of labour, clary sage would be inappropriate as it may interfere with the onset of established.

Complementary Therapy First Aid For Bonfire Night

We frequently see advice about avoiding the risk of injury during bonfire night - and we would always encourage families to take great care around bonfires and when enjoying fireworks. The first bonfire night was permitted by the government in 1605 to celebrate the foiling of the treasonous Gunpowder Plot to bring down Parliament. Early events were raucous, with much consumption of alcohol and vibrant partying, presumably sometimes resulting in accidents or ending in fights causing injury. We can but hope that contemporary events are a little more restrained, and the trend today is to encourage families to attend organised events. However, sometimes, accidents do happen - and here are a few simple first aid tips that may help. Of course, it is always important to seek medical advice if there is any concern.

The power of lavender essential oil for modern clinical use was first discovered by the chemist Gattefosse, who burned his hand in a laboratory experiment and plunged his hand into the nearest available liquid - which just happened to be lavender oil. His hand healed quickly with minimal pain or scarring. Minor burns and scalds can be treated by liberal application of good quality, neat lavender essential oil - and there is a reasonable body of formal research evidence to support this practice.

Arnica homeopathic cream is popularly used to relieve bruising, but contemporary research suggests that it may also be useful in relieving the pain of burns. Arnica is an energy medicine which does not work pharmacologically like drugs. It originates from a plant, by highly diluting it and produced in minute dilutions to treat shock. Although it is available in tablet form, one of the better first aid formats is the cream version - but it is important not to apply this to open wounds.

Many pets are highly sensitive to the unpredictable noises and flashing lights of bonfire night and should always be kept safely indoors. Rescue Remedy, a liquid medicine from the Bach flower remedy group, is particularly effective at relieving shock, in humans and animals. Just rub two drops on your cat or dog's lower lip or put four drops in their water bowl to help calm them down.

What Do Expectant Parents Talk About During Complementary Therapy Treatments?

Many years ago, Denise was involved in several research studies on reflexology with her colleague Peter Mackereth, a clinical nurse consultant in palliative care and co-author, with Denise, of two editions of the Clinical Reflexology textbooks (2002, 2010). Peter headed up a research study exploring topics of conversation raised by people receiving reflexology, which showed that therapy created a safe space for people to raise concerns and be receptive to advice and information.

Expectant parents are no different - having a set period of time with a midwife in a quiet secluded environment seems to give them “permission” to ask all those questions they perhaps feel midwives don’t ordinarily have time to answer. This is one of the great benefits of antenatal complementary therapies, although it does vary according to the therapy. A woman is less likely to raise delicate questions if she is enjoying a back massage, whereas with reflexology she is semi-recumbent and eye-to-eye with the midwife providing the treatment. The nature of the consultation process, in which midwife-therapists facilitate the expectant parents to lead the discussion (rather than by being driven by a computerised questionnaire) encourages clients to raise issues that are important to them, rather than to the maternity services. They may feel that their relationship or their sex life is suffering because of the way they feel physically in early pregnancy; there may be pressures at work - and still we hear of women being discriminated against because they are pregnant, despite the law. Others may have very clear views of what they would like for the birth of their baby but feel defensive because they know they may have to battle the system. Others may have money worries or childcare difficulties or, sometimes, raise issues that require safeguarding intervention.

In some respects, it may not matter which therapy expectant parents receive for their primary presenting indication (although some therapies are better for some conditions than others). What matters to women is that someone is listening to them, validating the way they feel and giving them the time to offload. Sometimes the issue requires no further action, because the woman feels better simply because she has had time to talk, and perhaps understands that she is not alone in the way she feels. The benefits of complementary therapies go way beyond dealing with physiological symptoms, but can be a great advantage to facilitating holistic wellbeing of expectant parents.

Can Acupuncture Resolve Needle Phobia?

The Expectancy acupuncture programme is a combination of theory and practice, but it can be daunting when they first start sticking needles into one another. Surprisingly, we have previously had midwives on the course with needle phobias, but we have been so proud of the way they have overcome their fears. It is important to emphasise that acupuncture needles are very fine and are not hollow (like injection needles). Often midwives have other issues - noticeably stress - and they all come away from the study days feeling quite relaxed - acupuncture has been proven to reduce stress hormones such as corticol and increase the feel good endorphins and encephalins. So not only do they complete the programme with a qualification, but get some of their own health issues treated along the way.

Did You Know ?

Did You Know that many herbal remedies have anticoagulant effects and can thin the blood? It is essential to ask anyone requiring a planned or emergency Caesarean (or other surgery in pregnancy) whether they have been taking any herbal remedies. Expectant parents requiring prescribed enoxaparin or aspirin should be strongly advised to avoid herbal medicines unless under the direction of a qualified medical herbalist.Those taking therapeutic doses of ginger continuously for more than three weeks it may be wise to take blood to test for clotting factors. Similarly, any expectant parent who reports bruising and bleeding, especially but not exclusively vaginal, should be asked whether they are taking any natural remedies, notably herbal medicines or drinking excessive amounts of herbal tea.

The Use Of Traditional Medicine In Pregnancy Across Sub-Saharan Africa

Sub-Saharan Africa is that part of the African continent which lies south of the Sahara desert. Only 50% of Africans have access to conventional healthcare facilities, and traditional medicine (TM) is often the primary solution to health issues, particularly in rural areas. TM is seen as being more accessible, more affordable and more culturally relevant than conventional treatment, which is often viewed with suspicion. Amongst the 3000 different tribal groups across Africa, the use of TM is based on historical, tribal, cultural and religious factors. There is a widespread belief that physical, emotional and spiritual dis-ease is caused by the malevolence of witches or evil ancestors.

Many people are familiar enough with the principles of indigenous plant medicine, (known as muthi by South African Zulus, mishonga amongst the Shona of Zimbabwe and miti shamba by Swahili-speaking peoples) to be able to self-medicate, although most consult traditional healers to determine the causes of their illness. Healers are seen as a spiritual focus in the community; they often undergo a profound spiritual experience in which they acquire secret knowledge enabling them to channel positive energies for therapeutic results. Traditional healers are known as inyangas (herbalists) or isangomas (diviners) by the Zulus, tsikamutanda by the Shona and waganga in Swahili. In addition to herbs, mineral and animal substances, massage and dietary constraints, African TM involves practices such as blood-letting, incantations, dream interpretation, “throwing the bones” and sacrificial practices.

It is estimated that over 80% of pregnant African women use TMs, usually derived from indigenous plants, to prepare for and aid progress in childbirth. In South Africa, over 60% of Xhosa women self-administer herbal remedies, although those in urban areas often combine traditional and conventional care; in Tanzania and Nigeria, up to 40% of women use a least one herbal remedy although research suggests as many as 67% may be self-administering TMs. Whilst many do not completely reject conventional maternity care, they often prefer to consult traditional healers as it is less expensive and logistically more appropriate, particularly for the birth. Over 60% are cared for by traditional birth attendants (TBAs or ababelithisi), many of whom use indigenous phytomedicines. TBAs are also responsible for teaching behavioural avoidance during pregnancy, performing ritual bathing and massage of mother and baby, assisting at births and ritual disposal of the placenta; the inyanga acts as a consultant in cases of difficult birth or other complications.

Language in the Context of Complementary Therapies in Midwifery

Denise was interested to read the results of the multidisciplinary Re:Birth study into the language of maternity care and how we need to rethink some of the traditional words and phrases. Here she discusses language in the context of complementary therapies (CTS) in midwifery.

One of the often-used words, but with gradually declining use, for a labour and birth that remains within physiological parameters is "normal". Physiological birth involves spontaneous onset at term, ie some time after 37 weeks' gestation, with gradual progress towards the birth of the baby, perhaps with some guidance but without intervention, and is followed by spontaneous separation and expulsion of the placenta and membranes without life-threatening haemorrhage. It is, however, easy to forget that the second stage of what has been an apparently "normal" labour may involve episiotomy, or the third stage may incur the use of drugs to expedite placental separation: these interventions are definitely not "natural". Perhaps, then, "normal birth" means "spontaneous vaginal birth" rather than using forceps or surgery to bring the baby into the world?

Others refer to physiological labour as "natural" birth, implying that it is without intervention. However, "natural" birth has another connotation- that of a labour and birth achieved with the support of "natural" remedies (NRs). Whilst some NRs can be useful to relieve subjective symptoms such as pain, nausea and anxiety, we should consider carefully their use when labour is changing from physiological to one in which pathological factors are emerging. NRs should not be used to treat issues that may evolve further and require medical assistance to ensure the safety of parents and babies.

