Denise and her blog

Self-Care For Midwives

There is so much pressure on midwives and the maternity services and midwives are all but burned out. Some are able to leave the NHS and find better job satisfaction and a better work-life balance by working in their own private practice, either as an independent midwife offering full pregnancy, birth and postnatal services, or focusing on antenatal and postnatal care and add-on services such as complementary therapies, lactation support and other aspects of the midwife’s role. However, many or forced to remain in the NHS, usually due to financial and family considerations. And, it must be said, there are some who enjoy their work and remain committed to NHS midwifery despite the difficulties,

However, continuing stress and pressure will eventually take its toll on both the mental and physical wellbeing of midwives.  It is, therefore, crucial to learn how to look after ourselves, both as individuals and as a professional group. You know what they say in the safety briefing on airplanes – “please fix your own oxygen mask before helping others”. It’s the same in healthcare, especially given the current state of midwifery. Midwives rarely manage to take breaks for lunch, a drink or even to go to the toilet. The work is physically and emotionally demanding, the shifts are inappropriately long, and many midwives stay way beyond their shifts to be there for the parents in their care. Families, social life and downtime suffer because midwives are too tired or unavailable. Yes, the “health” service does little to care for its staff and midwives are leaving their posts in droves, sometimes leaving healthcare altogether. It is long overdue to say the time has come to look after the profession and ourselves. Many midwives are too burned out to even have the energy to eat healthily, too strung up to rest and sleep well, and have little time or energy to exercise and get out into the fresh air.

This year, when we welcomed our new students to the Diploma in Midwifery Complementary Therapies and our Certificate programmes in individual therapies, we gave everyone a goody bag which was aimed at looking after themselves. The goody bags contained a reusable water bottle, a stress colouring book and set of crayons, a bar of organic vegan chocolate and a w roller ball with relaxing oils. We also included a link to a free online self-hypnosis relaxation session. In addition to our study days, regular webinars and tutorials, we have now introduced a regular monthly online hypnosis relaxation session, led by my colleague Laura who is the programme leader for our Certificate in Midwifery Clinical Hypnosis. Any of our students and Licensed Consultants (midwives in private practice) can attend as part of their membership of our Expectancy Community. They are well attended, and midwives tell us they value the opportunity to take time out for themselves.

Boundaries Of Midwifery Practice

I attended a fascinating workshop at the Normal Birth Conference in Hong Kong. Two American midwives presented a workshop on managing occipito-posterior (OP) position. They taught a manual manoeuvre that involved internally manipulating the fetal head into a more favourable anterior position. Essentially this is similar to the manoeuvre undertaken by an obstetrician when using forceps. 

Apparently, there is a high incidence of OP position in the units where these two midwives worked and the use of this technique by midwives had reduced Caesarean rates. However, since there is also a 90% epidural rate, it is hardly surprising that the incidence of OP position in second stage is high - the pelvic floor relaxes and fails to provide the resistance needed to aid rotation of the fetal head. Some delegates challenged why the epidural rate was not addressed but culturally, in a very high-tech medicalized system, epidural is - allegedly - what women want.

The discussion that ensued was about whether midwives in all countries represented would be permitted to use this manual rotation. In developing countries with poor access to medical care it could be a lifesaver for both mother and baby. However, in the UK, it is unlikely to be sanctioned by the NMC, when obstetric help is readily available. Two Irish midwives had the same reservations as those of us from the UK.

A Chinese Hong Kong midwife stressed that it would be almost physically impossible to perform the rotation as Chinese fingers are often short - this midwife told us she even has difficulty in reaching a posterior cervix during vaginal exam. The rotation technique requires the midwife's hand to be inserted fully into the vagina in order to reach round the fetal head.

 This workshop caused me to reflect on the boundaries of midwifery practice in different countries around the world. In developed countries we have the luxury of being able to attend to the psycho-social aspects of pregnancy, birth and early parenthood - although I believe this is increasingly at the expense of midwives fully understanding and applying the biological aspects to practice (more of that In another blog post). In developing countries, failure to recognise deviations from physiological progress can be fatal, and there is less focus on the social and mental health aspects of childbearing. 

