Here Denise discusses the ethical and physiological issues relating to the misuse of fragrance.
There is increasing concern amongst the scientific and medical communities about the general public's progressive over-exposure to chemicals. We are bombarded by chemicals in our cleaning products and air freshers, food preservatives, fuel and industrial pollution and fragrances, including perfumes, scented candles and bath products. We smell aromas in shopping centres, restaurants and even in the workplace. Many of these aromas are pleasant, positive and beneficial, lifting our mood; others are not. Professionally, aromatic essential oils can be extremely therapeutic when selected appropriately, each oil having various therapeutic properties depending on the chemicals within them. Expectant parents frequently use aromatherapy oils to relieve the symptoms of pregnancy, and many midwives now offer aromatherapy to relieve pain and aid progress in labour.
However, increasingly, people are experiencing adverse effects from inhaling chemicals contained within the aroma vapours, from any source. Repeated exposure to a particular fragrance or even a single chemical in an oil has a "drip-feed" effect which can eventually lead to serious consequences (we can liken this to the effects of something like a seafood allergy which can eventually cause anaphylactic shock - susceptible people usually carry "Epi-pens" to counteract the effects quickly). In my 35 years of teaching aromatherapy to midwives, I have seen more adverse effects in the last ten years than in the 25 years before, suggesting either that, for some reason, people are more sensitive to aromas and chemicals, perhaps due to their individual susceptibility, or their health status, especially with the massive over-use of chemicals in general. I have observed some serious effects on midwives exposed to essential oils of orange (often occurring in those with a known allergy to citrus fruit such as oranges and grapefruit, or to grass seed), rose and geranium (which share some similar chemicals known to affect some people adversely) and clary sage (from both a direct allergy and, more often, from over-use in labour). Effects include skin irritation, even when inhaled, nausea or hay fever or asthma attacks. This latter is not necessarily through exposure to a direct respiratory allergen such as pollen (which does not occur in fragrances and essential oils), but more commonly from a psychosomatic memory effect from previous inhalation of flowers such as lavender, ylang ylang and chamomile. I have personally had some negative experiences from inhalation of aromas, both in my own work using essential oils for many years and in shops selling scented candles.
Whilst many fragrances are pleasant and uplifting, at the very least, others will be disliked by some people. It may be acceptable to brew coffee when trying to sell a house, but I have to question the ethics of increasingly using scents to promote commercial sales, whether in the travel industry or elsewhere. I am particularly concerned to read in this article that some airlines are using fragrances which contain common allergens, such as rose and citrus oils. I challenge airlines to consider the legality of exposing everyone going through the airport lounges and ask whether they have policies in place to deal with anyone who develops an allergic reaction, which could be severe, when inhaling aromas to which they have a known allergy.
The problem with aromas is that, in general, people like them and fail to understand the way in which the chemicals in the oils can affect individuals. Many years ago, when I first trained in aromatherapy, there was a trend in some American hospitals to diffuse aromas in the medical wards - for example, an uplifting, calming oil in the reception area, stimulating oils in the mornings and relaxing and sedating oils in the evenings, while Japanese factories in the 1980s pumped oils such as lemon through the ventilation system, to increase productivity. Sadly also, despite many years trying to educate midwives about the risks as well as the benefits of aromatherapy, there are many maternity units and birth centres today that injudiciously diffuse essential oils in public areas where numerous expectant and birthing parents, their babies and visitors, as well as all the staff are repeatedly exposed to their chemicals.
Within any institutional settings - such as hospitals and other areas where the general public pass through and staff work - blindly using fragrances contravenes the UK Health and Safety at Work act and the Control of Substances Hazardous to Health (COSHH) regulations. This is not ethical, nor is it safe. It is an accident waiting to happen - both in the airlines and other commercial settings and in the health services.
Recently Denise met some of her Licensed Consultancy midwives at our monthly online problem-solving networking meeting. Some were already in business, having completed Expectancy’s Diploma and business training, others had taken a break during the pandemic and were getting back on track with their business planning and some were just completing their academic studies and preparing end-of-year assignments. We discussed how to promote our private practices – and what not to do. One of the group had reported last month on how “well” she was doing, drawing pregnant clients in for complementary therapy treatments – but at a knock-down price. After some discussion and reflection she went back to the drawing board and formalised her pricing structure. This resulted in her increasing her prices to an appropriate level, which meant that prospective clients valued her services more – and she was able to value herself more too. This is an important concept to get to grips with in business – if you don’t value yourself, your clients won’t value you or your services.
Recently, Denise had a busy day teaching student midwives. The first session was for students at the University of Bournemouth. This was a general introduction to complementary therapies in midwifery practice with a focus on aromatherapy, as part of the students’ medicines management module. She then rushed to the University of Greenwich for a session with students taking the labour care module, exploring aromatherapy, reflexology, acupressure and hypnosis for birth preparation and techniques for aiding labour progress and easing discomforts and anxiety.
Denise says: it was lovely to be with so many of the students, both online and face to face, and to offer them an introduction to the vast specialism that is midwifery complementary medicine. As always, many students were shocked by the issues they need to consider when advising parents on natural remedies or when midwives want to implement aromatherapy and other therapies in their practice. We particularly considered the fact that essential oils, which work in exactly the same way as drugs, must also be used along the same lines as medicines. Expectant and birthing parents wanting to use aromatherapy oils should be assessed to ensure it is safe for them to do so and observed for any side effects that may occur; blends must be individualised and confined solely to that individual – no wafting aroma vapours along the corridor and no diffusers in public areas. Aromatherapy treatment must be evaluated and recorded in the notes together with any specific aftercare advice given. In accordance with the post-Brexit Cosmetics Regulations 2020, oil blends cannot be given to parents for home use unless this first consultation and treatment has been undertaken by the same midwife.
