Denise has been seeing a lot of posts on Social media recently from students offering their used midwifery textbooks for sale at the end of their training. Here she explores the issues around academic reading and keeping up to date.
It’s that time of year when students are coming towards the end of their three year pre-registration midwifery programmes – and when those about to start midwifery training excitedly start preparing. Part of this preparation is thinking about which textbooks to buy. The two traditional UK midwifery texts are Myles’ Textbook for Midwifery and Mayes’ Midwifery, to both of which I have contributed chapters on complementary therapies on many occasions over the various editions. Another staple is Bailliere’s Midwives’ Dictionary, which I have edited every three years since 1997 and have just finished the 14th edition (Tiran, Redford 2022). However, there is such huge diversity within the modern midwifery profession, including obstetrics, physiology, psychology, sociology, research methods, obstetric emergencies and many contemporary issues, that there is a dizzying selection of textbooks, some of which cost up to £50 or more.
It is therefore understandable that students who have purchased their own copies may want to sell them on to incoming students. However, I am concerned that some books posted for sale on social media are extremely old and have been replaced with more recent editions. I recently saw a copy of the 11th edition of the Bailliere’s Midwives’ Dictionary (2009) for sale at £10, only marginally less than the latest edition which contains many new terms and more socially acceptable definitions. Another student was selling a 2011 copy of Obstetrics by Ten Teachers, despite it having been updated six years later. Some of the books are so old that they could be kept as historical texts - and prove very interesting to compare practice years ago with how it has evolved today.
However, whilst some books remain useful for new learners, many become out of date quickly. Remember that a newly published book is often already 18 months old or more by the time it is available for sale, since the writing of it and the publication process take considerable time. My advice to incoming student midwives (despite being an author wanting you to buy my books!) is just to buy one recent comprehensive textbook (either Myles’ or Mayes’) and the dictionary – and then wait to see what is available in the university library. You may develop an interest in a specific aspect of midwifery such as breast feeding, genital mutilation, genetics or complementary therapies, in which case you can look for the most recent academic textbooks on those specialisms. You could consider sharing books with a group of colleagues to enable you all to access both general midwifery and specialist texts. You could ask for Christmas or birthday presents for those you feel you would like to own. You may find cheaper versions of some books as digital copies. Bear in mind that many of the books you purchase for your own course will be out of date by the time you qualify and may not, therefore, be suitable for students coming along after you.
Books are wonderful, especially when you own a pristine hard copy, but it is essential to keep up to date. Not only could you lose assignment marks by referring to an old edition, it could also mean you are not up to date in your practice.
If you are lucky enough to own a previous edition, especially one that is more than 20 years old, keep it for posterity, but make sure your theory and practice are based on the most up to date editions.
The beautiful blue flowers are sometimes added to cocktails. More importantly, borage contains significantly more gamma linolenic acids, one of the primary therapeutic constituents, than evening primrose oil.
Both EPO and borage are traditional remedies to start labour although evidence for effectiveness is limited.
Care should be taken with borage as it can cause liver toxicity in some.
Z is for ZuSanLi, an acupuncture point also called Stomach 36. It is situated about four finger-widths below the bottom edge of the kneecap, between the two bones of the lower leg. In pregnancy it can relieve nausea, constipation, carpal tunnel syndrome, anxiety and aid birth preparation. It is useful for aiding progress in labour and postnatal recovery. Stomach 36 is one of the 15 points taught on Expectancy’s Certificate in Midwifery Acupuncture programme – we are now recruiting for September.
Y is for ylang ylang, (Cananga odorata), a wonderfully relaxing essential oil that is safe to use in pregnancy and birth. It can have strong sedative effects so should not be used for too long, and midwives caring for parents in labour who wish to use it should take regular breaks and keep hydrated to ensure they are alert enough to make clinical decisions (and drive).
It is very good for postnatal blues but caution is urged if there is a history of diagnosed clinical depression, as the effects can be so deep that the emotions can almost be pushed inwards, compounding the problem. The aroma is deep and floral but can be heavy and cloying for some people so use in small doses and for short periods of time.
In the home, ylang ylang should not be used near neonates, elderly relatives or animals (it is toxic to cats and dogs).
X is for X-rays – one of the sources of energy that can inactivate homeopathic remedies. Since homeopathic medicines are chemically very fragile, they can be easily inactivated by X-rays, mobile ‘phones, televisions and microwaves. Never store your homeopathic arnica and other remedies near electrical sources in the home – and take care when passing through the airport if you have homeopathic jetlag remedies with you.
W is for witch hazel, a common herbal remedy used for perineal healing after birth. However, witch hazel should not be used on an inflamed or infected wound. It can be useful for haemorrhoids after birth as it has an astringent effect, causing vasoconstriction, although the research evidence is poor. Witch hazel should not be taken orally.
V is for Vitex agnus castus - This herbal remedy, also called chaste berry, is a popular remedy for menopausal problems and is also used for infertility treatments. However, it should not be self-administered orally in the preconception period, pregnancy and when breast feeding, unless on the advice of a qualified medical herbalist. There is some suggestion that the plant hormones may compromise implantation of the embryo in early pregnancy. These also increase dopamine activity which blocks the production of prolactin, so it may affect lactation. Topical use of the cream appears safe.
Denise has been in Glasgow this week for various meetings. Flying from Heathrow, she reflected on the pre-flight safety briefing, including what to do in the event of reduced oxygen in the cabin, and related this to our work as midwives providing care for expectant and birthing parents. She says:
Midwives work incredibly hard in difficult circumstances, with inadequate staffing and long hours, often without time for a break, even a drink or visit to the toilet. Yet how can we expect to care for families if we are not fit, healthy and refreshed ourselves? Midwives become dehydrated, ketotic and exhausted which leaves them in no fit state to care for people. Put this in the context of the institution for which they work, with its dependence on risk avoidance and the pressures of an immensely punitive culture, and the stress on midwives and other maternity care providers is immense..It is hardly surprising that midwives are leaving the NHS in droves.
Isn't it about time we started looking after ourselves first? We need to praise and thank the midwifery workforce, not bully them into being a mechanistic corporate set of hands blindly doing the job. We.need to facilitate midwives and support workers to give mindful care that not only helps service users but also leaves service providers feeling fulfilled and valued.