 Back in the UK, it is interesting to see how many midwives are moving into fertility care (often, it appears, to enable them to leave the NHS). Whilst the WHO definition of the midwifery role encompasses fertility health and preconception care, it is not a standard element of midwifery practice in the UK. Similarly, miscarriage and abortion care is defined as within the remit of midwifery although it more commonly comes under gynaecology in the UK.

 At Expectancy, we have expanded the boundaries of practice of our "endorsed by Expectancy" midwives in private practice to enable them to offer services to women from the preconception period to the end of the first year following birth (subject to training and insurance). Many of our Licensed Consultants now provide fertility health consultations, Caesarean scar therapy and ongoing care and complementary therapies beyond the early postnatal period. They are not permitted to provide infertility care nor can they take on new clients who are more than eight weeks postnatal - they must work within the UK boundaries of midwifery practice. Since very few of our team are providing independent birth services, it is unlikely they will be in a position to have to make a decision about using the manual manoeuvre to turn a baby in the OP position to anterior. In any case they would be far more likely to have addressed this earlier with biomechanics and Rebozo.

Commitment to Learning: A Rant About Education!

Why is it that so many student midwives and nurses seem to want to do the basic minimum of study simply so they can pass the exam or scrape through to qualification? This is a growing problem,  not just in healthcare professions and not just in the UK. However it is extremely worrying that those entering midwifery and nursing seem not to appreciate that they will be responsible for people's lives. My partner, a university lecturer in anatomy and physiology, is constantly asked by nursing students "what do we have to learn for the exam?" who then seem surprised when he says " everything! " 

I wonder how comfortable these students would be if one of their relatives was in hospital being cared for by doctors, nurses or midwives with only half the knowledge relating to their particular condition. Any profession has a deep theoretical basis to support practice, including knowledge and understanding that may not be "needed" for everyday practice but may be essential at some point in the future to saving someone's life.

There also seems to be an undercurrent of student midwives struggling with the theory and developing the practical skills of the profession. Look - I know that things in the NHS are dire. I know there is unacceptable bullying especially towards students. I know we have large numbers of students with major personal or family health or social issues. But I'm sorry to say - if you can't stand the heat, get out of the kitchen. I know also that many readers will vilify me for this comment but - whether we like it or not - this is the current culture into which students are entering and we need them to be strong enough to challenge that culture and to help initiate change. We also need a profession - one that is currently threatened from all sides - that can continue to maintain its individuality. If we don't have expert midwives with comprehensive knowledge and refined skills, we are in danger of losing the profession or just becoming obstetric nurses.

Another issue is the expectation that once having learned something as a CPD activity, midwives can cascade their training to others - and often by using their own course notes and copyrighted teaching materials from their initial course. This is a real problem since we know that learners only retain around 60% of what they study, so cascade training causes a natural dilution when they pass it on to others who then only retain 60% of what they are taught. Yet not only clinical. midwives but also their managers condone this approach to learning - perhaps because it is quicker and cheaper to train up a group with sub-standard education than to pay for everyone to receive the training provided by quality educators. This occurs when managers don't appreciate the depth required for safe practice - and is a continuing issue when I go to NHS trusts to teach aromatherapy to midwives.

And then there are those who think they can have access to learning materials free of charge. I recently saw a post on another Facebook page where a friend of mine had been to a legal study day and someone asked if there were any slides or handouts - my friend's reply was "only if you've paid for it!"  Both she and I are freelance lecturers whose livelihood depends on the income from our training. You wouldn't go into a shop and not expect to pay for goods you want  - so is this attitude because education is not valued or respected?  Again, it's not only in the healthcare professions that this occurs, it seems to be a general issue, maybe because so much information is available free of charge via the internet. Copyrighted materials are not respected, yet people don't realise that these materials are protected by the law -  basically they're stealing someone else's work.