Denise was in Norwich again this week running some self care sessions for the midwives, students and support workers.
It’s so important for maternity staff to look after themselves - as they say on the airlines - please attach your own oxygen mask before helping others.
If maternity workers are stressed and tired that’s passed on to expectant and birthing parents. Congratulations to Head of Midwifery, Stephanie Pease for thanking the hard working staff and giving them some Me Time.
Here, Denise explores issues raised at the University of Surrey's Midwifery Society conference on Friday, which focused on diversity issues in perinatal care.
This student midwife conference handled a topical, sensitive subject well and provoked much discussion. Sessions on race, LBGTQIA+, disability, asylum seekers and other groups who experience discrimination during pregnancy and birth were not always easy listening but certainly caused a degree of personal reflection. Each speaker was passionate about their topic, being representative of the group about which they were speaking and able to recount their lived experiences.
There was a lot of emphasis on midwives using the "right" language and how we may inadvertently use words which could offend or upset people who do not fit into the "normal" mould (whatever that might be). A humorous but moving account was given by Diana, a Bolivian asylum seeker who only spoke Spanish, of her time in labour.An English midwife, trying to be kind, kept giving her hot chocolate to drink. Diana, trying to be polite and not sure how to decline it, would drink the hot chocolate even though she didn't like it. The midwife, assuming that Diana had enjoyed it, kept offering here more - and Diana's overriding memory of her labour in a UK maternity unit is one of hot chocolate which she now hates.
However, it was the final speaker who summed up the nub of all the issues. Abina Brown spoke about "birthing outside guidelines" and how maternity professionals "deal" with parents who choose to go against convention. Surely our role as midwives is to guide each parent through their childbearing experience irrespective of which category they best "fit". Whether we are giving dietary advice to people from another culture, asking transgender women what pronoun they wish us to use or how to communicate compassionately with a non English speaking asylum seeker, there are two fundamental issues here: understanding and individualisation.
Guidelines are NOT in the interests of the individual parent. They are not even there to protect the midwife.Guidelines are devised to protect the institution (the NHS), save money and avoid litigation - and sometimes do more harm than good for parents. Take, for example, the guideline on induction of labour in postdates pregnancy - the attitude that refusing induction may kill a baby is a powerful form of coercion for all, except the most assertive parents (who are then viewed as "difficult patients").
It is, however, easy to act in ways which others may view as discriminatory. How many midwives make assumptions about women who don't fit the traditional mould? Many will have heard colleagues say (or said it themselves) things like "oh she's got red hair, she will be more at risk of a postpartum haemorrhage"? Our assumptions affect our behaviour - about women who are obese, requesting a home birth after previous Caesarean or who are from the traveller community. We can discriminate in ways we don't realise because midwives are part of a society that takes a negative view towards those who are not the same as us. Other examples of negativity towards our clients are parents who choose unassisted birth against our advice, those who have ten children and are pregnant again, women who want to birth in the woods with whale music playing - anyone who sits outside our own view of what is "normal"
Yes, we need more education to understand people whose culture, race, language, sexuality or identity we do not understand, but more than that, we need to return to the basic tenets of being a midwife - to learn to care for the INDIVIDUAL. This has definitely been lost from midwifery education and practice because we are too busy form filling and trying to avoid litigation. Independent midwives have never had a problem.in caring for anyone who is "different" because every parent is seen as an individual with their own set of beliefs, needs and desires for the birth of their baby. Let's get back to true midwifery, forget the guidelines and care for each pregnant and birthing parent as an individual.
One of the biggest advantages of offering complementary therapies in private practice is that clients are given the time they need.
In some respects, it almost doesn't matter which therapy is used - it is the overall experience of having someone to talk to, who can explain things and answer questions, who they can come to know and be assured that they will see again next time.
Let us embrace the value of complementary therapies in helping expectant parents to cope with pregnancy and even to enjoy it as they prepare to bring new life into the world.
Denise has been seeing a lot of posts on Social media recently from students offering their used midwifery textbooks for sale at the end of their training. Here she explores the issues around academic reading and keeping up to date.
It’s that time of year when students are coming towards the end of their three year pre-registration midwifery programmes – and when those about to start midwifery training excitedly start preparing. Part of this preparation is thinking about which textbooks to buy. The two traditional UK midwifery texts are Myles’ Textbook for Midwifery and Mayes’ Midwifery, to both of which I have contributed chapters on complementary therapies on many occasions over the various editions. Another staple is Bailliere’s Midwives’ Dictionary, which I have edited every three years since 1997 and have just finished the 14th edition (Tiran, Redford 2022). However, there is such huge diversity within the modern midwifery profession, including obstetrics, physiology, psychology, sociology, research methods, obstetric emergencies and many contemporary issues, that there is a dizzying selection of textbooks, some of which cost up to £50 or more.
It is therefore understandable that students who have purchased their own copies may want to sell them on to incoming students. However, I am concerned that some books posted for sale on social media are extremely old and have been replaced with more recent editions. I recently saw a copy of the 11th edition of the Bailliere’s Midwives’ Dictionary (2009) for sale at £10, only marginally less than the latest edition which contains many new terms and more socially acceptable definitions. Another student was selling a 2011 copy of Obstetrics by Ten Teachers, despite it having been updated six years later. Some of the books are so old that they could be kept as historical texts - and prove very interesting to compare practice years ago with how it has evolved today.