One NHS trust has recently asked me to provide a series of half day relaxation events for its staff, to thank them for their efforts and to give them something back to show that they are, indeed, valued. Engaging in some rostered "me time", with relaxation to music, massage and time to chat over a cup of tea and cake can do wonders to boost morale. Offering a metaphorical "oxygen mask" goes some.way towards helping midwives and support workers feel appreciated and to revitalise them so they are in a better state to provide quality and caring support to parents and babies.
Denise recently interviewed a midwife for our Diploma who had just completed a Master's in Business Administration (MBA). Discussion turned to some of the issues plaguing the NHS and her insight into midwives’ lack of knowledge of the business of maternity care. Denise reflects on her conversation:
Midwives seem to have little concept of how the NHS works or how much everything costs.
For example, the difference in cost between a spontaneous vaginal birth and a Caesarean section is around £2000; an epidural costs at least £850; even the comparative pennies needed for a urine sample bottle or a pack of gauze swabs add up to a multibillion pound NHS.
A trial was done some years ago in a London surgical ward in which the prices of NHS equipment were listed on cupboard doors. Increased awareness of the nurses led to more mindful use, less wastage and considerable cost savings. I find it fascinating when teaching business studies to the midwives preparing to set up their own private practices via our Licensed Consultancy scheme to hear their views on money - costs, pricing and savings. One midwife recently told me she would be charging just £35 for an hour's complementary therapy treatment in her private practice. This was way below the average price of a pregnancy massage in her area. Further, she had not considered the money she had already spent to get to the point of starting her business - training and experience, NMC registration and revalidation, insurances, equipment and the costs of starting and running her business. She was, in effect, giving her services free of charge - and actually paying to provide them. It is interesting that independent midwives do not have the same reticence talking about their fees as midwives working solely in the NHS.
Asking people to pay for their services is not a problem. Indeed, it is the only way an independent midwife is paid. NHS midwives do not give their time free of charge – so why is there such a negative feeling about asking expectant parents - who have consciously chosen a private option – to pay the fees for services provided? No one would expect to go to the hairdresser or massage therapist without paying for their expert services – so why do we have a mindset that finds talking about “money” distasteful?. I believe that midwifery and all healthcare pre-registration programmes should include a mandatory module on the business of healthcare.
If NHS staff understood how much everything costs, there would be less wastage and savings would contribute to a more balanced use of NHS limited budgets. For midwives going into private practice, it would be wise to study business matters before commencing to avoid costly mistakes – professional and legal as well as financial.
A greater understanding of the business of maternity care would contribute to a more successful business.
U is for uterus. In foot reflexology the point for the uterus is on the inside of the heel. Many people think it's acceptable to massage this area to stimulate contractions, but it's not. Uterine contractions start in the pituitary gland so to aid labour requires stimulation of the reflex points for the anterior and posterior pituitary gland on the side of the big toes. Over-stimulating the uterus reflex points on the heels can disrupt labour physiology and, in extreme circumstances, may even cause placental separation and bleeding.
T is for “Therapy shopping”. Some people, when desperate to resolve a problem, try every complementary therapy they can find, in what is often called “therapy shopping”. It is not helpful to use several different therapies or natural remedies together as this can “confuse” physiology and often make things worse.
Expectant parents desperate to avoid an induction of labour may do this, trying all the herbal remedies they can think of, including clary sage, raspberry leaf, castor oil, as well as eating pineapple, dates and mangoes and consulting a reflexologist, acupuncturist and/or aromatherapist. Midwives and doulas should encourage parents to try just one thing at a time (although don’t leave raspberry leaf until term) unless under the direction of a fully qualified practitioner of complementary therapy who can balance the combination safely.
S is fo r syntocinon. If expectant parents need intravenous oxytocin they must not use oils or herbal remedies with similar effects. This includes clary sage, jasmine, rose, cinnamon and nutmeg oils, raspberry leaf, evening primrose, black and cohosh other herbal remedies.
Care should also be taken when vaginal pessaries of prostin are used to start labour especially if the woman is at home.
R is for raspberry leaf tea, a popular herbal remedy to time the uterine muscle in readiness for labour. If appropriate, it can be taken during the third trimester, gradually increasing to about 3-4 cups a day, then gradually reduced in the first two weeks after the birth. Raspberry leaf is not a means of starting labour - suddenly commencing it at term may lead to excessive contractions and possibly fetal distress.
Q is for quiet. Never underestimate the value of silence during a birth or when providing complementary therapies in pregnancy or after the birth. Music can be useful sometimes but there's a lot of psychology relating to using the right type of music. Quiet allows the birthing family to go into their own zone, to tune out the extraneous noises of the world and to focus inwardly in preparation for their new arrival.
P is for the Pericardium 6 (P6) acupuncture point, which is a useful point to combat nausea in pregnancy or labour or after Caesarean. Pressure can be applied with the thumbs or fingers, or a wristband can be worn; tiny press studs can also be taped to the point, which are almost unnoticeable. To find the P6 point measure three finger widths up the inside of the arm from the wrist crease - approximately where the buckle of a wristwatch might be. The point is found as a small dip between the tendons.
An interesting study has emerged from Australia and New Zealand about the ways in which information is disseminated and practice is influenced for acupuncturists involved in women's health. Here Denise explores the wider implications of the findings.
Acupuncture is a very popular adjunct to women's health, notably in the areas of fertility and pregnancy. It is perhaps even more popular in Australasia than the UK and USA although acupuncture is one of the most well accepted of all complementary therapies. This may be due to the level of training required, which is almost exclusively at graduate and postgraduate level. It may be because acupuncture is better regarded by conventional medical practitioners than other, more supportive therapies such a massage, and indeed is used by some anaesthetists as a means of pain control. Acupuncture is also very well researched, although this study suggests that practice is defined less by the evidence and more by collaborative information-sharing from conferences and other educational opportunities.
Referrals for acupuncture prior to and during pregnancy generally come from prospective clients, with some from doctors. However, there is a need for much greater awareness amongst conventional healthcare professionals of the benefits and effectiveness of acupuncture.
Midwives and obstetricians in particular should be better informed about the potential of acupuncture to resolve issues such as subfertility, and severe pregnancy back pain, sickness or breech presentation. Dealing with these issues by offering acupuncture treatment would reduce the complications and associated cascade of intervention that they bring. This in turn would save money for the health services and improve parental satisfaction and wellbeing.