As I have commented on many occasions previously, just because something is natural, does not mean it is safe, or safe for everyone. Some NRs used before and during the birth process may help some parents but are not appropriate for all and should always be individualised to each person. It concerns me that the use of the word "natural" persists, implying that everything is - apparently - "normal" yet failing adequately to press home the point that NRs can interfere with prescribed medications, interact with one another, exacerbate an emerging sign or symptom of a complication - and occasionally, when not used correctly, can be a direct cause of serious issues for mother, baby or the progress of the pregnancy or birth.

What Is The Worst Reaction You've Had To Exposure To Essential Oils?

Many people develop insensitivites, allergic reactions or occasionally experience serious systemic effects from exposure to essential oils. These reactions can affect not only people receiving aromatherapy, but also those administering them. Sometimes reactions occur due to prolonged or excessive use, but reactions may also develop suddenly and unpredictably when someone is unknowingly sensitive to a single chemical in an oil.

Denise has seen some alarming adverse reactions in students who are sensitive to citrus oils, geranium, rose and clary sage, and the number of students experiencing negative effects has increased over the past decade, with a far higher proportion than in the previous 30 years of teaching aromatherapy.

Headaches, nausea, skin irritation,  respiratory difficulties and increased menstrual flow are relatively common, even when from the oils safe enough to use in midwifery, but other reactions include panic attacks, skin burns, eye irritation and vomiting and diarrhoea. One midwife sniffed geranium and had an instantaneous wave of heat pass up her whole body, and she had to rush out and had projectile vomiting. 

More serious toxicity, whilst rare, can arise from ingesting essential oils - mouth and oesophageal burns, chronic asthma, liver toxicity and even pancreatitis. 

Midwives and doulas using aromatherapy or accompanying people using their own oils need to be alert to the possibility of adverse reactions in expectant and birthing parents, companions, other staff and themselves and take steps to minimise the risks. This is where good education comes in and emphasises that aromatherapy is not something in which to dabble, it is not something to be played with. Ill-informed midwives and doulas risk missing evolving reactions or, indeed, severe iatrogenic reactions going unrecognised and leading to even more serious complications.

What Does Nice Say About Complementary Therapies In Pregnancy? 

The National Institute for Health and Care Excellence (NICE) is generally not in favour of complementary therapies (CTs) because, it argues, there is insufficient evidence to support its use (which isn’t actually true, it’s just that most studies are not “gold standard” randomised controlled trials). Indeed, NICE is ignorant of many issues around CTs and, particularly, natural remedies, sometimes advocating that professionals offer expectant parents suggestions that may be inappropriate for individual women or which are unsustainable because maternity professionals themselves do not know enough to advise women safely.  

The 2021 Antenatal care guidelines suggest that, at the booking appointment, expectant parents should be asked about their use of current and recent medicines, including over-the-counter medicines, health supplements and herbal remedies. Further, they advocate that, at every antenatal contact, midwives or doctors should “update the antenatal records to include details of medicines and that advice should be given about the safe use of medicines, health supplements and herbal remedies during pregnancy.

Later, in respect of mild to moderate pregnancy sickness, for those who prefer a “non-pharmacological” option, professionals should “suggest they try ginger” (NICE 1.4.3). Ginger – and all other herbal remedies – acts in the same way as all drugs and is therefore not a “non-pharmacological” option. This blanket advice is not only inappropriate because ginger can cause heartburn and other side effects in some, it’salso unsafe, since it can cause blood thinning. Ginger is contraindicated in anyone with bleeding, coagulation disorders or on ANY anticoagulant medication, including prophylactic aspirin or enoxaparin, or in conjunction with other herbal remedies. Despite a general rejection of CTs, clause 1.4.6 suggests that midwives and doctors could “consider acupressure as an adjunct treatment” yet gives no advice as to how this may be achieved.

In the Intrapartum Care guidelines, whilst massage is stated to be a possible pain-relieving option, other therapies are not, with clause 1.3.10 stating “do not offer or advise aromatherapy, yoga or acupressure for pain relief in the latent phase” yet advising professionals to respect parents’ wishes if they wish to “use any of these techniques”. Later, in clause 1.8.3 on pain relief in established labour, NICE states “if a woman chooses to use massage techniques that have been taught to birth companions, support her in this choice”. Similarly, in clause 1.8.8 “do not offer acupuncture, acupressure or hypnosis, but do not prevent women who wish to use these techniques from doing so. 

In the 2021 guidelines on induction of labour, the following statement is made (1.4.20: “be aware that the available evidence does not support the following methods for induction of labour – herbal supplements, acupuncture, homeopathy or castor oil”. This statement is not entirely correct because there is considerable evidence in the form of randomised controlled trials, to support the use of acupuncture and acupressure to aid labour onset. Further, there is no acknowledgement of the huge interest in using CTs and natural remedies amongst desperate parents at term trying to avoid medical intervention. 

Look - either complementary therapies are safe - or they are not. It doesn’t matter whether it’s a well-informed midwife or the parents themselves who make the suggestion or provide the care. Indeed, it’s entirely possible that, without adequate knowledge to support women’s self-administration (or partner’s use) of various therapies, midwives and obstetricians will not recognise when any complications or deviations from normal progress result from inappropriate use of CTs or natural remedies. We see this all the time from inappropriate use of pharmacologically active raspberry leaf tea, a herbal remedy used in preparation for birth, or with clary sage aromatherapy oil used inappropriately in well-established labour which can lead to excessive contractions and fetal distress or eventually to cessation of contractions. 

The fundamental problem is that NICE is confused, ill-informed and – when they choose to do so - advocating natural remedies or therapies without understanding the clinical issues behind each suggestion. In addition, whilst it is all very well to advocate CTs and natural remedies, perhaps in an attempt to be seen to support expectant parents’ wishes and the trends in CTs, the majority of maternity professionals do not have enough knowledge or understanding of the subject to be able to advise parents safely. Indeed, some will decline to provide any information because they acknowledge that they know nothing. Others, who could be called enthusiastic amateurs with an interest in and awareness of the subject, try to act as the parents’ advocates but are not sufficiently well-informed to provide accurate or comprehensive advice. 

NICE produces guidelines for practice – they are not directives to be adhered to at all costs. When it comes to complementary therapies in pregnancy and birth, they should be taken with a large pinch of salt, or disregarded altogether. NICE committees look at the research evidence, which is all very well, but fails utterly to appreciate that “complementary therapies” and “natural remedies” encompass so many different elements, many of which cannot be studied using standard research methodology. Further, NICE guidelines take no account whatsoever of what is actually being done by and for expectant and birthing parents. Like so much of contemporary maternity care, they are far too medicalised and risk averse, yet leave the door wide open for dangers of which they are totally unaware. It is time to rethink the use – or even the continuing existence – of NICE and its controversial guidelines, and for midwives and obstetricians to rise up against their dictatorial, ill-informed and unhelpful approach to family-centred maternity care. 

Quince

Did you know that in Ancient Greek and Roman times quince was seen as a symbol of love and fertility? Quince are rich in essential nutrients including fibre, vitamins C, B1, B6, copper, zinc, potassium and magnesium as well as antioxidants that reduce metabolic stress and inflammation. There is some evidence to suggest quince syrup may ease pregnancy nausea and vomiting, indigestion and some allergic reactions, as well as reducing blood sugar and supporting the immune system. It’s best not to eat quince raw as they have a very sharp sour taste.

A Brief History Of Reflexology

Reflex therapy is derived from ancient Chinese, Indian and Egyptian techniques. Its use in Europe can be traced back to the 14th century, but modern (western) reflex therapy emerged in the late 19th and early 20th centuries. In Russia, the neuropsychiatrist, Professor Vladimir Bekhterev (1857-1927), best known for his work on recognising the role of the hippocampus in memory, also studied human conditioned reflexes.  Bekhterev’s research led him to believe that there were zones in the brain, each with a specific distal function within the body. He introduced a manual therapy based on the principles of reflex points and published two books specifically on reflex therapy. His neuropsychology contemporaries Ivan Pavlov, who studied operant conditioning, and Naum Efimovich Ischlondsky further explored the concepts of reflex therapy, the latter eventually taking its principles to the USA 

Elsewhere, in the 1890s, the personal experience of the German doctor, AlfonsCornelius, recovering from illness, revealed that firm pressure, when applied only to painful areas of the body, relieved pain and encouraged recovery more quickly than full body massage. Around the same time, the American ear, nose and throat surgeon, William Fitzgerald (1872-1942), also recognised that patients would often subconsciously apply pressure to their hands to suppress pain. Fitzgerald used this principle of what he termed “zone analgesia” to perform minor surgery without anaesthesia and defined the locations of reflex zones on the feet and hands. Fitzgerald, with medical colleagues Edwin Bowers and Joseph Shelby Riley, developed modern reflex therapy theory and created the initial reflex zone charts for the use of zone therapy as a clinical intervention (as taught by Expectancy). 