However, whilst some books remain useful for new learners, many become out of date quickly. Remember that a newly published book is often already 18 months old or more by the time it is available for sale, since the writing of it and the publication process take considerable time. My advice to incoming student midwives (despite being an author wanting you to buy my books!) is just to buy one recent comprehensive textbook (either Myles’ or Mayes’) and the dictionary – and then wait to see what is available in the university library. You may develop an interest in a specific aspect of midwifery such as breast feeding, genital mutilation, genetics or complementary therapies, in which case you can look for the most recent academic textbooks on those specialisms. You could consider sharing books with a group of colleagues to enable you all to access both general midwifery and specialist texts. You could ask for Christmas or birthday presents for those you feel you would like to own. You may find cheaper versions of some books as digital copies. Bear in mind that many of the books you purchase for your own course will be out of date by the time you qualify and may not, therefore, be suitable for students coming along after you.
Books are wonderful, especially when you own a pristine hard copy, but it is essential to keep up to date. Not only could you lose assignment marks by referring to an old edition, it could also mean you are not up to date in your practice.
If you are lucky enough to own a previous edition, especially one that is more than 20 years old, keep it for posterity, but make sure your theory and practice are based on the most up to date editions.
The beautiful blue flowers are sometimes added to cocktails. More importantly, borage contains significantly more gamma linolenic acids, one of the primary therapeutic constituents, than evening primrose oil.
Both EPO and borage are traditional remedies to start labour although evidence for effectiveness is limited.
Care should be taken with borage as it can cause liver toxicity in some.
Z is for ZuSanLi, an acupuncture point also called Stomach 36. It is situated about four finger-widths below the bottom edge of the kneecap, between the two bones of the lower leg. In pregnancy it can relieve nausea, constipation, carpal tunnel syndrome, anxiety and aid birth preparation. It is useful for aiding progress in labour and postnatal recovery. Stomach 36 is one of the 15 points taught on Expectancy’s Certificate in Midwifery Acupuncture programme – we are now recruiting for September.
Y is for ylang ylang, (Cananga odorata), a wonderfully relaxing essential oil that is safe to use in pregnancy and birth. It can have strong sedative effects so should not be used for too long, and midwives caring for parents in labour who wish to use it should take regular breaks and keep hydrated to ensure they are alert enough to make clinical decisions (and drive).
It is very good for postnatal blues but caution is urged if there is a history of diagnosed clinical depression, as the effects can be so deep that the emotions can almost be pushed inwards, compounding the problem. The aroma is deep and floral but can be heavy and cloying for some people so use in small doses and for short periods of time.
In the home, ylang ylang should not be used near neonates, elderly relatives or animals (it is toxic to cats and dogs).
X is for X-rays – one of the sources of energy that can inactivate homeopathic remedies. Since homeopathic medicines are chemically very fragile, they can be easily inactivated by X-rays, mobile ‘phones, televisions and microwaves. Never store your homeopathic arnica and other remedies near electrical sources in the home – and take care when passing through the airport if you have homeopathic jetlag remedies with you.
W is for witch hazel, a common herbal remedy used for perineal healing after birth. However, witch hazel should not be used on an inflamed or infected wound. It can be useful for haemorrhoids after birth as it has an astringent effect, causing vasoconstriction, although the research evidence is poor. Witch hazel should not be taken orally.
V is for Vitex agnus castus - This herbal remedy, also called chaste berry, is a popular remedy for menopausal problems and is also used for infertility treatments. However, it should not be self-administered orally in the preconception period, pregnancy and when breast feeding, unless on the advice of a qualified medical herbalist. There is some suggestion that the plant hormones may compromise implantation of the embryo in early pregnancy. These also increase dopamine activity which blocks the production of prolactin, so it may affect lactation. Topical use of the cream appears safe.
Denise has been in Glasgow this week for various meetings. Flying from Heathrow, she reflected on the pre-flight safety briefing, including what to do in the event of reduced oxygen in the cabin, and related this to our work as midwives providing care for expectant and birthing parents. She says:
Midwives work incredibly hard in difficult circumstances, with inadequate staffing and long hours, often without time for a break, even a drink or visit to the toilet. Yet how can we expect to care for families if we are not fit, healthy and refreshed ourselves? Midwives become dehydrated, ketotic and exhausted which leaves them in no fit state to care for people. Put this in the context of the institution for which they work, with its dependence on risk avoidance and the pressures of an immensely punitive culture, and the stress on midwives and other maternity care providers is immense..It is hardly surprising that midwives are leaving the NHS in droves.
Isn't it about time we started looking after ourselves first? We need to praise and thank the midwifery workforce, not bully them into being a mechanistic corporate set of hands blindly doing the job. We.need to facilitate midwives and support workers to give mindful care that not only helps service users but also leaves service providers feeling fulfilled and valued.
One NHS trust has recently asked me to provide a series of half day relaxation events for its staff, to thank them for their efforts and to give them something back to show that they are, indeed, valued. Engaging in some rostered "me time", with relaxation to music, massage and time to chat over a cup of tea and cake can do wonders to boost morale. Offering a metaphorical "oxygen mask" goes some.way towards helping midwives and support workers feel appreciated and to revitalise them so they are in a better state to provide quality and caring support to parents and babies.
Denise recently interviewed a midwife for our Diploma who had just completed a Master's in Business Administration (MBA). Discussion turned to some of the issues plaguing the NHS and her insight into midwives’ lack of knowledge of the business of maternity care. Denise reflects on her conversation:
Midwives seem to have little concept of how the NHS works or how much everything costs.
For example, the difference in cost between a spontaneous vaginal birth and a Caesarean section is around £2000; an epidural costs at least £850; even the comparative pennies needed for a urine sample bottle or a pack of gauze swabs add up to a multibillion pound NHS.
A trial was done some years ago in a London surgical ward in which the prices of NHS equipment were listed on cupboard doors. Increased awareness of the nurses led to more mindful use, less wastage and considerable cost savings. I find it fascinating when teaching business studies to the midwives preparing to set up their own private practices via our Licensed Consultancy scheme to hear their views on money - costs, pricing and savings. One midwife recently told me she would be charging just £35 for an hour's complementary therapy treatment in her private practice. This was way below the average price of a pregnancy massage in her area. Further, she had not considered the money she had already spent to get to the point of starting her business - training and experience, NMC registration and revalidation, insurances, equipment and the costs of starting and running her business. She was, in effect, giving her services free of charge - and actually paying to provide them. It is interesting that independent midwives do not have the same reticence talking about their fees as midwives working solely in the NHS.