At the very least, midwives and obstetricians should receive an introduction to the concept, effectiveness and evidence base of acupuncture during their pre-registration education, to increase their awareness and understanding of the therapy. Further, for those midwives with a special interest, being able to introduce an acupuncture service into their practice or place of work would further facilitate an improvement in care for those expectant parents suffering prolonged and intractable pregnancy symptoms which can impact on the progress and enjoyment of their whole pregnancy.
Denise recently read an article in which the use of essential oils was debated as a possible adjunct to restorative clinical supervision by professional midwifery advocates (PMAs). The author, a midwifery lecturer, rightly addresses aromatherapy safety issues but concludes that NHS trusts could consider the use of diffusers to assist in boosting staff mental wellbeing, especially as part of restorative clinical supervision (RCS). Here Denise expresses some concerns about the concept.
Essential oils can be relaxing and ease the symptoms (but not the causes) of stress when used appropriately, but I have grave concerns about PMAs advocating the use of diffusers within RCS sessions. It is not the role of the PMA to address health issues of midwives, merely to recognise them and refer on to the relevant sources of help.
When midwives are trained to use essential oils for expectant and birthing parents, they learn only a minimal aspect of the vast profession of aromatherapy and do not have the knowledge or skills to help non-pregnant staff. Even using essential oils for relaxation needs to be done in accordance with a complete assessment of the intended recipient, acknowledgement of physiological allergies and psychological odour memory and preferences. Indeed, there could be an insurance issue here in the event of any untoward adverse reactions, not only of the individual midwife undergoing RCS but also any other midwife affected. Further, the use of diffusers in these RCS sessions contravenes the Health and Safety at Work Act 1974 and the Control of Substances Hazardous to Health regulations, which require employers and employees to minimise the risks of chemicals in the workplace. I find it worrying in the extreme that this message is not getting across to midwives and that the author suggests the need for research into diffuser use within RCS.
Research on effectiveness of any complementary therapy should be preceded by understanding fully the safety issues to ensure that aromatherapy in general, and specific oils in particular, are safe: no single oil is safe for everyone. Using oils in rooms which may later be used by other staff (or parents) risks exposing them to the risks of aromatherapy – in which case the NHS trust managers could be liable for any adverse effects on individuals by having permitted the oils to be used in this way.
O is for orange essential oil. Sweet orange oil and other citrus oils such as tangerine, mandarin, lime or grapefruit, are gentle oils to use in pregnancy, birth and the postnatal period. They're uplifting, good for emotional distress and effective for constipation.
Always check before use in case the mother or any other person present ( including the person administering it) has an allergy to citrus fruit - in which case it should be avoided.
N is for natural remedies, which should be used with extreme care in pregnancy. Just because they are natural does not mean they are always safe.
Many herbal remedies such as St John's wort, should be avoided in pregnancy and SJW should never used together with antidepressants. Homeopathic remedies don't act like drugs - they do not work chemically but work energetically (according to physics) and should also be used carefully - using the wrong remedy or using the right remedy for too long can cause an increase in symptoms rather than resolving them.
M is for massage, a simple tool for midwives and doulas to use during labour. The power of touch is enormous. Physically, massage can stimulate circulation and encourage the woman''s body to work efficiently. It can ease pain through the gate control mechanism - touch impulses reach the brain quicker than pain impulses. Emotionally, massage adds to the sense of nurturing that is so powerful during labour and birth.
Currently travelling in South Africa, Denise reflects on the power of the sun to raise the spirit and heal the body and mind.
It's been three long years since I've been able to visit South Africa and I'd almost forgotten how hot it can get, even at the end of the summer. I've noticed, however, how happy everyone is here, even in the cities, and certainly in the rural areas. I'm convinced this is due to the sunshine and warmth, the open air lifestyle and the space around us.
Getting a good dose of vitamin D positively impacts on our mental health, making us feel uplifted. The beaches and forests play their part allowing us to breathe deeply of the clean air; the sounds of birds are not overwhelmed by excessive traffic noise; the taste of fresh, locally sourced food (and the occasional glass of good South African wine!) nourishes the body - and taking time to relax over meals aids digestion.
Holidays are good for mind and spirit, healing us from within and without. They give us time to talk to loved ones, to share experiences with family and friends and to reflect on life. Taking a holiday, even for a short time, is therapeutic and re-energising - the ultimate complementary therapy!
Currently staying with her son in South Africa, Denise has been able to reconnect with a friend she hasn't seen for almost 30 years. Christine Lynne Stormer-Fryer was a health visitor in the early 1980s when Denise was a community midwife in Surrey (she actually introduced Denise to her husband!) On emigrating, Chris, who had trained in reflexology, opened the Reflexology Academy of Southern Africa and became a world-renowned presenter on her particular type of reflex therapy. Although the Academy is long gone, Chris's unique style of presentation and writing continues.
As is the way with old friends, gifts were exchanged - Denise gave a copy of her Using Natural Remedies Safely in Pregnancy book, and Chris gave her two self-published reflexology books. Chris's Hot-Footing It to Health is a fascinating read. Much more spiritual than Denise's scientific clinical approach, it is nevertheless a supportive text for practitioners and gives an insight to its approach for those receiving reflexology. Chris's way with words leads her to unlock language and give it new meaning, for example "Feet, being the platforms on which the body takes a stand, provide a remarkable understanding as to the 'ins and outs' of what it is to be human".
This is not a book about the practice of reflexology, and does not focus on any particular style, neither traditional European nor eastern meridian therapy, and certainly not clinical reflex zone therapy as taught by Expectancy. It explores the concept and philosophy of an ancient healing art and attempts to set it in the context of modern life. It contains a collection of sound bites - or, as Chris herself might say, "foot notes" to aid reflection on the purpose of reflexology in restoring and maintaining health and wellbeing.
Despite their reunion being short, Denise and Chris had a lovely morning and intend to keep in touch better. If you'd like to buy Chris's book the ISBN number is 9781986332064.