That brings me on to AI. So many students are now using artificial intelligence to write their assignments that university lecturers are having to do the same and then put the AI-produced work through TurnItIn which checks for plagiarism. Only in this way can they check students" work to see if they've used AI.

So .... back to my original rant about commitment to learning. If you want midwives, nurses and other professionals who know only half what they need to know in order to practise safely, then let them be told the exam questions so they know what they need to revise. Let them use AI for their essays so they can achieve a good. Degree based on someone else"a work.. Let's send one person on a course who can then use their limited new knowledge to train up everyone else. Let's undermine the quality of learning in general by making everything free and accessible to anyone who wants to steal the work of others by infringing copyright law. And - let's face it - you can buy a PhD in the USA so why don't we just do that as well.?

Rant over!! 

International Labour and Birth Research Conference in Hong Kong

What an incredible experience I had at the International Labour and Birth Research Conference in Hong Kong!

From reconnecting with familiar faces to meeting inspiring new colleagues, it was a whirlwind three days packed with insightful lectures and hands-on workshops.

I explored everything from the latest in birth technology to innovative techniques for supporting fetal positioning—and, of course, I had my own workshops on complementary therapies for postdates pregnancies.
The conference was beautifully organised, with speakers exceptionally well looked after.

To top it off, I enjoyed a fabulous 13-course Chinese banquet for the conference dinner last Tuesday!

Thank you to everyone who made it such a memorable event. Here's to bringing these insights back home and continuing my journey in supporting physiological birth!

Diagnosis and Professionalism in Reflexology

I recently saw a Facebook post on a reflexologists’ page, in which an obviously inexperienced therapist was querying why expectant mothers should not lie flat on their backs at 39 weeks’ gestation. Whilst it is worrying that she did not understand and possibly had not undertaken specific training on working with pregnant clients, the responses from her colleagues were even more worrying. Many (although not all) did not seem to appreciate the impact of supine hypotension on maternal and fetal oxygenation, nor did they fully understand safe positioning to avoid not only resulting dizziness and fainting but also how to avoid excess strain on the spinal muscles and ligaments and the symphysis pubis. Another post, a few days earlier, - of a type which I see frequently – was the group’s attempt to make a diagnosis from a photograph of a client’s feet. There were some extremely worrying comments, with therapists jumping to conclusions about possible medical conditions which they had “recognised” from the picture, with no other history available. Even more concerning were the comments about how reflexologists might actually treat this person, based on their so-called diagnosis.

As a midwife for over 40 years, a clinical reflex zone therapist for 35 years and having treated almost 6000 pregnant clients, I am alarmed by the attitudes of these practitioners, which showed little knowledge and understanding of the physiology and possible pathology of the client in question. I have no doubt at all that it is possible to examine the feet visually and via palpation, as well as taking into account the reactions of the client in terms of areas of tenderness and pain in relevant reflex zones on the feet. I have, myself, often seen or felt variations on the foot reflex zones that indicate changes in physiology or impending pathology, and my main interest in the therapy is its diagnostic potential. For example, I have undertaken formal research whilst at the University of Greenwich in the 1990s, to show that it is possible to predict stages of the menstrual cycle from an examination of the feet zones relating to the pituitary gland, ovaries, fallopian tubes and uterus – I have around a 70-75% success rate in so doing. I teach this in my courses for midwives and lead on to teaching how they can estimate the onset of labour, using the same theories.

However, a clinical diagnosis is achieved from a complete assessment of the client, including taking a comprehensive medical (and obstetric) history, ascertaining the current signs and symptoms, then a visual examination and thorough palpatory examination of the feet. Having drawn some conclusions, it is then essential to understand the physiopathology behind the assumed condition and to work out whether or not reflexology is an appropriate treatment to reduce the severity of symptoms, rather than resolving the condition. More often than not, medical conditions are a contraindication, even for a statutorily regulated health profession, and certainly for a reflexologist who is not a clinician.   I am sure the injudicious attempt to work out what is happening and how reflexology may be able to help people with specific medical conditions arises from a compassionate but misplaced enthusiasm to help people.