Asking people to pay for their services is not a problem. Indeed, it is the only way an independent midwife is paid. NHS midwives do not give their time free of charge – so why is there such a negative feeling about asking expectant parents - who have consciously chosen a private option – to pay the fees for services provided? No one would expect to go to the hairdresser or massage therapist without paying for their expert services – so why do we have a mindset that finds talking about “money” distasteful?. I believe that midwifery and all healthcare pre-registration programmes should include a mandatory module on the business of healthcare.
If NHS staff understood how much everything costs, there would be less wastage and savings would contribute to a more balanced use of NHS limited budgets. For midwives going into private practice, it would be wise to study business matters before commencing to avoid costly mistakes – professional and legal as well as financial.
A greater understanding of the business of maternity care would contribute to a more successful business.
U is for uterus. In foot reflexology the point for the uterus is on the inside of the heel. Many people think it's acceptable to massage this area to stimulate contractions, but it's not. Uterine contractions start in the pituitary gland so to aid labour requires stimulation of the reflex points for the anterior and posterior pituitary gland on the side of the big toes. Over-stimulating the uterus reflex points on the heels can disrupt labour physiology and, in extreme circumstances, may even cause placental separation and bleeding.
T is for “Therapy shopping”. Some people, when desperate to resolve a problem, try every complementary therapy they can find, in what is often called “therapy shopping”. It is not helpful to use several different therapies or natural remedies together as this can “confuse” physiology and often make things worse.
Expectant parents desperate to avoid an induction of labour may do this, trying all the herbal remedies they can think of, including clary sage, raspberry leaf, castor oil, as well as eating pineapple, dates and mangoes and consulting a reflexologist, acupuncturist and/or aromatherapist. Midwives and doulas should encourage parents to try just one thing at a time (although don’t leave raspberry leaf until term) unless under the direction of a fully qualified practitioner of complementary therapy who can balance the combination safely.
S is fo r syntocinon. If expectant parents need intravenous oxytocin they must not use oils or herbal remedies with similar effects. This includes clary sage, jasmine, rose, cinnamon and nutmeg oils, raspberry leaf, evening primrose, black and cohosh other herbal remedies.
Care should also be taken when vaginal pessaries of prostin are used to start labour especially if the woman is at home.
R is for raspberry leaf tea, a popular herbal remedy to time the uterine muscle in readiness for labour. If appropriate, it can be taken during the third trimester, gradually increasing to about 3-4 cups a day, then gradually reduced in the first two weeks after the birth. Raspberry leaf is not a means of starting labour - suddenly commencing it at term may lead to excessive contractions and possibly fetal distress.
Q is for quiet. Never underestimate the value of silence during a birth or when providing complementary therapies in pregnancy or after the birth. Music can be useful sometimes but there's a lot of psychology relating to using the right type of music. Quiet allows the birthing family to go into their own zone, to tune out the extraneous noises of the world and to focus inwardly in preparation for their new arrival.
P is for the Pericardium 6 (P6) acupuncture point, which is a useful point to combat nausea in pregnancy or labour or after Caesarean. Pressure can be applied with the thumbs or fingers, or a wristband can be worn; tiny press studs can also be taped to the point, which are almost unnoticeable. To find the P6 point measure three finger widths up the inside of the arm from the wrist crease - approximately where the buckle of a wristwatch might be. The point is found as a small dip between the tendons.
An interesting study has emerged from Australia and New Zealand about the ways in which information is disseminated and practice is influenced for acupuncturists involved in women's health. Here Denise explores the wider implications of the findings.
Acupuncture is a very popular adjunct to women's health, notably in the areas of fertility and pregnancy. It is perhaps even more popular in Australasia than the UK and USA although acupuncture is one of the most well accepted of all complementary therapies. This may be due to the level of training required, which is almost exclusively at graduate and postgraduate level. It may be because acupuncture is better regarded by conventional medical practitioners than other, more supportive therapies such a massage, and indeed is used by some anaesthetists as a means of pain control. Acupuncture is also very well researched, although this study suggests that practice is defined less by the evidence and more by collaborative information-sharing from conferences and other educational opportunities.
Referrals for acupuncture prior to and during pregnancy generally come from prospective clients, with some from doctors. However, there is a need for much greater awareness amongst conventional healthcare professionals of the benefits and effectiveness of acupuncture.
Midwives and obstetricians in particular should be better informed about the potential of acupuncture to resolve issues such as subfertility, and severe pregnancy back pain, sickness or breech presentation. Dealing with these issues by offering acupuncture treatment would reduce the complications and associated cascade of intervention that they bring. This in turn would save money for the health services and improve parental satisfaction and wellbeing.
At the very least, midwives and obstetricians should receive an introduction to the concept, effectiveness and evidence base of acupuncture during their pre-registration education, to increase their awareness and understanding of the therapy. Further, for those midwives with a special interest, being able to introduce an acupuncture service into their practice or place of work would further facilitate an improvement in care for those expectant parents suffering prolonged and intractable pregnancy symptoms which can impact on the progress and enjoyment of their whole pregnancy.
Denise recently read an article in which the use of essential oils was debated as a possible adjunct to restorative clinical supervision by professional midwifery advocates (PMAs). The author, a midwifery lecturer, rightly addresses aromatherapy safety issues but concludes that NHS trusts could consider the use of diffusers to assist in boosting staff mental wellbeing, especially as part of restorative clinical supervision (RCS). Here Denise expresses some concerns about the concept.