L is for laminaria, a type of seaweed has traditionally been used to open the cervix for termination of pregnancy and to aid cervical ripening in postdates pregnancy, as well as to help the insertion of radium in cancer patients. When inserted as a “tent” into the opening of the cervix, the gel within the leaves becomes wet it swells to help dilatation (it is a precursor of the intracervical rods currently in use in some maternity units. However, laminaria may cause infection or uterine bleeding and is no longer used medically. It should not be taken orally as it contains high levels of iron and arsenic, which may be toxic.
K is for Kidney, an acupressure point on the sole of the foot which is an excellent relaxation point.
It is also used for relaxation in reflexology, and is thought to correspond to the solar / coeliac plexus where people feel “butterflies” when anxious. Gentle pressure applied to this point on both feet can be very relaxing especially during labour or when a woman is waiting to have a Caesarean section.
J is for juniper berry essential oil which is contraindicated in pregnancy. It contains chemicals which be harmful to the developing baby and which may affect renal perfusion especially through the maternal kidneys. Many essential oils should be avoided in pregnancy - if in doubt, avoid using them.
Expectant parents wishing to avoid induction can be helped with an effective package of complementary therapies including acupressure, aromatherapy, massage and reflex zone therapy. Some maternity units are now using this Expectancy package to reduce significantly their induction rates. If you'd like a course for midwives in your unit, please contact firstname.lastname@example.org
A powerful clinical tool to help parents prepare for the birth and to overcome their fears and anxieties. It can also be effective for smoking cessation in pregnancy. Expectancy now offers midwives a programme in midwifery clinical hypnosis with the option to progress to a full hypnotherapy qualification. Contact email@example.com for more information.
Commonly used to combat sickness in pregnancy. Ginger biscuits are not the answer as there's too much sugar (which can make sickness worse) and not enough ginger to be effective. Ginger tea made from grated root ginger is best, sipped throughout the day. Ginger essential oil should not be used in pregnancy as it may trigger uterine contractions.
Teaching a group of midwives recently, Denise was disappointed to see, during the practical work, one of the midwives flicking through her mobile 'phone whilst receiving foot massage from another midwife. When asked to put her 'phone to one side, she said it helped her relax. She challenged Denise, stating that young women like to use their 'phones all the time and might want to do so during a massage, without any understanding of why this is inappropriate.
First, being on her 'phone whilst having the massage was disrespectful and certainly did not enable her to appreciate the power of relaxation from her own experience. Her attitude was that her partner had access to her feet to practise but she could not relate this to what she could apply to her midwifery practice. She did not recognise the opportunity for social interaction that comes from an expectant parent being face to face with a midwife whilst enjoying some "me" time. It's amazing what women talk about during foot massage (or reflexology) that they don't discuss during a normal antenatal appointment - this has been shown in research.
More importantly, a mobile 'phone is a source of energy (heat) that interferes with hormonal energy. It's been proven that men who carry mobile 'phones in their trouser pockets may have reduced fertility because the constant heat near the scrotum interferes with sperm production. Similarly, this heat exacerbates the stress hormone, cortisol, and adds to, rather than reduces, internal stress levels. Given that stress contributes to disturbances in the pregnancy and may cause either preterm or delayed onset of labour, it stands to reason that expectant parents should be encouraged to use them less, and at the very least, to enter into the spirit of relaxation that comes from having a massage.
When expectant parents are offered complementary therapies, they must understand that it requires them to work in partnership with the practitioner. This includes agreeing to comply with the aftercare advice such as increasing fluid intake and avoiding toxins eg coffee and alcohol. It also means that those who refuse to put down their mobile 'phones should be informed that they cannot receive masage, reflexology or other therapies (homeopathy, for example, is inactivated by the heat from mobiles, TVs and microwaves). And for midwives, it requires a commitment to what they are learning and how the experience of receiving massage can contribute to that learning.
Or perhaps fear of the maternity services, fear of being left alone during labour or fear of being coerced into accepting something expectant parents don't want.
Clinical hypnosis can be very effective at helping women face their fears and is individualized to each woman to help her overcome them.
A remedy used in some African countries to prepare for and ease the birth process.
Any type of dancing can boost the feel-good endorphins and reduce stress hormones.
Belly dancing is particularly popular and helps to allow some give in the pelvic brim in preparation for birth, and encourages the baby to settle into an optimum position for birth.
C is for chiropractic, a statutorily regulated profession supplementary to hea!thcare.
One of the most used medical therapies in the world, chiropractic is similar to osteopathy but uses different techniques to realign deviations in the musculoskeletal system caused by injury, disease or genetics. In pregnancy, it is effective not only for backache, sciatica and other bone and muscle issues but can also help to turn a breech baby to head first and relieve heartburn and indigestion.
B is for backache in pregnancy, caused by the effects of progesterone and relaxin on the musculoskeletal system. It's often accompanied by sciatica and pelvic and groin pain.
Osteopathy or chiropractic are probably the most effective therapies, but massage, aromatherapy or reflexology may bring some temporary relief. Acupuncture can also help.
A is for Acupuncture - a credible, well researched therapy that is effective in treating many pregnancy issues including sub-fertility, sickness, backache, headache, constipation and carpal tunnel syndrome.
It can be used for postdates pregnancy, slow latent phase, pain relief in labour and retained placenta.
Denise says: Valerian tea can be helpful for insomnia but there is conflicting advice about whether it is safe in pregnancy and a few studies suggest it may reduce the level of zinc in the fetal brain. It is generally felt that expectant parents should avoid taking valerian. It can cause drowsiness and interact with sedative and antidepressant drugs and certain herbs such as Sr Johns' wort (another herb that should be avoided in pregnancy). In non-pregnant people, valerian should not be taken regularly for more than six weeks as it can lead to liver toxicity; suddenly stopping it after a prolonged period of time can cause palpitations and hallucinations.
For the third year running Denise has had to teach aromatherapy to midwives and therapists in Japan as an online course.
Having been teaching in Japan for over 20 years she misses visiting - but is hoping next year will be different. This last weekend she was up all night teaching because of the 9 hour time difference!
The pandemic has affected maternity care badly in Japan with women still having to wear masks in labour and are unable to have their partners with them.
There is also a notably increased rate of suicide amongst expectant and new mothers.
The public is however is far more compliant with wearing masks, self-isolating and accepting vaccinations.
Homeopathic arnica is a useful remedy to relieve bruising and trauma after birth, but did you know it should not be taken preventatively before any bruising has occurred?