The American physiotherapist and masseuse, Eunice Ingham, an assistant to Fitzgerlad, produced the first contemporary charts and instigated a change of name of the modality to “reflexology”. Ingham is credited with bringing reflexology to Europe in 1915. Another authority, Doreen Bayly, introduced Ingham reflexology to the UK in the 1960s and further developed the procedures and treatment regimens. Most forms of reflexology currently used in the UK, USA and southern Europe are based on modified versions of the Ingham and Bayly charts. The Ingham method, adapted from Fitzgerald’s original zone therapy focuses on relaxation and a belief that reflexology balances homeostasis, thus aiding the body to heal itself. Mostly, when members of the public seek “reflexology”, they will access practitioners who use a modified Ingham or Bayley methods, some of whom may combine treatments with other therapies such as general massage, aromatherapy or reiki. 

In the 1950’s, the German midwife, Hanne Marquardt, further refined the concept of longitudinal and horizontal reflex zones throughout the body, as originally considered by Fitzgerald and his colleagues. Fitzgerald’s work provided the origins of the northern European style of reflex zone therapy. Marquardt evolved RZT into a dynamic clinical tool for treating various physiological and pathological conditions, and focuses less on the relaxation effect even though most people who receive reflex zone therapy feel relaxed at the end of a treatment session. The Marquardt style of reflex zone therapy (more recently renamed as “reflexotherapy”) is commonly used by midwives and nurses in Germany, Switzerland, Austria and Scandinavia. 

Reflex zone therapy is the basis of Denise’s personal style of practice which she has taught to many hundreds of midwives around the world. It is notably different from Ingham or Bayley reflexology, with a different “map” of the feet, different terminology, different therapeutic techniques and different pressures. RZT is based far more solidly on anatomical and physiopathological knowledge than other forms of reflexology and the chart is more logically anatomical than many other charts. Reflexotherapy fits well with the clinical practice of midwives, and Expectancy’s courses all concentrate on the application of RZT to pregnancy, birth and the postnatal period. 

World Reflexology Week 19-25 September    

“Reflexology” is a generic term for a wide variety of different modalities in which one small area of the body (usually the feet but sometimes the hands, face, ears, tongue or back) represents a “map” of the whole, with all parts of the body reflected in that defined area.

Most forms of reflex therapy use the feet to represent the “map” or chart of the whole, with every part of the body identifiable on one or both feet, although the precise location of different organs differs considerably between the various styles. Although many styles of reflexology incorporate some elements of massage, reflexology is so much more than simple massage. The application of manual pressure to specific points aims to induce a sense of relaxation, relieve pain, reduce stress and, with some types, to treat specific physiopathological issues. By working on these precise points on the feet, impulses are thought to be directed to the various organs, having a physiological effect on that distal part of the body to which the foot point relates. Practitioners use their hands, fingers and thumbs to apply pressure, which may be combined with more traditional massage techniques on the feet and lower legs, such as stroking, kneading, tapping, hacking and other movements. Some Far Eastern styles of reflex therapy also incorporate the use of the practitioner’s elbows and implements such as sticks or rollers to apply deeper pressure to specific points. 

At Expectancy we teach and practise reflex zone therapy (RZT), a German clinical style which aims to treat various clinical conditions. In midwifery, RZT can be useful for all the physical and emotional symptoms of pregnancy, aid the onset and progress of labour and help recovery from the birth. We have a few places for midwives or students on our second course of the academic year, to be held from April to June 2023 (one weekend per month). Contact info@expectancy.co.uk for more information. 

Dr. Denise Tiran - Personal and professional challenges

Dr. Denise Tiran - Personal and professional challenges #MidwiferyHour

https://youtu.be/OGY6jFXFtCw

A tribute to The Queen

Elizabeth II was born less than 23 years after the Wright brothers carried out the first ever powered flight. Four of Queen Victoria's children were still alive when she was born. The last one of them died in 1944 when Elizabeth was already 18.

She lived for more than a third of the entire age of the United States (1776) - a nation which is only 246 years old. And well over half the age of Canada (1867), and all but 25 years of the nation of Australia (1901).

She became Queen at the age of just 25, when Stalin and Truman were also in post, just 7 years after the end of WWII.

Her first Prime Minister was born in 1874. Yes, the 1800s!!!
Her last PM was born only two years before her Silver Jubilee in 1975 - so her first and last PMs were born over 100 years apart!
She was already 51 when she celebrated that first Jubilee in 1977.

Ruling in her own right (with no regent, like Louis XIV had for 13 years), she was the longest reigning monarch in World history, no matter what Wikipedia says. In my book, Regencies don't really count as "doing the job" - you don't really 'rule' when you're only 4 years old, like he was!

She lived through three kings herself before she even took the throne - George V, Edward VIII, and her father George VI

She saw the jet age arrive, the birth of electronic computing, and the space age - all before she was 35 years old.

She ruled for 70 years at the age of 96, more than 35 years after the age at which most people retire.

Her reign is over 7% of the entire history of Britain since William the Conqueror took the crown - 956 years ago - and that's considering that we've had 41 monarchs in that time. So, on a pro-rata basis, each reign would only be 23 years. So, she's done the equivalent of over three tours of duty.

So, yeah, she certainly *was* Great Britain and everything that we've seen and grown up with. She was with us through, literally, all we've ever known in living memory.

Her selfless service to this country was simply astonishing, when she could have 'retired' from the job decades ago and enjoyed some well-deserved rest.

She is now a huge part of British history herself, there is no 'was' about it anymore. She *is* and will remain an integral component of this country, having overseen an amazing Elizabethan Age.

Rest in Peace Ma'am with your beloved Philip.
Your duty has been done ... multiple times over

Benchmarking Standards For Complementary Therapies Education

In countries where complementary therapies and natural medicine are used alongside conventional medical care, there are very active attempts to set standards for education, often at graduate level. This paper addresses general standards for natural medicine degrees in both India and Ghana. When Denise developed and managed the BSc (Hons) degree in Complementary Therapies in the 1990s and early 200s, there were several other UK degree programmes on the subject, but there were never any nationally defined standards for education preparing students for professional practice, although there was a lot of discussion about the need for higher education programmes and research into complementary therapies.

Insofar as midwifery is concerned, there are no standards at all for the education required by midwives wishing to use complementary therapies (CTs) in their own practice, or even for those who may not wish to practise but often need to answer questions from expectant and birthing parents about their use of therapies and natural remedies. This is not only disappointing and reduces CTs to an insignificant element of pregnancy and birth care, but is also unsafe. We should however develop specific standards for the protection of parents and babies, given the huge number of people who choose to use CTs – in some areas, almost 90% of expectant and birthing parents may be using them. Whilst it is not a major component of midwifery practice per se, the fact that the subject remains unrecognised means that many midwives are poorly educated in CTs and therefore engaging in poor practice. At the very least, midwives should understand the anatomy, physiology, chemistry, pharmacology, mechanisms of action, indications, contraindications, legal, ethical and psychosocial elements of the therapies they wish to use within their practice, and should be able to apply research findings to support their practice.

Benchmarking-Naturopathy-Education-Comparing-the-Indian-and-Ghanaian-Curricula.pdf (researchgate.net)

Denise's week

Denise is having a busy week this week.

As a borough Councillor, she has been signing books of condolence for the Queen in both the borough and the two parishes which she represents and joining with colleagues to lay a wreath.

She has also been finalising the preparations for our incoming students commencing the Diploma and Certificate programmes in complementary therapies this coming weekend.

Where To Now? Moving On After Studying Complementary Therapies With Expectancy

Midwives who've studied complementary therapies with us have gone on to develop a range of services for expectant parents. Many return to their NHS work to set up a particular service, the most popular being a postdates pregnancy clinic, offering aromatherapy, acupressure and sometimes reflex zone therapy (clinical reflexology) to facilitate labour onset and reduce inductions of labour. Two of our recently completed cohort will be setting up birth trauma services incorporating clinical hypnosis. Others introduce acupuncture for labour or establish a specialist clinic for women with backache, sciatica and pelvic girdle pain in pregnancy.