Essential oils can be relaxing and ease the symptoms (but not the causes) of stress when used appropriately, but I have grave concerns about PMAs advocating the use of diffusers within RCS sessions. It is not the role of the PMA to address health issues of midwives, merely to recognise them and refer on to the relevant sources of help.
When midwives are trained to use essential oils for expectant and birthing parents, they learn only a minimal aspect of the vast profession of aromatherapy and do not have the knowledge or skills to help non-pregnant staff. Even using essential oils for relaxation needs to be done in accordance with a complete assessment of the intended recipient, acknowledgement of physiological allergies and psychological odour memory and preferences. Indeed, there could be an insurance issue here in the event of any untoward adverse reactions, not only of the individual midwife undergoing RCS but also any other midwife affected. Further, the use of diffusers in these RCS sessions contravenes the Health and Safety at Work Act 1974 and the Control of Substances Hazardous to Health regulations, which require employers and employees to minimise the risks of chemicals in the workplace. I find it worrying in the extreme that this message is not getting across to midwives and that the author suggests the need for research into diffuser use within RCS.
Research on effectiveness of any complementary therapy should be preceded by understanding fully the safety issues to ensure that aromatherapy in general, and specific oils in particular, are safe: no single oil is safe for everyone. Using oils in rooms which may later be used by other staff (or parents) risks exposing them to the risks of aromatherapy – in which case the NHS trust managers could be liable for any adverse effects on individuals by having permitted the oils to be used in this way.
O is for orange essential oil. Sweet orange oil and other citrus oils such as tangerine, mandarin, lime or grapefruit, are gentle oils to use in pregnancy, birth and the postnatal period. They're uplifting, good for emotional distress and effective for constipation.
Always check before use in case the mother or any other person present ( including the person administering it) has an allergy to citrus fruit - in which case it should be avoided.
N is for natural remedies, which should be used with extreme care in pregnancy. Just because they are natural does not mean they are always safe.
Many herbal remedies such as St John's wort, should be avoided in pregnancy and SJW should never used together with antidepressants. Homeopathic remedies don't act like drugs - they do not work chemically but work energetically (according to physics) and should also be used carefully - using the wrong remedy or using the right remedy for too long can cause an increase in symptoms rather than resolving them.
M is for massage, a simple tool for midwives and doulas to use during labour. The power of touch is enormous. Physically, massage can stimulate circulation and encourage the woman''s body to work efficiently. It can ease pain through the gate control mechanism - touch impulses reach the brain quicker than pain impulses. Emotionally, massage adds to the sense of nurturing that is so powerful during labour and birth.
Currently travelling in South Africa, Denise reflects on the power of the sun to raise the spirit and heal the body and mind.
It's been three long years since I've been able to visit South Africa and I'd almost forgotten how hot it can get, even at the end of the summer. I've noticed, however, how happy everyone is here, even in the cities, and certainly in the rural areas. I'm convinced this is due to the sunshine and warmth, the open air lifestyle and the space around us.
Getting a good dose of vitamin D positively impacts on our mental health, making us feel uplifted. The beaches and forests play their part allowing us to breathe deeply of the clean air; the sounds of birds are not overwhelmed by excessive traffic noise; the taste of fresh, locally sourced food (and the occasional glass of good South African wine!) nourishes the body - and taking time to relax over meals aids digestion.
Holidays are good for mind and spirit, healing us from within and without. They give us time to talk to loved ones, to share experiences with family and friends and to reflect on life. Taking a holiday, even for a short time, is therapeutic and re-energising - the ultimate complementary therapy!
Currently staying with her son in South Africa, Denise has been able to reconnect with a friend she hasn't seen for almost 30 years. Christine Lynne Stormer-Fryer was a health visitor in the early 1980s when Denise was a community midwife in Surrey (she actually introduced Denise to her husband!) On emigrating, Chris, who had trained in reflexology, opened the Reflexology Academy of Southern Africa and became a world-renowned presenter on her particular type of reflex therapy. Although the Academy is long gone, Chris's unique style of presentation and writing continues.
As is the way with old friends, gifts were exchanged - Denise gave a copy of her Using Natural Remedies Safely in Pregnancy book, and Chris gave her two self-published reflexology books. Chris's Hot-Footing It to Health is a fascinating read. Much more spiritual than Denise's scientific clinical approach, it is nevertheless a supportive text for practitioners and gives an insight to its approach for those receiving reflexology. Chris's way with words leads her to unlock language and give it new meaning, for example "Feet, being the platforms on which the body takes a stand, provide a remarkable understanding as to the 'ins and outs' of what it is to be human".
This is not a book about the practice of reflexology, and does not focus on any particular style, neither traditional European nor eastern meridian therapy, and certainly not clinical reflex zone therapy as taught by Expectancy. It explores the concept and philosophy of an ancient healing art and attempts to set it in the context of modern life. It contains a collection of sound bites - or, as Chris herself might say, "foot notes" to aid reflection on the purpose of reflexology in restoring and maintaining health and wellbeing.
Despite their reunion being short, Denise and Chris had a lovely morning and intend to keep in touch better. If you'd like to buy Chris's book the ISBN number is 9781986332064.
L is for laminaria, a type of seaweed has traditionally been used to open the cervix for termination of pregnancy and to aid cervical ripening in postdates pregnancy, as well as to help the insertion of radium in cancer patients. When inserted as a “tent” into the opening of the cervix, the gel within the leaves becomes wet it swells to help dilatation (it is a precursor of the intracervical rods currently in use in some maternity units. However, laminaria may cause infection or uterine bleeding and is no longer used medically. It should not be taken orally as it contains high levels of iron and arsenic, which may be toxic.
K is for Kidney, an acupressure point on the sole of the foot which is an excellent relaxation point.