Arnica tablets can be commenced immediately after the birth, the dose depending on the severity of the trauma - so a higher dose would be needed after a Caesarean than after a spontaneous vaginal birth.
Taking too high a dose, or taking it for more than four days can lead to a "reverse proving" in which it may actually cause further bruising.
The Midwives’ journal of the RCM reported on a recent OpenDemocracy survey of 7000 members of the public and 500 NHS staff, which found around 40% of patients (all clinical specialisms) feeling dissatisfied with their NHS options, notably long waiting times for appointments and surgery.
Around half of these had been advised to consider private treatment by NHS staff who were concerned about the adverse effects of waiting on people’s health.
Whilst there are huge concerns about the state of the NHS, we must remember that people do have choices. In maternity care, this includes the option to consult private midwives or obstetricians, and to seek supportive services such as complementary therapies and birth preparation classes in the private sector.
Indeed, an increasing number of midwives are working part-time in the NHS and part-time offering private services to support expectant parents – enhanced postnatal care, tongue-tie division, lactation support and much more. In some countries, such as Iceland, it is standard for midwives to be paid by the state for essential services including antenatal and birth care, but for expectant parents to pay for supporting services such as antenatal education, acupuncture and some aspects of postnatal care, which are provided by the same midwives they see for their pregnancy and birth care. In a profession that advocates choice for parents, it seems contrary to the philosophy not to accept the fact that some parents may wish to pay for additional support.
Nausea and vomiting is pregnancy is usually attributed to hormonal upheaval but there is also a correlation with back or neck problems. Misalignment of the spine and musculoskeletal system can put tension on various organs, making hormonal sickness much worse.
A history of whiplash injury is particularly significant as it puts strain on the vomiting centre in the brain, increasing symptoms. Osteopathy or chiropractic can help correct the neck problem.
Denise also uses a dynamic technique adapted from reflex zone therapy (the type of reflexology taught by Expectancy) to release the neck tension - like osteopathy via the feet.
Call the Midwife's use of Leeches - the ultimate alternative medicine.
Watching Call the Midwife on Christmas Day, Denise was reminded of her student nurse days at St Bartholomew's Hospital, London, in the mid-1970s when leeches were used to remove excess blood from bruises. She says:
I was a student nurse on Casualty when leeches were re-introduced. Of course,.we.thought it was a bit gross but once both the patients and the staff had overcome their qualms about having live animals attached to the body, we realised how successful a treatment they were for large haematomas (bruises). They were initially used on the medical students who had sustained black eyes and "cauliflower ears" playing rugby - and they were the most squeamish of all. I seem to remember there was a small trial being conducted (research studies were not as common as they are today) - so everyone was fascinated. Leeches are still in use in many parts of the world as an alternative to more invasive medical procedures. I'm not sure how I feel about using them for bruising of the buttocks after birth though - that might be a step too far to have leeches attached to your bottom whilst trying to feed the baby!
Clary sage (Salvia sclarea) contains certain chemicals that make it unsafe for expectant parents prior to term (37 weeks of pregnancy). It is often used to start labour although caution should be used as it can cause excessively strong contractions leading to fetal distress. It is also used by many midwives for pain relief in labour although it should not be seen as a panacea for everything in labour. Prolonged or excessive use in established labour can also cause contractions that are initially too strong but if the clary sage is continued beyond this point it will eventually have the opposite effect, causing the contractions to peter out. Care should also be taken in the postnatal period and clary sage should not be used is there are any retained products of conception or heavy bleeding with large clots as it could precipitate a major haemorrhage. Clary sage is a useful oil in maternity care but should always be used with caution.
Denise has recently discovered that the Royal College of Midwives will no longer be accrediting courses from external organisations from 2022. She says:
This news is disappointing because Expectancy’s courses have been accredited for midwives’ continuing professional development (CPD) by the RCM for over a decade. However, this information has caused me to reflect on the purpose of having courses accredited by a professional or academic organisation. We also discussed it on one of our online problem-solving sessions with our Licensed Consultants, to debate what midwives want in terms of CPD, a requirement of maintaining up to date and contemporary midwifery practice.
Accreditation aspires to provide a kitemark of quality so that prospective participants can be assured that the course is appropriate for their needs. Pre-registration midwifery programmes undergo rigorous examination by both a higher education institution (university) and the Nursing and Midwifery Council (NMC) and must demonstrate an appropriate professional and academic standard that complies with national and international requirements for midwifery registration. In terms of postgraduate education, courses must be fully applicable to the role of the midwife but do not necessarily have to be of a particular academic standard. They may be one-day introductory courses or long academic programmes that complement the role of the midwife. They should always strive to help midwives keep up to date and enhance their skills, and knowledge so they can provide safe, effective, evidence-based care. Many courses have hitherto been accredited by the RCM or RCN, and occasionally also by universities. Expectancy’s Diploma was originally accredited by the University of Greenwich at a time when many midwives were upgrading from diploma to BSc level academic qualifications: our programme could be used as credit towards a BSc )Hons) degree in Professional Practice. Although it is not currently academically accredited, we retain some link with the university sector by having an Academic Conduct Officer who is a senior lecturer in two universities, whose job is to monitor Expectancy’s robust assessment processes and ensure parity with other academic organisations and equity for students.
However, when it comes to accreditation for complementary therapy education for midwives, most accrediting organisations are in uncharted waters because the specialism transcends two professional borders – midwifery and complementary therapies. Midwifery accrediting organisations cannot easily assess the validity of the complementary therapies content; conversely, complementary therapy organisations cannot monitor the calibre of the maternity elements (and in any case, only provide maternity-related courses as CPD for therapists who are not registered healthcare professionals). Applications for accreditation from the course provider are assessed by the accrediting body based on what is in the documents presented (very rarely is direct observation of a course included). The documentation requires explicit demonstration of course aims and outcomes applied to midwifery practice and an academic level commensurate with at least that required for pre-registration midwifery education (academic levels 4-6, or preferably higher for post-registration education, at levels 6 or 7). Applications must also demonstrate the credibility of the course providers, with at least one of the teachers / facilitators being required to be a midwife (and in the case of complementary therapies, teachers must have a full qualification in the relevant therapy).