Many of our students have also taken business studies as part of their programme and aim to set up private maternity complementary therapy services via our Licensed Consultancy scheme (see www.expectancy.co.uk/if-youre-pregnant). Some combine it with antenatal education, enhanced private antenatal and postnatal care or fertility support, depending on their qualifications and insurance. 

And some alumni get what we call "the Expectancy bug" and continue studying with us! those who have completed one of our specialist Certificate programmes often "top up" to our Diploma, those who have done the Diploma may move on to our acupuncture programme and a few who have studied clinical hypnosis with Expectancy move on to full hypnotherapy training with our partners, Learning Curve Studio.

If you're interested in studying complementary therapies in midwifery, we offer a unique range of courses and academic programmes. Our new year starts on 17th September - contact us NOW on info@expectancy.co.uk

Contraindications To Receiving Complementary Therapies In Pregnancy And Birth

I recently saw a post on a reflexology group page stating that there are NO contraindications to reflexology. This is not true, nor is it professional or safe to believe so. For any complementary therapy, there are always some contraindications and precautions, even when the therapy is offered solely as a relaxation tool. There are general medical and, in the case of pregnancy, obstetric issues to consider, and there are therapy-specific contraindications. There may, for midwives, also be professional, legal or institutional contraindications. It is irresponsible for any therapist - or midwife or doula using aspects of CTs - to assume that they can launch right in and treat everyone who comes through the door (I once taught a reflexologist who took no notes, thought there were no contraindications and who would treat, without question, every pregnant woman who arrived asking him to "start labour").

In midwifery, clinical guidelines should specify the contraindications and precautions, both clinical and non-clinical. These should include:

Absolute contraindications - any expectant or birthing parent with major pre-existing illness or gestational complications that require obstetrician and physician supervision - epilepsy, major cardiac disease, renal  or hepatic conditions, cancer and bleeding or coagulation disorders. It should also include anyone admitted to the antenatal ward whose pregnancy, by definition, is compromised, as well as anyone in the labour ward with deviations from physiological progress.

General contraindications - anyone on medication not included above should be excluded from receiving CTs, although there are some exceptions (with care), such as those on prophylactic medication eg enoxaparin or aspirin. 

Obstetric situations would include women whose pregnancies are compromised in any way, including abnormal fetal lie, multiple pregnancy, pre-eclampsia, preterm labour etc, who should not receive CTs unless the practitioner can justify them in terms of safety. Sometimes CTs are contraindicated at different stages - for examples, during active assisted conception stages, whereas treating an expectant parent with an IVF pregnancy at term is acceptable if there are no other issues. It may also be a matter of degree, the more serious the situation, the greater reason not to treat. 

Medical conditions such as insulin-dependent diabetes, both pre-existing and pregnancy related, constitute a contraindication, although some simple massage without essential oils may be acceptable, as may clinical hypnosis. Aromatherapy and reflex zone therapy are not permitted as they may affect the diabetic state. 

Therapy-specific issues - Some conditions such as medicated hypertension are contraindicated for aromatherapy to avoid overloading the liver metabolising both drugs and oils, whereas thyroid disease is a contraindication for reflex zone therapy as excessive manipulation of the foot zones may over-stimulate or sedate the thyroid gland. There are specific contraindications for each essential oil, and foot-related ones for reflexology. With clinical hypnosis, anyone with a history of, or current, mental health problems is not suitable for treatment, nor are those with addictions to drugs or alcohol. For acupuncture, anticoagulants or haemorrhagic conditions preclude the use of needle insertion, although acupressure may be possible. And so it goes on - this list is, in no way, exhaustive.

Professional issues - these include training and continuing development parameters, indemnity insurance cover, informed consent, documentation, considering the priorities of the service - and professional intuition.

Legal contraindications include general health and safety issues especially in a maternity unit or birth centre, health and safety at work, control of substances hazardous to health regulations (for aromatherapy) and manual handling regulations.

Ethical contraindications should include lack of consent, lack of evidence to support the use of the therapy and use of obscure therapies (the latter is not so much a problem in maternity care but often raises its head in cancer care).

There are many other medical, obstetric and therapy-specific contraindications or precautions, too numerous to mention here. The point I am making is that NO therapy is without some contraindications. It is essential that midwives, doulas, therapists and others working with expectant and birthing parents understand this. If in doubt - leave it out!

"The Quack Remedies Being Peddled By NHS Midwives That Prove The Obsession With Natural Births Really Has Gone Too Far”

Here, Denise includes in full her response to Eve Simmons article in Saturday’s Daily Mail Online. Denise has also sent a modified version of this letter as a complaint to the Independent Press Standards Organisation.

Dear Ms Simmons, 

The tone of your article is sensationalist, biased and facetious. It contains several factual inaccuracies on the subject of complementary medicine, and some grammatical errors (for example, midwives do not “peddle” - ie sell – remedies). You reference the shortage of midwives to the Royal College of Nursing, whereas I think you will find it is the Royal College of Midwives that has expressed concern about poor recruitment and midwifery attrition.

You mix reports of alleged complementary therapy (CTs) practice by midwives with other more general comments about childbirth and the current state of the maternity services. For example, you muddle the alleged use of CTs with that of malnourished babies when midwives “refused to let mothers give them a bottle of formula milk”.    By so doing, you infer that all the problems of maternity care can be placed at the feet of midwives using “quack therapies”. You use the very sad case of parents whose baby died in Morecombe Bay – in 2008, 14 years ago – to influence your readers, whilst not actually knowing whether complementary therapies contributed to the baby’s death (which was actually due to sepsis). To ask for a comment from any father whose baby has died, on something unrelated to his particular experience, is bound to be biased in favour of better medical supervision of childbirth, and is inappropriate here.

You state that your “evidence” for midwives using complementary therapies comes from “a little Twitter scrolling” which is hardly the best resource for factual information or statistics. You quote a maternity campaigner, Catherine Roy, who states that “some hospitals are using acupuncture”, a factually correct statement, but with no link to your argument against using it in childbirth.

You state that there is “no evidence” to support the use of complementary medicine in pregnancy and birth, which is incorrect. You reference this supposition to obstetricians who, themselves, are obviously ignorant of the subject. Indeed, some areas of complementary medicine are exceptionally well researched, including acupuncture, which is used by some anaesthetists and general practitioners for pain management, as well as by midwives, nurses and physiotherapists.

You erroneously and disparagingly mention moxibustion as involving “rubbing your feet with hot leaves”. Moxibustion involves the use of a heat source directed at specific acupuncture points to facilitate internal energy flow to the uterus which then allows an amount of “give” to aid the baby to turn. It has been shown to be 68% successful in turning a baby from breech to head-first, a statistic which is considerably better than the 50% success rate of external cephalic version (ECV), the procedure employed by obstetricians (and less painful). In fact, had you investigated this subject further, you might have found that, whilst NICE does not support moxibustion because of a lack of their “gold standard” randomised controlled trials, the Royal College of Obstetricians and Gynaecologists includes it in their advice to parents with a breech baby. It is very well researched, can avoid the trauma and costs of a Caesarean section and, with some exclusions, can be offered to many women with a breech baby.

Aromatherapy – or, more accurately, the use of pharmacologically active essential plant oils which act in the same way as drugs – has become very popular amongst expectant and birthing parents, and midwives have responded to this demand by introducing it in birth centres where labour is progressing along accepted parameters, without complications. There is considerable evidence to support the use of certain essential oils for pain relief, relaxation and aiding progress during labour. I find it inconceivable that you quote an obstetrician as saying that relaxation “perhaps reduces sensitivity to pain” when it is a well-known fact, born out by research unrelated to complementary medicine, that reducing stress hormones such as cortisol correspondingly increases the birth hormone, oxytocin.

You choose to mention several maternity units which have produced information leaflets for parents stating that specific elements of complementary medicine can facilitate “natural birth”. You use this phrase as if it is something to be belittled - yet are you aware that, actually, childbirth IS a natural physiological process? Indeed, constant intervention by obstetricians, ostensibly to reduce complications, has had the opposite effect, resulting in iatrogenic complications. This is a proven fact and one that is currently being investigated at length. You, however, obviously favour the interventionist approach, including “epidurals and strong painkillers”, without any acknowledgement that these too have a range of side effects, some of which can be serious and even fatal.  