If we want reflexology to be seen as a credible therapy with underpinning theory and evidence-based practice, practitioners MUST acknowledge the boundaries of their personal practice. These parameters may be different in different therapists due to their training and experience, but it is fundamental to professionalism to know when not to treat as much as it is essential to understand how to treat someone. This certainly applies to working with pregnant clients – and it is usually a post-registration training and qualification to be eligible to treat pregnant and newly-birthed women. For someone working with a client at 39 weeks of pregnancy and not to understand the most basic principle of positioning is obviously due to lack of, or poor, training and the fact that she was still about to treat the client is bordering on negligence. Further, I would assume that if she did not know this, she would certainly not be prepared to deal with any emergencies that might arise such as the woman having a rapid labour resulting in a precipitate birth whilst in the consulting room, or her waters breaking and the umbilical cord prolapsing.

Guidelines On Herbal Remedies In Pregnancy 

The term “natural remedies” refers to herbal remedies, herbal teas, aromatherapy essential oils, homeopathic medicines, plus traditional (indigenous) medicines, whether sourced from plants, minerals or animals.

• All natural remedies should be treated with the same respect as pharmaceutical drugs.

• “Natural” does not mean that all remedies are safe, or safe for everyone, particularly during pregnancy and childbirth.

• Natural remedies should not be used as a replacement for proven medical treatment, especially in the event of an emergency. 

• Expectancy parents should be advised to avoid ALL natural remedies, including aromatherapy oils, 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 if they are using any remedies, especially herbal medicines and aromatherapy oils and again as they prepare for the birth, especially if they are desperate to avoid induction of labour. 

• Advise parents that not all remedies are approved, regulated or evidence based. Remedies 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 remedies, including adverse effects such as allergies and interactions with prescribed medications, foods or other remedies.

• Advise women against combining several different NRs / complementary therapies: take only one remedy at a time, particularly at term when trying to avoid induction.

• Natural remedies are completely contraindicated for pregnant women with major hepatic, renal, cardiac and neurological conditions and cancers of any type, irrespective of whether they currently require pharmaceutical medications. 

• Anyone taking medically prescribed drugs, by whatever route of administration, should be strongly advised against using NRs at any time.

• Midwives should be alert to the possibility that deviations from physiological progress in pregnancy or labour may be linked with undisclosed use of natural remedies.

• Women admitted to the antenatal ward have, by definition, pathological complications requiring medical attention and should avoid self-administering all natural remedies. It is not appropriate for midwives and doulas to advocate natural remedies for these women or to use essential oils for aromatherapy in the antenatal ward area.

• Women should be advised to discontinue all pharmacologically active herbal and traditional medicines at least two weeks prior to elective surgery or dental extraction to reduce the risk of excessive bleeding. Anaesthetists and dental surgeons should check whether women have continued to use remedies immediately prior to surgery, many of which may have an adverse effect on blood clotting. 

• Medical, midwifery and health visitor pre-registration education and doula and antenatal teacher preparation should include an appropriate introduction to the safe use of natural remedies in pregnancy and childbirth that balances benefits and risks. 

• There is an urgent need for more research on natural remedy safety, although not all modalities can be studied using a randomised, controlled, blinded approach.

Midwives, did you know? 🌿

If a pregnant woman needs to change from her pre-pregnancy antidepressant, the popular alternative remedy, St. John's Wort may not be a safe alternative.

This herbal remedy works in a similar way to some antidepressants and can carry similar risks during pregnancy.

Always advise your clients to consult with their midwife or a qualified herbalist before considering St. John's Wort. (NB always midwife before doctor!!)

Keeping both mother and baby safe is always the top priority!

This week is World Reflexology Week!

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

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

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

Complementary Therapies and The M25 

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

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

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

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

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

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

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

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

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

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

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

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

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

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