This does not, however, mean that the course is “good”. The course may be enjoyable but in practice may have little relevance to contemporary midwifery practice. Usually this is not by inclusion but by omission, for example, not setting the subject in the context of NMC parameters, or not focusing on the legal and professional issues pertinent to midwifery practice. This is noticeable in many of the short courses available to midwives on subjects that generally sit outside standard practice, particularly complementary therapies. A course may be taught by a therapist (who may or may not have maternity experience) and – in order to obtain accreditation – facilitated by a midwife (who may or may not be qualified in the therapy). Courses may focus on the benefits and only include safety and risks in a very limited manner – perhaps because the perceived negativity of risk issues detracts from participants’ enjoyment of the therapy during practical work on the course. This approach does not adequately meet the requirements of the NMC Code 2018 which requires midwives to “maintain knowledge and skills required for safe practice” (6.2) and to “work within the limits of their competence” (13).
Whilst many midwives still adhere to studying only those courses which have been accredited by the RCM this will no longer be possible from 2022. So how can they be assured of the quality of a complementary therapy course? The NMC leaves this decision very much in the hands of inpidual registrants and it can be difficult to determine the credibility and appropriateness of a course. Complementary therapy courses for midwives must be taught by dual qualified midwives – they must be fully qualified in the therapy, qualified and insured to teach it and have had considerable experience of using the therapy within their own practice. They must be able to imbue in their students an understanding of both the benefits and the pitfalls of using the therapy for expectant and birthing parents, within the parameters outlined by the NMC and within the NHS and other institutional settings. The midwives with whom I discussed this issue were kind enough to point out the credibility of Expectancy’s courses based on my personal reputation from 40 years of experience of teaching complementary therapies at higher education level and a tenacious adherence to safe practice.
It’s up to you to decide whether the complementary therapy courses you attend are “adequate and appropriate” for use within your midwifery practice.
The incidence of allergies is increasing with everyday exposure to allergies and pollutants. Fragrance allergies and intolerances are common, although it is not known if this is allergy to the actual fragrance or to the chemicals within them.
Long Covid is being recognised for an ever-expanding list of unusual symptoms and alterations in the sense of smell is now well known. However, in addition to this and total loss of the sense of smell(anosmia) a new phenomenon is now being recognised - allergy to smells in general and in particular to chemical fragrances such as perfumes.
This poses the question of whether midwives and doulas offering aromatherapy should check if each pregnant or birthing parent has had Covid and particularly if they have long Covid. Anosmia does not mean that people are unaffected by the essential oil chemicals, and allergies to fragrances may, as yet, be unrecognised by the individual.
Midwives and doulas offering aromatherapy in pregnancy or birth should, as part of their standard assessment for suitability to receive aromatherapy, ask about the woman's Covid history, the presence of long Covid and the sense of smell. This should include asking about alterations, absence or hypersensitivity to smells and any reactions which might suggest existence or recent development of an allergy to perfumes, chemical vapours, cleaning products and other substances with fragrance such as aromatic candles, diffusers etc. In these situations it might be prudent to abstain from using aromatherapy for or near the parents.
Today, Denise discusses a strange phenomenon that can occur in pregnancy and how complementary therapies may help.
Excess salvation is a distressing symptom that occurs in pregnancy more than you might think. It's hormonal and often occurs with severe sickness - or the salvation itself triggers nausea - but the causes are not understood.
It appears to be most common in women of black origin, particularly those from West Africa, although no one knows why. It commonly resolves spontaneously towards the second trimester but may persist throughout pregnancy for an unlucky few. Some women produce up to two litres of saliva daily and need to keep spitting it out.
In addition to keeping the mouth clean, sipping water to keep hydrated and avoiding starchy foods which often make it worse, sucking limes of lemon may help. However homeopathic remedies can also be effective, but the most appropriate remedy depends on the symptoms:
Taking one 30c strength tablet three times daily for 3-4 days should help but if the symptoms are no better, 're-evaluate and try another remedy. It's important not just to keep taking the remedy for longer if it hasn't worked in a few days as it can have a reverse effect and make things worse.
Acupuncture or osteopathy may also be effective, and there have been reports of hypnotherapy improving the symptoms. These therapies will require consultation with a qualified practitioner if self-administration of homeopathic remedies brings no relief.
Martin Bromiley, an airline pilot, founded the Clinical Human Factors Group after the death of his wife from minor surgery, which was later found to be due to “human factors” including poor communication between individuals and departments. (See http://chfg.org/).
Bromiley asserts that safety is integral to compassionate care and cannot be separated from it. If maternity care is unsafe then it cannot claim to be compassionate. This applies equally to the use of complementary therapies in pregnancy and birth. Midwives justify their use of complementary therapies as enabling them to return to being “with woman”, offering relaxing and pleasant strategies to help women through pregnancy, birth and new motherhood.
They defend their practice by alleging that complementary therapies combat the negative, often unwanted and unwarranted interventions which are so prevalent in maternity care today. They use the misconception that complementary therapies are “safe” because they are “natural” as an argument to support their introduction into maternity care.
However, this unthinking and incorrect declaration is, in itself, unsafe, adherence to which risks the wellbeing of mothers and babies, and of staff. Where midwives have long-standing complementary therapy services in place, there is a risk of complacency which could threaten the safety – and thus the compassionate delivery - of the strategies provided.
Compassionate care should apply equally to the incorporation of complementary therapies within maternity care, especially since these “alternatives” are often required to justify themselves twice over in order to convince the sceptics that they are safe, effective, satisfying and cost-effective. Several maternity units are known to this author where, it could be argued, midwives no longer provide compassionate – or safe – complementary therapies to pregnant and childbearing women because there has been little, if any, on-going updating, evaluation or development. Adapted from Denise’s book Complementary Therapies in Maternity Care, an evidence-based approach 2018 (Singing Dragon).
Today, Denise has chosen to remind us all of the NMC Code in respect of requiring mandatory Covid vaccinations.
The government has decided that all NHS front line clinical staff must be fully vaccinated against Covid by spring of 2022. Of course, there are many who raise the ethical dilemma of effectively forcing all staff to submit to something they may not want - or risk losing their jobs. Then there will be those whose political opinions differ from the government’s and those who see this as one more step away from our democratic or human rights. All of these are issues for the individual and are not the point of my post today.