In reference to several maternity services currently under review, you include the Ockenden team’s investigation into neonatal and maternal deaths in Nottingham. You repeat the accusation implied by your colleague in the Telegraph article on this subject (20^th September) suggesting that aromatherapy is to blame, at least in part, for these deaths. However, the use of aromatherapy in Nottingham has not yet been fully investigated so it is prejudicial to make a statement inferring that this is the case.  

Of course, there are major failings in the UK maternity services, but the use or possible misuse of complementary therapies by midwives is not the dominant issue. Midwives who use acupuncture, aromatherapy, moxibustion, hypnosis, reflexology and other therapies in their care of expectant and birthing parents must, under the requirements of the Nursing and Midwifery Council, be adequately and appropriately trained to do so, remain updated and set complementary therapies in the context of the maternity services and institutional use within the NHS. They should not be used when pregnancy or birth deviate from physiological norms and should only be used as supportive mechanisms to aid the physiological process.

I suggest you check your facts before writing an article on a subject about which you know nothing.

Oh, and by the way, perineal sunning is NOT a complementary therapy and is NOT recommended for pregnant or postnatal women.

original article:

https://www.dailymail.co.uk/health/article-11152761/EVE-SIMMONS-quack-remedies-peddled-NHS-midwives.html

What Can You Expect From An Expectancy Course?

As we finalise our preparation for midwives joining our new academic year in mid-September, it's worth thinking about what benefits you'll get from joining us if you're looking for courses on midwifery complementary therapy courses.

If you'd like to join us, look at these benefits and contact us  NOW on  info@expectancy.co.uk

•  Expert teachers who are senior midwives with full qualifications in complementary therapies who have implemented therapies into NHS practice, researched various aspects of CTs and also offer them in private practice

•  Expectancy was founded by Dr Denise Tiran, Fellow of the Royal College of Midwives, an international authority on midwifery complementary therapies, who developed the first clinically based degree programme in CTs at the University of Greenwich before setting up Expectancy

• An absolute focus on safety, professional accountability and evidence-based practice in Midwifery CTs

• Over nineteen years' experience of teaching CTs to midwives and birth workers

• Accredited programmes that prepare you to practise CTs in the NHS, or in private practice via our Licensed Consultancy scheme

•  Study days, online webinars and access to our Members' site of resources

•  The opportunity to join our Expectancy Community of like-minded midwives interested in CTs

•  The start of your journey to a new focus in midwifery CTs so you can offer care to expectant and birthing parents in the way you want to

Midwives' Use Of Complementary Therapies: Who Is Responsible For Safe Practice?

Some of the comments to my recent post, as well as many of the mass of personal emails and 'phone calls I received from colleagues, called for greater regulation of complementary therapy (CT) use by midwives. The Nursing and Midwifery Council has always stated that it is not responsible for regulating CTs which are different professions from midwifery (and nursing).This is true in part, but indicative of a lack of awareness of NMC regulators about what is actually being used, advised or advocated by midwives out there in the field. This has led to a myopic abdication of responsibility which is unhelpful and potentially unsafe, for service users, grass roots clinicians and managers.

Regulation of midwives' use of CTs needs to come from the top. There needs to be greater understanding that expectant and birthing parents are self-administering natural remedies and that they are also keen for therapies such as aromatherapy to be part of their care options.  Midwifery managers cannot just assume that clinical midwives are always practising CTs safely, but have a responsibility to understand what their staff is doing and to be able to monitor its value and safety for service users in their trusts.

Despite having championed the incorporation of CTs in midwifery for several decades, I feel we are no nearer, as a profession, in getting it right. Indeed, it feels as if we have taken a step backwards in the last few years. The pandemic led to the discontinuation of many birth centre aromatherapy services, a large number of which have not recommenced. Added to this is the misconception amongst midwives that once "trained" in aromatherapy there is no need for updating. I was even asked recently by a consultant midwife if it was necessary for midwives who had trained pre-pandemic (and pre-Brexit, which brought its own changes) to undertake updating.

I have written on many occasions about the standard and academic level of CTs education for midwives. Cascade training is inappropriate and dangerous. Indeed, some commercially available courses are taught by midwives who are  essentially cascade training since they are themselves not fully qualified in the therapy and have no experience of having implemented CTs into their own midwifery practice. Until recently, these courses were accredited by the RCM, again despite members of their accreditation committee having no understanding of the issues involved.

Whilst a revised set of NMC standards for midwifery education was only recently published (2020), there is no longer any overt reference to CTs, even in relation to medicines management. The subject continues to be viewed as  "nice relaxation" that some midwives practise, but there is an intransigent refusal to acknowledge the need for better awareness and understanding of CTs amongst midwives. This is not about learning how to use a therapy, but rather to understand the risks of ill-informed use by expectant and birthing parents. 

The CQC is also to be considered complicit in indiscriminately condoning midwives' use of CTs, yet most inspectors have so little knowledge of the subject that they are unable to assess whether or not midwives are using CTs safely. I know from discussions with senior colleagues that some CQC inspectors have the same reaction as many clinical midwives in mistakenly viewing CTs as a wonderful enhancement of care, without acknowledging that it should be assessed as rigorously as all other aspects under inspection.

NiCE attempts to take a punitive approach based on the perceived lack of quality evidence, but again there is no knowledge of the research that has been done to date, albeit of variable quality. It is easy to state that there are no randomised controlled studies but impossible to eliminate the use of CTs in pregnancy and birth, not least because It is largely consumer driven.

It would be inappropriate for the complementary therapy regulatory bodies to monitor and assess the incorporation of CTs into midwifery care, because it is not entirely about the actual therapies. This is particularly important as most midwives using them are not fully qualified therapists but have merely "cherry picked" some elements of different therapies to add to their midwifery specific skills. Further, it would be impossible for therapy regulators to appreciate fully the context in which the therapies are being used by midwives, a fact compounded by the vast number of therapies and the variations between several styles of the same therapy group, such as we see with reflexology.

Who then, is responsible for monitoring the use of CTs by midwives? Is it the NMC, the CQC, the educators and universities, the managers or the midwives themselves? How can we ensure that CTs are being used by midwives justifiably and judiciously? Should we take more of a regulatory approach to the use of CTs within midwifery - and if so, who should be involved - when most midwives, at all levels, have limited knowledge and understanding of the subject?  CTs are here to stay; they are popular with expectant and birthing parents and we owe it to them to ensure standards are safe. 

Aromatherapy In Midwifery: Has “The Accident” Happened? 

Following Saturday’s article in the Times’, “Nottingham University Hospitals NHS Trust used ‘quack’ therapy on new mothers”, Denise questions yet again the inappropriate use of aromatherapy by midwives in some maternity units and birth centres.

Nottingham University Hospitals (NUH) NHS trust is under investigation following the deaths of several babies, in a review being led by Donna Ockenden with, apparently, further enquiries to follow into the Trust’s use of intrapartum aromatherapy. I am not able to comment specifically on NUH’s use of aromatherapy, although I am aware of several maternity units across the UK where midwives are using essential oils unsafely and against the principles of medicines management, health and safety and Control of Substances Hazardous to Health (COSHH) regulations and, in some cases, against the law. 

I have long challenged midwives’ ill-informed use of aromatherapy - at conferences, in my textbooks and journal papers, on social media and on my blog (see https://expectancy.co.uk/denise-and-her-blog ). I have written ad nauseum about the dangers of using diffusers in institutional settings and have considered aromatherapy use by midwives in some units to be “an accident waiting to happen”. Sadly, I think it is possible that the “accident” has happened, and we may all now be tarred with the same brush, even in those birth centres and maternity units where aromatherapy is being used safely.

From the Times’ article, there are some identifiable issues with the alleged aromatherapy practice at NUH, including the use of basil oil to aid placental expulsion, an oil which is totally contraindicated in pregnancy, birth and postnatally. NUH midwives’ use of aromatherapy, allegedly for “retained placenta”, may in fact have been prolonged third stage. In this case, inhalation of oils such as clary sage whilst awaiting transfer to theatre for manual removal may aid separation, effectively eliminating the need for surgery. Conversely, it is absolutely paramount that midwives understand the pathology of the case, since aromatherapy may potentially complicate the situation if the placenta has separated and is retained in the cervical canal. Similarly, the use of “aromatherapy” for cystitis is inappropriate in pregnancy even though essential oils have antibacterial properties: antenatal urinary infections left untreated (with antibiotics) can lead to preterm labour and severe kidney disease. Further, whilst some essential oils have been shown to aid wound healing, compresses on fresh Caesarean wounds are not appropriate since contemporary wound management requires the wound to be kept dry (and in any case, a compress requires pressure which would be painful at this early stage).

