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).