It is also used for relaxation in reflexology, and is thought to correspond to the solar / coeliac plexus where people feel “butterflies” when anxious. Gentle pressure applied to this point on both feet can be very relaxing especially during labour or when a woman is waiting to have a Caesarean section.
J is for juniper berry essential oil which is contraindicated in pregnancy. It contains chemicals which be harmful to the developing baby and which may affect renal perfusion especially through the maternal kidneys. Many essential oils should be avoided in pregnancy - if in doubt, avoid using them.
Expectant parents wishing to avoid induction can be helped with an effective package of complementary therapies including acupressure, aromatherapy, massage and reflex zone therapy. Some maternity units are now using this Expectancy package to reduce significantly their induction rates. If you'd like a course for midwives in your unit, please contact firstname.lastname@example.org
A powerful clinical tool to help parents prepare for the birth and to overcome their fears and anxieties. It can also be effective for smoking cessation in pregnancy. Expectancy now offers midwives a programme in midwifery clinical hypnosis with the option to progress to a full hypnotherapy qualification. Contact email@example.com for more information.
Commonly used to combat sickness in pregnancy. Ginger biscuits are not the answer as there's too much sugar (which can make sickness worse) and not enough ginger to be effective. Ginger tea made from grated root ginger is best, sipped throughout the day. Ginger essential oil should not be used in pregnancy as it may trigger uterine contractions.
Teaching a group of midwives recently, Denise was disappointed to see, during the practical work, one of the midwives flicking through her mobile 'phone whilst receiving foot massage from another midwife. When asked to put her 'phone to one side, she said it helped her relax. She challenged Denise, stating that young women like to use their 'phones all the time and might want to do so during a massage, without any understanding of why this is inappropriate.
First, being on her 'phone whilst having the massage was disrespectful and certainly did not enable her to appreciate the power of relaxation from her own experience. Her attitude was that her partner had access to her feet to practise but she could not relate this to what she could apply to her midwifery practice. She did not recognise the opportunity for social interaction that comes from an expectant parent being face to face with a midwife whilst enjoying some "me" time. It's amazing what women talk about during foot massage (or reflexology) that they don't discuss during a normal antenatal appointment - this has been shown in research.
More importantly, a mobile 'phone is a source of energy (heat) that interferes with hormonal energy. It's been proven that men who carry mobile 'phones in their trouser pockets may have reduced fertility because the constant heat near the scrotum interferes with sperm production. Similarly, this heat exacerbates the stress hormone, cortisol, and adds to, rather than reduces, internal stress levels. Given that stress contributes to disturbances in the pregnancy and may cause either preterm or delayed onset of labour, it stands to reason that expectant parents should be encouraged to use them less, and at the very least, to enter into the spirit of relaxation that comes from having a massage.
When expectant parents are offered complementary therapies, they must understand that it requires them to work in partnership with the practitioner. This includes agreeing to comply with the aftercare advice such as increasing fluid intake and avoiding toxins eg coffee and alcohol. It also means that those who refuse to put down their mobile 'phones should be informed that they cannot receive masage, reflexology or other therapies (homeopathy, for example, is inactivated by the heat from mobiles, TVs and microwaves). And for midwives, it requires a commitment to what they are learning and how the experience of receiving massage can contribute to that learning.
Or perhaps fear of the maternity services, fear of being left alone during labour or fear of being coerced into accepting something expectant parents don't want.
Clinical hypnosis can be very effective at helping women face their fears and is individualized to each woman to help her overcome them.
A remedy used in some African countries to prepare for and ease the birth process.
Any type of dancing can boost the feel-good endorphins and reduce stress hormones.
Belly dancing is particularly popular and helps to allow some give in the pelvic brim in preparation for birth, and encourages the baby to settle into an optimum position for birth.
C is for chiropractic, a statutorily regulated profession supplementary to hea!thcare.
One of the most used medical therapies in the world, chiropractic is similar to osteopathy but uses different techniques to realign deviations in the musculoskeletal system caused by injury, disease or genetics. In pregnancy, it is effective not only for backache, sciatica and other bone and muscle issues but can also help to turn a breech baby to head first and relieve heartburn and indigestion.
B is for backache in pregnancy, caused by the effects of progesterone and relaxin on the musculoskeletal system. It's often accompanied by sciatica and pelvic and groin pain.
Osteopathy or chiropractic are probably the most effective therapies, but massage, aromatherapy or reflexology may bring some temporary relief. Acupuncture can also help.
A is for Acupuncture - a credible, well researched therapy that is effective in treating many pregnancy issues including sub-fertility, sickness, backache, headache, constipation and carpal tunnel syndrome.
It can be used for postdates pregnancy, slow latent phase, pain relief in labour and retained placenta.
Denise says: Valerian tea can be helpful for insomnia but there is conflicting advice about whether it is safe in pregnancy and a few studies suggest it may reduce the level of zinc in the fetal brain. It is generally felt that expectant parents should avoid taking valerian. It can cause drowsiness and interact with sedative and antidepressant drugs and certain herbs such as Sr Johns' wort (another herb that should be avoided in pregnancy). In non-pregnant people, valerian should not be taken regularly for more than six weeks as it can lead to liver toxicity; suddenly stopping it after a prolonged period of time can cause palpitations and hallucinations.
For the third year running Denise has had to teach aromatherapy to midwives and therapists in Japan as an online course.
Having been teaching in Japan for over 20 years she misses visiting - but is hoping next year will be different. This last weekend she was up all night teaching because of the 9 hour time difference!
The pandemic has affected maternity care badly in Japan with women still having to wear masks in labour and are unable to have their partners with them.
There is also a notably increased rate of suicide amongst expectant and new mothers.
The public is however is far more compliant with wearing masks, self-isolating and accepting vaccinations.