Aromatherapy offers a means of relaxation, easing pain and contributing towards labour progress. It is relatively safe for women in physiological labour on the birth centre or choosing home birth. However, aromatherapy in labour is as much a clinical intervention as any other, not simply a means of enhancing the environment. As with any other clinical intervention, anything that has the power to do good also has the potential to do harm, if not used appropriately.  Essential oil use must be discontinued if either the mother’s or baby’s wellbeing is compromised. By definition, this means that it is not appropriate to use essential oils on the main delivery suite for women with pathological complications. It is not appropriate to use diffusers in common areas accessed by numerous parents, staff and visitors, some of whom may have undisclosed medical conditions in which essential oil inhalation is contraindicated. A common example is midwives in early pregnancy being exposed to the chemical vapours of oils thought to aid uterine contractions, such as clary sage or jasmine. Neonates should not be exposed to essential oil vapours at any stage so, in all cases, even those without complications, aromatherapy should be discontinued at the onset of the second stage.

Midwives must receive adequate and appropriate training in the use of essential oils and be able to apply theory to practice, as well as setting the clinical principles of aromatherapy within the context of the institutional settings of the NHS. There are some aromatherapy courses for midwives which focus on the pleasant aromas and massage aspects of aromatherapy but which fail adequately to tackle the professional issues pertinent to midwives, especially those working in the NHS. Crucially, midwives must, in accordance with the NMC Code, keep updated (I suggest two-yearly). I know for a fact that there are many midwives around the UK currently using aromatherapy who have not received adequate training nor kept updated and whose practice is potentially unsafe or even illegal.  Further, I am aware of maternity units commissioning poor quality aromatherapy training, permitting “cascade training” by midwives who themselves have no real knowledge or experience and, in one recent cause for concern, a university promoting the training as suitable for student midwives to use aromatherapy in labour, even when their mentors are not trained. These are very serious issues that need addressing urgently.  In addition, we must accept that many expectant and birthing parents self-administer aromatherapy at home or bring their own oils into the labour environment, often without adequate understanding of the possible risks of using them. It is imperative that student midwives and midwives are taught about the use of essential oils and other natural remedies as it is now at an all-time high. 

On the other hand, I would not have been teaching midwives how to use aromatherapy (and other complementary therapies) for almost 40 years if I did not feel there were benefits - for expectant and birthing parents, as well as for midwives’ job satisfaction and, indeed, for the maternity services, in terms of reduced interventions and consequent cost savings. It is extremely sad that parents at NUH have had such grievous experiences, and this may be very worrying for other parents currently using the maternity services. Although it is impossible for me to state that aromatherapy per se may have played a part in the cases under investigation, it must be considered that midwives’ practice of aromatherapy could have contributed to the overall concerns of the review team. I sincerely hope that the fall-out from this and other high-profile cases across NHS maternity services does not sound a death knell for aromatherapy in midwifery practice.

Moxibustion

In response to our post about our forthcoming online Moxibustion for Breech Presentation study day, Denise was recently asked a very common question about whether midwives would be able to practise moxibustion themselves. This is a rather thorny issue and it is all a matter of having appropriate professional indemnity insurance.

Moxibustion it has been shown to be 67-68% successful in turning a breech to cephalic. It involves a course of 10-14 treatments performed twice a day for five to seven days. Moxa sticks (from dried herbs) are lit, the flame extinguished and the smoking tip focused over acupuncture points on the toes to stimulate internal energies to encourage the fetus to turn. However, in the UK, the only practitioners who can physically light the sticks and perform the full course of treatment are fully qualified acupuncturists.

Standard care by midwives is to teach parents how to do the procedure themselves following a full antenatal examination, confirmation of the presentation and exclusion of any factors that means moxibustion is contraindicated.

In the NHS, whether you could physically light the moxibustion sticks and perform the treatment on site would be dependent on having managerial permission, ratified, up to date clinical guidelines and having the fire regulations and alarm sensitivity checked to ensure that the smoke would not set off the fire alarms. In this case, you would be covered by the trust’s vicarious liability insurance. However, physically performing the whole course of treatment is time consuming and costly so most NHS midwives teach parents how to do it themselves.

In private practice, you would not be able to offer moxibustion unless you had professional indemnity insurance (separate from RCM medical malpractice insurance). Midwives trained in moxibustion who are not qualified acupuncturists cannot perform the procedure themselves but are permitted to teach parents how to do it. It is a matter of semantics, however, because you can teach the parents how to do the treatment, you can do a mock-up with unlit sticks, you can physically light the moxa sticks and hand them to the partner and you can observe / supervise the partner whilst the treatment is done. You just can’t hold the smoking moxa sticks over the acupuncture points yourself!

The other issue is whether or not you palpate the mother’s abdomen to confirm the breech presentation, which is fundamental to safe midwifery practice. In private practice you would need Royal College of Nursing insurance to be able to provide antenatal care, in which case you are insured for abdominal examination.

With Expectancy’s courses, our long Diploma and Certificate programmes are accredited by the Federation of Antenatal Educators (FEDANT) so that you can obtain insurance to practise privately. You are then insured to teach parents how to do the treatment as it is just another element of antenatal education, but you would also need RCN insurance to undertake abdominal examination and listen to the fetal heart before and after the treatments.

See www.expectancy.co.uk/if-youre-pregnant for a free downloadable information leaflet for parents.

Reflexology To Start Labour ?

Once again the controversial issue of whether or not to use reflexology to start labour has raised its head. On a reflexology Facebook page, a practitioner proudly claimed she had "started off" a woman's labour by working on the uterus reflex zone on the inside of the heels - and that the birth occurred so quickly once contractions commenced (20 minutes) that the baby "shot out".

This is worrying and shows that, while the reflexologist wanted to help, she did not understand the process of the onset of labour. Uterine contractions do not start in the uterus, but in the pituitary gland in the brain so, if anything is to be done, reflexology would focus on stimulation of the pituitary gland points on the big toes, first the zone for the anterior pituitary and then the the posterior gland. Over-stimulating the uterus zone will not start labour and may cause separation of the placenta leading to haemorrhage.

Further, whilst reflexology can be relaxing, reducing stress hormones and causing a corresponding rise in birth hormones, it is not the responsibility of a reflexologist who is not a midwife to start labour. Remember, any interference in the natural process of labour onset is an intervention and can lead to the same cascade of intervention as a medical induction. In this case, although it cannot be confirmed that the reflexology accelerated labour to such an extent that the baby was born within 20 minutes, the practitioner showed no awareness of the risks of such a precipitate birth, both to mother and baby.

Reflexologists should focus on the relaxation effects which may in themselves encourage initiation of contractions. Midwives with the appropriate training may be in a position to use reflexology (or more specifically, reflex zone therapy as taught by Expectancy) to encourage labour onset. However, both groups should be mindful of their professional boundaries and take care not to encroach on each other's.

Similarly, midwives must respect their own parameters of practice and remember that "inducing" labour with reflexology is not their brief either since induction is a medical procedure undertaken when it is necessary to expedite the birth (although the reasons for this are often spurious). Stimulation of reflex zones on the feet can -and will- encourage labour onset but needs to be done with due regard to the clinical situation and in controlled conditions. 

See Denise's forthcoming book Complementary Therapies for Post dates Pregnancy (December 2022). To learn more about using reflexology to expedite the birth, why not enrol for our Certificate in Midwifery Reflex Zone Therapy starting in September.

Midwives Need Caution When Advising On Clary Sage Oil

Yesterday, Denise received an email from an expectant mother stating that her midwife had advised her to purchase some 100% clary sage oil for labour. No other information or advice was offered and the woman had contacted Denise for confirmation that it was acceptable.

The short answer, Denise says, is that this is not acceptable "advice". The woman had no idea why she should buy clary sage, nor what purpose it might serve in labour. Indeed, she knew nothing, really, about aromatherapy - she had not asked about it but had been told to buy the oil.

Midwives suggesting any aromatherapy oils must have in-depth knowledge to provide parents with enough information to help them make an informed decision. This includes: 

• What aromatherapy is and how it may benefit individuals in labour
• Which oils to buy - with Latin names and guidance on quality (brands) to ensure suitability for clinical use
• When, why and how to use it judiciously
• What to avoid to ensure safety for parents and babies - when not to use it
• Correct dosage, administration and duration of use
• The evidence to support the use of aromatherapy in labour 
• Assessment of contraindications and precautions 

I find it extremely worrying that midwives continue to promote aromatherapy without having any knowledge or understanding of its mechanism of action, possible side effects and the issues pertinent to using essential oils within an NHS /  institutional setting, taking account of the  NMC Code, health and safety law and other issues.