Healthcare workers have long been required to undergo occupational health assessments to ensure physical and mental fitness to practice. Midwives must be immune to rubella or agree to receive the rubella vaccination. Those exposed to blood products, including midwives using acupuncture in their practice must ensure they are immune to hepatitis B – or receive the vaccine in order to practice. increasingly midwives and nurses are required to have the annual influenza vaccination and others working in particular clinical fields may need to have vaccinations against tuberculosis, hepatitis A and other infectious diseases. Mandatory vaccinations to work in the healthcare professions are not new.
As registrants with the Nursing and Midwifery Council, we are all bound by The Code (2018) which directs nurses, midwives, health visitors and nursing associates towards safe, accountable practice. The NMC’s responsibility is to uphold the safety of the public and to ensure that its registrants are working within the guidelines on which professional healthcare workers should depend. We can apply many of the NMC Code’s clauses to this issue:
Finally, there are two other clauses in the NMC Code that relate directly to discussing this current issue on social media:
Individuals are, of course, entitled to their views on the issue of mandatory vaccinations. However, whilst we welcome your comments on the content of this post, we will immediately delete anything which contravenes these principles. Be Kind!
It's very alarming to see some Facebook pages or websites making suggestions for the use of complementary therapies (CTs) in pregnancy that are completely unsafe. Here Denise discusses when aromatherapy and reflexology should NOT be used in pregnancy and birth.
Complementary therapies offer midwives a range of additional choices to help expectant and birthing parents. Aromatherapy and reflexology can be very effective when used appropriately and cautiously. However it is very worrying that suggestions are often made for using CTs to help with medical or obstetric complications.There are certain situations when aromatherapy or reflexology should not be used at all in pregnancy and birth:
Liver disease or obstetric cholestasis - essentail oils are metabolized via the liver and may exacerbate any existing hepatic issues. Women taking prescribed medication for any major medical issue should also avoid using oils which may interact with the drugs. Reflexology can also compromise drug metabolism or impact on the liver if there is cholestasis or cirrhosis or other hepaticcondition - over-working the foot reflex zone for the liver can accelerate drug metabolism and reduce their effectiveness.
Other major medical conditions including cardiac disease, unstable or insulin-dependent diabetes, epilepsy, thrombosis or clotting disorders or severe thyroid problems - indeed, any condition requiring medication or that is compromised by the pregnancy.
We must remember that aromatherapy and reflexology are intended to complement rather than replace medical treatment. They can have serious adverse effects when used injudiciously by women with more complex pregnancies. Midwives and doulas offering therapies, or.discussing parents' self-administration should be alert to those situations when CTs are inappropriate and possibly even dangerous.
Further, CTs are generally less well accepted by medics and less well researched than obstetrics, but more importantly, less effective than proven medical treatments for major medical conditions. They do not replace medical treatment. Even when used simply for relaxation, they may do.more harm.than good.
Caution is the watch-word here - if in doubt, leave them.out!
Denise was concerned this morning to receive an email from a midwife stating that she has completed two days of aromatherapy training with Expectancy in 2013; she continues to use it in the NHS, and was wondering if she could now use it in private practice.
Denise says: It is really worrying when midwives believe that it is acceptable to continue including complementary therapies (CTs) in their midwifery care for years without any updating.
The Nursing and Midwifery Council Code (NMC 2018) states that registrants must keep up to date in ALL aspects of their practice. Much has changed in aromatherapy since 2013 (indeed, in the last two years) and the context of its use within the NHS has changed too. The law has tightened up, Brexit having required a change to laws and regulations that govern certain aspects of essential oil use.
The NHS is more focused on risk aversion and avoiding litigation than it was in 2013 and several health and safety laws have changed. Medicines management regulation have transferred from individual regulatory bodies to the Royal Pharmaceutical Society. The NMC Code has changed at least twice in this period too, with some clauses having been changed, firmed up or, occasionally, removed. Indemnity insurance issues have also changed and this may also apply to NHS vicarious liability insurance in certain circumstances.
This midwife is in urgent need of updating of her knowledge of aromatherapy in relation to using it in midwifery practice. At Expectancy we recommend updating and reflection on existing practice every two years. This does not have to mean paying for expensive courses – although in this case, I would certainly recommend a full refresher course. However, professional development can be achieved also by many other means. CPD can be achieved by reflecting on situations where aromatherapy has worked well and where, perhaps, it has not been successful or caused adverse effects for individual women, or searching the research literature to ensure you remain contemporary and able to justify your actions in terms of the evidence-base. It is really worrying that midwives believe that a short training course is all they need to incorporate CTs into their midwifery practice - and that is it.
Why do some midwives feel that they do not need to keep updated on aromatherapy, moxibustion, reflexology or acupuncture and that they can just continue to use it in their care of expectant and birthing parents.
These midwives are actually jeopardising their NMC registration and potentially putting parents and babies, as well as staff, at risk.
Denise is often asked by midwives about whether women wanting a vaginal birth after a previous Caesarean section (VBAC) can use complementary therapies and natural remedies to start labour. Obviously these women are desperate to avoid another Caesarean and often try everything they can find to help. Of course, having a nice relaxing massage or reflexology treatment can be good - it reduces the stress hormone, cortisol, and encourages an increase in oxytocin so labour is more likely to start naturally. Hypnotherapy can also help, by encouraging the expectant mum to focus on the positives of the impending birth rather than on the negative feelings about the past Caesarean.
However just because they're natural doesn't necessarily make self-administered natural remedies safe. This applied to all pregnant women but it's a particular risk when those wanting a VBAC start trying every remedy they've heard of - and often all together. More is definitely not better - indeed, using lots of remedies may confuse physiology so much that it actually increases the risk of complications, leading to the need for another Caesarean.
Maternity professionals - midwives, doulas, doctors - and therapists treating pregnant women should advise those trying for a VBAC to:
* have regular relaxation treatments from a suitably qualified therapist who is insured for maternity work
* avoid self-administering castor oil, raspberry leaf tea, clary sage oil, evening primrose oil and other herbal remedies - and NEVER EVER to take them all at the same time
* inform their midwife or doctor about any complementary therapies they've had, and especially any herbal remedies they've taken or aromatherapy oils they've used.