Homeopathic arnica is a useful remedy to relieve bruising and trauma after birth, but did you know it should not be taken preventatively before any bruising has occurred?
Arnica tablets can be commenced immediately after the birth, the dose depending on the severity of the trauma - so a higher dose would be needed after a Caesarean than after a spontaneous vaginal birth.
Taking too high a dose, or taking it for more than four days can lead to a "reverse proving" in which it may actually cause further bruising.
The Midwives’ journal of the RCM reported on a recent OpenDemocracy survey of 7000 members of the public and 500 NHS staff, which found around 40% of patients (all clinical specialisms) feeling dissatisfied with their NHS options, notably long waiting times for appointments and surgery.
Around half of these had been advised to consider private treatment by NHS staff who were concerned about the adverse effects of waiting on people’s health.
Whilst there are huge concerns about the state of the NHS, we must remember that people do have choices. In maternity care, this includes the option to consult private midwives or obstetricians, and to seek supportive services such as complementary therapies and birth preparation classes in the private sector.
Indeed, an increasing number of midwives are working part-time in the NHS and part-time offering private services to support expectant parents – enhanced postnatal care, tongue-tie division, lactation support and much more. In some countries, such as Iceland, it is standard for midwives to be paid by the state for essential services including antenatal and birth care, but for expectant parents to pay for supporting services such as antenatal education, acupuncture and some aspects of postnatal care, which are provided by the same midwives they see for their pregnancy and birth care. In a profession that advocates choice for parents, it seems contrary to the philosophy not to accept the fact that some parents may wish to pay for additional support.
Nausea and vomiting is pregnancy is usually attributed to hormonal upheaval but there is also a correlation with back or neck problems. Misalignment of the spine and musculoskeletal system can put tension on various organs, making hormonal sickness much worse.
A history of whiplash injury is particularly significant as it puts strain on the vomiting centre in the brain, increasing symptoms. Osteopathy or chiropractic can help correct the neck problem.
Denise also uses a dynamic technique adapted from reflex zone therapy (the type of reflexology taught by Expectancy) to release the neck tension - like osteopathy via the feet.
Call the Midwife's use of Leeches - the ultimate alternative medicine.
Watching Call the Midwife on Christmas Day, Denise was reminded of her student nurse days at St Bartholomew's Hospital, London, in the mid-1970s when leeches were used to remove excess blood from bruises. She says:
I was a student nurse on Casualty when leeches were re-introduced. Of course,.we.thought it was a bit gross but once both the patients and the staff had overcome their qualms about having live animals attached to the body, we realised how successful a treatment they were for large haematomas (bruises). They were initially used on the medical students who had sustained black eyes and "cauliflower ears" playing rugby - and they were the most squeamish of all. I seem to remember there was a small trial being conducted (research studies were not as common as they are today) - so everyone was fascinated. Leeches are still in use in many parts of the world as an alternative to more invasive medical procedures. I'm not sure how I feel about using them for bruising of the buttocks after birth though - that might be a step too far to have leeches attached to your bottom whilst trying to feed the baby!
Clary sage (Salvia sclarea) contains certain chemicals that make it unsafe for expectant parents prior to term (37 weeks of pregnancy). It is often used to start labour although caution should be used as it can cause excessively strong contractions leading to fetal distress. It is also used by many midwives for pain relief in labour although it should not be seen as a panacea for everything in labour. Prolonged or excessive use in established labour can also cause contractions that are initially too strong but if the clary sage is continued beyond this point it will eventually have the opposite effect, causing the contractions to peter out. Care should also be taken in the postnatal period and clary sage should not be used is there are any retained products of conception or heavy bleeding with large clots as it could precipitate a major haemorrhage. Clary sage is a useful oil in maternity care but should always be used with caution.
Denise has recently discovered that the Royal College of Midwives will no longer be accrediting courses from external organisations from 2022. She says:
This news is disappointing because Expectancy’s courses have been accredited for midwives’ continuing professional development (CPD) by the RCM for over a decade. However, this information has caused me to reflect on the purpose of having courses accredited by a professional or academic organisation. We also discussed it on one of our online problem-solving sessions with our Licensed Consultants, to debate what midwives want in terms of CPD, a requirement of maintaining up to date and contemporary midwifery practice.
Accreditation aspires to provide a kitemark of quality so that prospective participants can be assured that the course is appropriate for their needs. Pre-registration midwifery programmes undergo rigorous examination by both a higher education institution (university) and the Nursing and Midwifery Council (NMC) and must demonstrate an appropriate professional and academic standard that complies with national and international requirements for midwifery registration. In terms of postgraduate education, courses must be fully applicable to the role of the midwife but do not necessarily have to be of a particular academic standard. They may be one-day introductory courses or long academic programmes that complement the role of the midwife. They should always strive to help midwives keep up to date and enhance their skills, and knowledge so they can provide safe, effective, evidence-based care. Many courses have hitherto been accredited by the RCM or RCN, and occasionally also by universities. Expectancy’s Diploma was originally accredited by the University of Greenwich at a time when many midwives were upgrading from diploma to BSc level academic qualifications: our programme could be used as credit towards a BSc )Hons) degree in Professional Practice. Although it is not currently academically accredited, we retain some link with the university sector by having an Academic Conduct Officer who is a senior lecturer in two universities, whose job is to monitor Expectancy’s robust assessment processes and ensure parity with other academic organisations and equity for students.