Breast is Best

Breastfeeding is absolutely the best way of providing nourishment for newborn babies but it's not always easy. The first few weeks can bring stress, discomfort and worry for many parents. Here are a few natural suggestions to help get lactation established:

• For relaxation, a back massage with carrier oil such as grapeseed or possibly with gentle essential oils including citrus (orange bergamot, mandarin), with the "ultimate calming oil, frankincense, or perhaps lavender, can help. Adding 6 drops of the oils to a warm bath can also be relaxing - but wash the breasts with plain water afterwards to avoid the baby ingesting oil molecules left on the nipple. 

• To stimulate lactation - in addition to encouraging on-demand suckling - reflex zone therapy, with specific stimulation of the pituitary gland zones to encourage prolactin release is very effective. Massaging over and betwen  the knuckles of the hands is a simple self-help way to work on the reflex zones for the breasts. Fennel tea can be effective, or use the herb, fenugreek. Acupuncture is also good if parents have time to visit a practitioner.

• For engorgement, cabbage leaves inside the bra help reduce inflammation and ease discomfort. It's essential not to wash or freeze the leaves as they work through a process of osmosis - so getting them wet defeats the purpose.

DID YOU KNOW ?

DID YOU KNOW THAT 130 million babies are now born worldwide every year, but it is thought that only about 4% are actually born on their exact “due” date?  When Denise was first a midwife in the mid-1970s, many babies were born at home and there was far less emotional pressure for women to birth their babies “on time”. In those days, women often did not work and let nature take its course in terms of conception, pregnancy and birth.

Most pregnancies occurred between the ages of around eighteen and the early thirties, with those having their first babies over the age of 34 being considered “elderly primigravidae”. Women accepted the trials of pregnancy and complied with medical and midwifery advice to rest. If they were working, the maternity benefits system enabled women to take maternity leave from around 32-33 weeks’ gestation; they were encouraged to use the remaining weeks to rest and prepare physically and emotionally for the birth of their babies.

Labour started spontaneously and most births were vaginal, even after longer labours of over 24 hours. The majority of women did not return to work but became full-time mothers, although formula feeding was common. 

Conflicts Of Interest For Midwives Using Complementary Therapies

Have you thought about how midwives' use of complementary therapies (CTs)  could cause professional and ethical issues? Many midwives who have trained in one or more therapies become so enthusiastic about their new tools that it can be easy to forget that not all expectant and birthing parents wish to use them, for a variety of reasons. Enthusiasm for CTs can also occasionally cloud our judgement and stop us thinking with our "midwifery head". 

Midwives offering CTs in private practice face more potential conflicts of interest - we need to differentiate between being an NMC registered midwife and a therapist (especially when trained only in midwifery CTs and not as a registered therapist) and we must  prioritise clinical needs over the desire to earn money. Advertising your private services may cause issues relating to the NMC Code which does not permit you to market yourself overtly nor to claim that being a midwife somehow infers that you are a "better" therapist. And of course, if you work both in the NHS and in your own private practice, conflict can arise between being employed and being self-employed.Expectancy's Licensed Consultancy scheme provides a support network to help you avoid these conflicts.

Aromatherapy cannot be used by student midwives and MSWS on their own accountability

It has come to our notice that some online aromatherapy courses for midwives are also targeting student midwives and maternity support workers in their marketing. This is of grave concern, particularly as we have learned that some maternity managers and university lecturers are supporting their students and MSWs to complete this course as an inexpensive and quick way of increasing the number of staff able to use aromatherapy for expectant and birthing parents.

Student midwives and other staff who are not registered midwives cannot use aromatherapy unless their mentor has also trained in the subject and consolidated her/his skills. The midwife remains accountable for the care of women in pregnancy and labour, including any aromatherapy oils that are used during the period she is being cared for within the maternity services. Even when a student is a qualified aromatherapist, they are not the person who is legally responsible for the care of birthing women.

The problem is compounded by some course organisers requiring attendees to provide themselves with essential oils – yet until students have completed a course they will have no understanding of which brands constitute good quality oils suitable for clinical practice. Further, we have become aware that some courses are being advertised as being accredited by the Royal College of Midwives (RCM) which is untrue, since the RCM no longer provides accreditation to external organisations.

If you have any questions about seeking aromatherapy training for yourself or your unit, please do PM us.  

Is It Unethical To Use Fragrance To Attract Custom?

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.

Value Yourself

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. 

Knowledge is Important

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.

Self Care for Midwives

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.

Individualisation Is The Key To Diversity

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.

Embracing Complementary Therapies

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.

Old Books For New:

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 14^th 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 11^th 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.

Borage Explained

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

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

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

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

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

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.

Adjust Your Own Oxygen Mask Before Helping Others

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.

The Business Of Midwifery 

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

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”

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 for Syntocinon

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

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

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

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.

Acupuncture Explained

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.

Essential Oil Use In Midwifery Clinical Supervision

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

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

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

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.

The Power Of Holiday Therapy

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!

A Reflexology Approach To The Soul

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

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

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

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.

I is for Induction of Labour

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 info@expectancy.co.uk

H is for Hypnotherapy

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 info@expectancy.co.uk for more information.

G is for Ginger

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.

Mobiles And Massage Don't Mix!

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.

F is for Fear of Birth

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. 

E is for Elephant Dung

A remedy used in some African countries to prepare for and ease the birth process. 

D is for Dancing in Pregnancy

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

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

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 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. 

Valerian Tea Explained

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.

Teaching Online Long Distance

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

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. 

Private Or Public Maternity Care? 

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.

Pregnancy Sickness and Neck or Back Problems

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. 

A Word About Leeches

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

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.

Continuing Development: What Makes A Credible Course?

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.

Should Expectant Parents With Long Covid Avoid Aromatherapy?

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.

Hypersalivation In Pregnancy

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: 

• Kreosotum is possibly the first remedy to try, especially if there is bad breath
• Merc sol is better if the saliva is thick and the tongue is spongy, leaving imprints of the teeth
• Kali carb Is useful if the saliva causes drooling during sleep, notably between 2 and 4am
• Ipecac may help if saliva is profuse, vomiting is frequent and the tongue is clean
• Nux vomica if the tongue is yellow and pasty looking
• Antim crud if the tongue is white with a thick coating 

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.

Compassionate Use Of Complementary Therapies In Maternity Care

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).

Mandatory Covid Vaccinations For All NHS Staff

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:

• Treat people with kindness, respect and compassion (1.1) – compassionate care means safe care and putting people at risk is not compassionate
• Respect and uphold people’s human rights (1.5) – patients and clients have a human right to be cared for by midwives and nurses who cannot pass on an infection
• Pay attention to promoting wellbeing and preventing ill-health (3.1) – unvaccinated midwives and nurses may of course, pass Covid on to the people in their care
• Act in the best interests of people at all times (4) – it goes without saying that risking passing on the virus to patients and clients is not in their best interests
• Always practice in line with best-available evidence (6) – evidence suggests that Covid tends to occur late in pregnancy, increasing the risk of preterm birth; vaccinations are now being advised for expectant mothers
• Take account of your own safety as well as that of people in your care (13.4) – speaks for itself
• Be aware of and reduce as far as possible any potential for harm associated with your practice (19) including:
• Keep to and promote recommended practice in relation to controlling and preventing infection (19.3) and
• Take all reasonable personal precautions to avoid any potential health risks to colleagues, people receiving care and the public
• Keep to and uphold the standards and values set out in the Code (20.1) – relates to all of the above
• Keep to the laws of the country in which you are practising (20.4) – vaccination is now legal required
• Maintain the level of health you need to carry out your professional role (20.9)  – including taking steps to prevent Covid

Finally, there are two other clauses in the NMC Code that relate directly to discussing this current issue on social media:   

• Make sure you do not express your personal beliefs (including religious, political or moral beliefs) in an inappropriate way (20.7) and
• Use all forms of spoken, written and digital communication (including social media and networking sites) responsibly (20.10)

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!

Complementary Therapies Are Not A Panacea For Everything In Pregnancy And Birth

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!

Why Do Midwives Think It Is Ok To Attend A Short Course In A Complementary Therapy And Fail To Update For Almost Ten Years?