Here, Denise discusses an issue that arose on a recent aromatherapy course in which a midwife reacted adversely to the oils.
During our aromatherapy course for midwives this weekend, one student had a significant reaction to the essential oils, which we finally identified as being caused by frankincense. The student had already told me she suffered with eosinophilic asthma and I had urged her to be cautious but explained that some reactions cannot be anticipated or attributed to specific oils.
As the midwives were deciding on their preferred blends for the practical massage session, this midwife began to experience tightening in her throat and the beginnings of symptoms indicative of an asthma attack. Fortunately, she was able to move to another room and the oils she and her partner had chosen did not seem to affect her so she was able to engage in the practical work.
I have had several other midwives experiencing adverse reactions to oils during courses, some of which have been quite severe. Different oils have been involved including geranium, rose, clary sage, sweet orange, lavender and now frankincense. Indeed, I have witnessed a far greater number of midwives having negative effects from oils in the last five years than in all the years of teaching aromatherapy before that. Another midwife had such a serious reaction to simply sniffing clary sage from the bottle that we thought we would have to take her to A&E (she declined the offer and eventually the effects wore off). Other symptoms have included midwives being violently sick (from geranium) or developing an acute migraine-like headache (after using chamomile). One midwife reacted so badly to the use, by another midwife, of rose hand cream that she had to go home – she later informed us that she was allergic to roses.
I know of several maternity units where midwives with allergies to citrus fruits are unable to use oils such as orange, grapefruit, neroli or other citrus oils. Another unit has not one, but two members of staff severely allergic to lavender, one having been seriously affected when a mother brought her own lavender oil into the birth centre.
I cannot stress enough that midwives must take care when using aromatherapy in their practice, offering it to birthing parents or using it around other staff. The adverse effects can be unpredictable, severe and long-lasting. It is unethical, unsafe and unprofessional to assume that all people exposed to the oils in a birth centre either like the aromas or can tolerate the chemical effects. Get to know your oils and their benefits and possible adverse effects!
Denise is in Portsmouth again this week, teaching aromatherapy and acupressure for postdates pregnancy. Having had a good first day, the course is having to decamp on Tuesday to another hospital due to lack of room availability. The group was due to use a church hall but a last minute change was required when the church rescinded its booking, claiming that aromatherapy and massage did not fit with its religious ideals. Here, Denise reflects on the attitudes towards complementary therapies.
What a shame that we were unable to use the church hall for the second day of our course due to a possible conflict between religious views and what is sometimes still seen as "new age" therapies. Complementary medicine still has to fight its cause on many fronts. Scientists accuse CTs of being poorly evidenced. Purists feel that "alternatives" have no place in conventional healthcare; obstetricians claim they can interfere with medical interventions (true to a certain extent but they may also avoid the need for medical intervention). Managers sometimes reject them because , they say, there is not enough time to use them. Others claim they are dangerous, illogical or are an element of fringe medicine (or witchcraft).
In almost 40 years of practising, teaching, researching and writing about complementary therapies, I have encountered many views and much opposition. People are, of course, entitled to their views, although it is sad that some are based on lack of knowledge and understanding of what CTs are about, how they work and how they can be used beneficially to enhance maternity care.
We hear a lot, today, about different lifestyles, perspectives and views on everything from sexuality to religion to disability to politics. Everywhere there are pleas for greater inclusivity. Why then does complementary medicine continue to be sidelined by the conventional healthcare and scientific communities? Is it not time that complementary medicine was brought in from the cold and considered equally alongside other forms of medicine and healthcare?
I've seen many posts on social media about the deplorable state of midwifery and the maternity services in Britain but I've also seen similar posts from French midwives where midwifery is possibly even more.medicalised.than in the UK. Midwifery is in crisis in the western world - I would say we are seeing the death of midwifery as we know it unless radical action is taken now.
Blame is heaped on the current government yet this situation has been evolving for decades. It's not the fault of one government or one political party. One government can't cure the problems of fifty year's worth of intervention, control and pathologising of childbirth.
Poor pay is also sometimes raised - but you don't go into midwifery or nursing for the money (that argument is for another day but it's not just the UK that pays its nurses and.midwives poorly). No amount of pay increases will bring more people into midwifery training or stop the deluge of departures from those already working in the system.
I believe the problem lies in the culture and attitudes of the system. Midwives are mainly women and although many obstetricians are now female, they too work in a male dominated, paternalistic - and I would say, sometimes misogynistic - culture and often become part of the problem. Historically women have been moulded into "bodies that have vaginas" (as the recent Lancet referred to) and childbirth has become just another medical problem.
I heard only yesterday of a midwife committing suicide, possibly partly as a result of extreme bullying at work by her colleagues and managers. Bullying is rife in the NHS and possibly worst in midwifery - contributing to midwives leaving the profession for a better work-life balance and as.a.way to protect their own mental wellbeing.
Pressures on the maternity services have risen exponentially with increased population and increased complex needs of those using the services - obesity, diabetes, mental health issues and so on. More users bring higher demands and need more resources - including staff. Yet this means that those with complex needs take priority and those whose pregnancies and births are "normal" are left to get on with it - so they feel dissatisfied. More complex needs mean more emphasis on pathology to the extent that we all begin to see childbirth as a pathological condition.
The problems of midwifery are multifactorial and not easily rectiified. My preference would be to return to a community-based profession with individualised continuity of care and carer -but it's not going to happen easily. I believe midwives should adopt the independent midwifery model but this will be difficult in the NHS which exists for the majority and not for the individual. I feel that unless we do something soon, midwives will become obstetric nurses during birth, antenatal care will focus on the biological and not the psychosocial aspects and postnatal care -well, will there be any at all?
I don't know what the answer is because the situation is so complicated but unless we act soon as a united profession we won't have anything to fight for. Long live midwifery.
If you’re wanting to implement aromatherapy into your midwifery practice, what do you need to learn? Here Denise shares a checklist for midwives and doulas preparing to use aromatherapy for labour care. The list can also be applied to the postgraduate study by aromatherapists wanting to specialise in maternity work.
Old Books For New:
Z is for ZuSanLi
Y is for ylang ylang
X is for X-rays
W is for witch haze
V is for Vitex agnus castus
Adjust Your Own Oxygen Mask Before Helping Others
The Business Of Midwifery
U is for Uterus