Denise and her blog

Published : 16/07/2024

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.


Published : 13/07/2024

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.

 


Published : 30/06/2024

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.


Published : 25/06/2024

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!

 


Published : 12/06/2024

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 17th 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.


Published : 11/06/2024

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!

 


Published : 10/06/2024

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.


Published : 25/05/2024

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)


Published : 13/05/2024

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.


Published : 04/05/2024

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 20th 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 28th September 2024.


Published : 02/05/2024

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. 


Published : 01/05/2024

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)


Published : 16/04/2024

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.


Published : 14/04/2024

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. 


Published : 08/04/2024

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.

 


Published : 04/04/2024

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

April 4th 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 20th anniversary on September 4th 2024 – watch this space for more about that later in the year.

 


Published : 02/04/2024

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.


Published : 18/03/2024

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.


Published : 11/03/2024

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


Published : 06/03/2024

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.


Published : 03/03/2024

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.


Published : 27/02/2024

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


 


Published : 24/02/2024

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


Published : 22/02/2024

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).


Published : 20/02/2024

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/


Published : 19/02/2024

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


Published : 12/02/2024

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/

 


Published : 07/02/2024

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.

 


Published : 05/02/2024

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.

 


Published : 02/02/2024

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!


Published : 31/01/2024

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).


Published : 29/01/2024

In Japan

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

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


Published : 28/01/2024

Some Amazing Pregnancy and Birth Facts

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

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

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

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

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

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


Published : 27/01/2024

In Japan

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

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

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

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


Published : 20/01/2024

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

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

 

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

 

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

 


Published : 15/01/2024

Less Is More: Complementary Therapies for Postdates Pregnancy

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

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

 



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


 

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



Published : 14/01/2024

Have You Set Your Professional Goals For 2024?

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

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

 


Published : 13/01/2024

Impact of Aromatherapy Oils on Midwives

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


Published : 10/01/2024

Herbal Medicines Considered Unsafe For Use In Pregnancy

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

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

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


Published : 06/01/2024

Take Your Shoes Off !

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


Published : 05/01/2024

Pregnancy Sickness Causes 

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

 


Published : 21/12/2023

More Criticism of Complementary Medicine

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

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

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


Published : 15/12/2023

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

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

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

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


Published : 03/12/2023

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

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

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

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


Published : 01/12/2023

Differences Between Midwifery Training Standards in The 1970s and Today

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

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

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

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


Published : 22/11/2023

Midwifery Aromatherapy Under Scrutiny

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

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

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


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

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

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


Published : 21/11/2023

A Conundrum ?

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

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


Published : 17/11/2023

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 is 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)


Published : 16/11/2023

Postdates Pregnancy

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











Published : 15/11/2023

Denise and Amanda’s Week

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

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

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

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

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


Published : 24/10/2023

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

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


Published : 23/10/2023

Why Do Expectant And Birthing Parents Turn To Complementary Therapies?

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


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


Published : 21/10/2023

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

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

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


Published : 19/10/2023

Surreal conversation

Surreal conversation during our midwifery aromatherapy course recently:

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

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

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

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

Midwife 2: to prepare him for hibernation

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

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

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

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


Published : 14/10/2023

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

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

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

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


Previous articles

Annual Networking Day

My Favourite Aromatherapy Oils

The Conveyor Belt Of Childbirth

Best Foot Forward: Teaching Reflexology In Hong Kong 

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

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

It’s Aromatherapy Awareness Week!

Making The Move To Starting Your Own Maternity-Related Business

What Is A Practising Midwife?

The Power of Reflexology: Predicting Stages of the Menstrual Cycle