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. 

Vaginal and Caesarean Births…Some Advice

Denise is often asked by midwives about whether women wanting a vaginal birth after a previous Caesarean section (VBAC) can use complementary therapies and natural remedies to start labour. Obviously these women are desperate to avoid another Caesarean and often try everything they can find to help. Of course, having a nice relaxing massage or reflexology treatment can be good - it reduces the stress hormone, cortisol, and encourages an increase in oxytocin so labour is more likely to start naturally. Hypnotherapy can also help, by encouraging the expectant mum to focus on the positives of the impending birth rather than on the negative feelings about the past Caesarean.

However just because they're natural doesn't necessarily make self-administered natural remedies safe. This applied to all pregnant women but it's a particular risk when those wanting a VBAC start trying every remedy they've heard of - and often all together. More is definitely not better - indeed, using lots of remedies may confuse physiology so much that it actually increases the risk of complications, leading to the need for another Caesarean.

Maternity professionals - midwives, doulas, doctors - and therapists treating pregnant women should advise those trying for a VBAC to: 

* have regular relaxation treatments from a suitably qualified therapist who is insured for maternity work

* avoid self-administering castor oil, raspberry leaf tea, clary sage oil, evening primrose oil and other herbal remedies - and NEVER EVER to take them all at the same time

* inform their midwife or doctor about any complementary therapies they've had, and especially any herbal remedies they've taken or aromatherapy oils they've used.

Aromatherapy Oils Are Not To Be Played With

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

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

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

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

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

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

Why is Complementary Medicine not Included?

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

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

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

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

What’s Happened to Midwifery?

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

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

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

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

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

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

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

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

Aromatherapy in Midwifery Practice

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

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

A Word About Essential Oils

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

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.

Black and Blue Cohosh Explained

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

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

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

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

The Science of Aromatherapy Oils

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

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

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

Why are Good Midwives Being Driven Away?

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

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

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

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

Pineapple Fritters Anyone?

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

The Caring Role of a Midwife

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. 

About Herbal Teas

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.

The Need for education on Complementary Therapies

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

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.

Breech Presentation

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.

Oils and Allergies

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.

The Benefits of Frankincense Oil

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-a few words

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.

Moxibustion

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.

All About Ginger

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.

Testimonials and Compliments

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

Watch Out For Your Pets

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.

Homeopathic Remedies

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.

Course Update

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:

• What the remedy is 
• How it works
• Correct dosage
• Method of administration
• Frequency and duration of use
• When not to take it
• Possible side effects
• Success rates based on evidence where possible.
• Recording in the notes the information that is given 

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.

The "Negativity" Of Safety Information On Complementary Therapies

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.

Has Hypnobirthing Had Its Day?

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. 

Seaweed For Postdates Pregnancy?

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.

Ten Tips For Midwives Looking For Complementary Therapy Courses

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)

The Dangers Of Passing It On

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.

When Will Nice Stop Categorising All Complementary Therapies As “Non-Pharmacological”?

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).

Essential Oil Responsibilities

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.  

The Business Of Maternity Care

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!

Complementary Therapies

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?

15th May 2021- Today is International Hyperemesis Awareness Day

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.

Reflex Zone Therapy

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.

Misleading advice

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

Homeopathy is not a placebo effect

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).

Hyperpolarisation

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:

• Use clary sage in doses of no more than 3% to aid onset of labour
• Avoid using clary sage once contractions have become well established
• Avoid diffusion of clary sage (and other oils) in labour to prevent over-saturation of the atmosphere
• Never use clary sage for the duration of a labour
• Only use clary sage, in a 2% dose, to encourage labour that has slowed down if all other causes have been excluded (hypoglycaemia, full bladder, ketosis, obstructed labour, pain etc)
• Be alert to the possibility that clary sage, if over-used, can have the opposite to the desired effect on contractions
• Never use clary sage oil with drugs intended to facilitate labour

The Future of Midwives

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.

Aromas Are Chemicals 

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.

Antibacterial Soap

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.

Synthetic Fragrances

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.)

Informed Consent

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:

• What the therapy is
• How it works ( mechanism of action)
• How it can benefit the pregnant or birthing woman at this time
• Reasons for use
• How likely it is to be successful in relieving symptoms / condition
• How it is used (what to expect during treatment)with
• Method of administration
• Contraindications and precautions (assessment of individual)
• Possible expected (normal) healing reactions to therapy
• Possible unexpected side effects from appropriate use
• Possible complications from inappropriate use (self administration)
• Risks of possible interaction with medication or other treatments
• What to report after treatment (with contact details)
• Explanation about any research - and its overall calibre
• Statement that NICE guidelines do not support the use of  complementary therapies in pregnancy and birth as it is generally poorly researched

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 info@expectancy.co.uk

The Debate on Cascade Training of Complementary Therapies

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 -  info@expectancy.co.uk

Denise's Latest Book

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.  

Thought For The Day...Clinical Hypnosis

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.

A Few Words On Reflexology

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.

Thought For The Day

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.

How Times Change

Here Denise reflects on changing times in the pregnancy and birth arena and considers how stressful life is now compared to 40 years ago.

She says:

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.

The Misuse of Complementary Therapies

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:

• A woman whose husband is in intensive care being ventilated for Covid, whose nurses agreed that it was acceptable for her to bring in an essential oil diffuser to “ease his breathing”. This is one of the most worrying incidents I have seen. Whist diffusion of specific oils may aid respiration for people recovering from Covid at home, the very fact that this man is in ITU means that he needs specialist medical and nursing care and aromatherapy is completely contraindicated at this time. Further, it is frankly irresponsible of the nursing staff to agree to this: obviously they have no understanding of the dangers of diffusing oils in an area where people are in life-threatening conditions and how they may affect, not only this man, but other patients in the unit.
   
• Various reflexology “professional” groups with numerous questions asking whether reflexology can “heal” particular medical conditions or  what reflexology treatment should be done to treat specific medical conditions. These questions are usually followed by numerous helpful suggestions from therapists who obviously do not understand the pathology of the conditions being discussed and do not appreciate their professional boundaries. Some of the conditions mentioned are so serious that the reflexologist should not be treating them at all yet there appear to be no posts urging caution, just total amateurish enthusiasm. In any case, reflexologists are not permitted to treat medical conditions unless they have undertaken extra training, are insured and preferably also communicate with the relevant medical doctor.
   
• Reflexologists posting pictures of feet and asking what various changes mean, for example, lines, bulges or cracks on the feet. I have discussed this before and it worries me that these people make sweeping statements and  giving supposed “diagnoses” without any knowledge of the person’s history, symptoms or other factors that need to be taken into account when treating clients.
   
• Certain essential oil companies advocating that oils can be taken by mouth as medicines. Again, this irresponsible publicly-available information is extremely dangerous and risks causing serious adverse effects, especially when used as an alternative to essential medical care. Oral  administration is not part of aromatherapy practice and should only be advised by medical practitioners who have been trained to use essential oils as medicines.  
   

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. 

A New Book On The Horizon!

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 emailinfo@expectancy.co.uk 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

Brave New World...online learning

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.

Denise says:

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.

January Webinar News

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

·      All webinars cost £20 – or book any two for £36.

·      Book via info@expectancy.co.uk

·      Full payment is required by direct bank transfer before we send the access link for your chosen webinar

·      Certificate of attendance emailed to you after the webinar

Pineapples and Fertility

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.

Christmas Foods And Spices

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.

How Antenatal Education Has Changed

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!

 

Being Professional

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.

She says:

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.

Expectancy Licensed Consultancy Explained

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?

Chips With Everything

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!

Are Complementary Therapies Safe In Pregnancy 

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:

• Enquire about clients’ use of CTS and NRs prior to and during pregnancy – at booking and at various stages throughout pregnancy
• Advise caution with ALL CTs and NRs unless prescribed or administered by a fully qualified practitioner
• Advise extreme caution with herbal remedies including herbal teas, which may have adverse effects such as blood thinning or toxicity
• Maternity professionals should be adequately trained and insured to administer / advise on CTs and NRs
• CTs practitioners should be trained and insured to treat pregnant clients
• Communication between maternity professionals and complementary practitioners should be encouraged
• If in doubt, do not use – especially if there are any individual medical or obstetric complications
• Less is more – never exceed the dose, duration or frequency of administration of any CTs / NRs
• Remember – “natural” does not always mean “safe”

Fantastic news!!!!

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 27^th 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.

Changing Childbirth

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".