However, when it comes to accreditation for complementary therapy education for midwives, most accrediting organisations are in uncharted waters because the specialism transcends two professional borders – midwifery and complementary therapies. Midwifery accrediting organisations cannot easily assess the validity of the complementary therapies content; conversely, complementary therapy organisations cannot monitor the calibre of the maternity elements (and in any case, only provide maternity-related courses as CPD for therapists who are not registered healthcare professionals). Applications for accreditation from the course provider are assessed by the accrediting body based on what is in the documents presented (very rarely is direct observation of a course included). The documentation requires explicit demonstration of course aims and outcomes applied to midwifery practice and an academic level commensurate with at least that required for pre-registration midwifery education (academic levels 4-6, or preferably higher for post-registration education, at levels 6 or 7). Applications must also demonstrate the credibility of the course providers, with at least one of the teachers / facilitators being required to be a midwife (and in the case of complementary therapies, teachers must have a full qualification in the relevant therapy).
This does not, however, mean that the course is “good”. The course may be enjoyable but in practice may have little relevance to contemporary midwifery practice. Usually this is not by inclusion but by omission, for example, not setting the subject in the context of NMC parameters, or not focusing on the legal and professional issues pertinent to midwifery practice. This is noticeable in many of the short courses available to midwives on subjects that generally sit outside standard practice, particularly complementary therapies. A course may be taught by a therapist (who may or may not have maternity experience) and – in order to obtain accreditation – facilitated by a midwife (who may or may not be qualified in the therapy). Courses may focus on the benefits and only include safety and risks in a very limited manner – perhaps because the perceived negativity of risk issues detracts from participants’ enjoyment of the therapy during practical work on the course. This approach does not adequately meet the requirements of the NMC Code 2018 which requires midwives to “maintain knowledge and skills required for safe practice” (6.2) and to “work within the limits of their competence” (13).
Whilst many midwives still adhere to studying only those courses which have been accredited by the RCM this will no longer be possible from 2022. So how can they be assured of the quality of a complementary therapy course? The NMC leaves this decision very much in the hands of inpidual registrants and it can be difficult to determine the credibility and appropriateness of a course. Complementary therapy courses for midwives must be taught by dual qualified midwives – they must be fully qualified in the therapy, qualified and insured to teach it and have had considerable experience of using the therapy within their own practice. They must be able to imbue in their students an understanding of both the benefits and the pitfalls of using the therapy for expectant and birthing parents, within the parameters outlined by the NMC and within the NHS and other institutional settings. The midwives with whom I discussed this issue were kind enough to point out the credibility of Expectancy’s courses based on my personal reputation from 40 years of experience of teaching complementary therapies at higher education level and a tenacious adherence to safe practice.
It’s up to you to decide whether the complementary therapy courses you attend are “adequate and appropriate” for use within your midwifery practice.
The incidence of allergies is increasing with everyday exposure to allergies and pollutants. Fragrance allergies and intolerances are common, although it is not known if this is allergy to the actual fragrance or to the chemicals within them.
Long Covid is being recognised for an ever-expanding list of unusual symptoms and alterations in the sense of smell is now well known. However, in addition to this and total loss of the sense of smell(anosmia) a new phenomenon is now being recognised - allergy to smells in general and in particular to chemical fragrances such as perfumes.
This poses the question of whether midwives and doulas offering aromatherapy should check if each pregnant or birthing parent has had Covid and particularly if they have long Covid. Anosmia does not mean that people are unaffected by the essential oil chemicals, and allergies to fragrances may, as yet, be unrecognised by the individual.
Midwives and doulas offering aromatherapy in pregnancy or birth should, as part of their standard assessment for suitability to receive aromatherapy, ask about the woman's Covid history, the presence of long Covid and the sense of smell. This should include asking about alterations, absence or hypersensitivity to smells and any reactions which might suggest existence or recent development of an allergy to perfumes, chemical vapours, cleaning products and other substances with fragrance such as aromatic candles, diffusers etc. In these situations it might be prudent to abstain from using aromatherapy for or near the parents.
Today, Denise discusses a strange phenomenon that can occur in pregnancy and how complementary therapies may help.
Excess salvation is a distressing symptom that occurs in pregnancy more than you might think. It's hormonal and often occurs with severe sickness - or the salvation itself triggers nausea - but the causes are not understood.
It appears to be most common in women of black origin, particularly those from West Africa, although no one knows why. It commonly resolves spontaneously towards the second trimester but may persist throughout pregnancy for an unlucky few. Some women produce up to two litres of saliva daily and need to keep spitting it out.
In addition to keeping the mouth clean, sipping water to keep hydrated and avoiding starchy foods which often make it worse, sucking limes of lemon may help. However homeopathic remedies can also be effective, but the most appropriate remedy depends on the symptoms:
Taking one 30c strength tablet three times daily for 3-4 days should help but if the symptoms are no better, 're-evaluate and try another remedy. It's important not just to keep taking the remedy for longer if it hasn't worked in a few days as it can have a reverse effect and make things worse.
Acupuncture or osteopathy may also be effective, and there have been reports of hypnotherapy improving the symptoms. These therapies will require consultation with a qualified practitioner if self-administration of homeopathic remedies brings no relief.
Martin Bromiley, an airline pilot, founded the Clinical Human Factors Group after the death of his wife from minor surgery, which was later found to be due to “human factors” including poor communication between individuals and departments. (See http://chfg.org/).
Bromiley asserts that safety is integral to compassionate care and cannot be separated from it. If maternity care is unsafe then it cannot claim to be compassionate. This applies equally to the use of complementary therapies in pregnancy and birth. Midwives justify their use of complementary therapies as enabling them to return to being “with woman”, offering relaxing and pleasant strategies to help women through pregnancy, birth and new motherhood.
They defend their practice by alleging that complementary therapies combat the negative, often unwanted and unwarranted interventions which are so prevalent in maternity care today. They use the misconception that complementary therapies are “safe” because they are “natural” as an argument to support their introduction into maternity care.
However, this unthinking and incorrect declaration is, in itself, unsafe, adherence to which risks the wellbeing of mothers and babies, and of staff. Where midwives have long-standing complementary therapy services in place, there is a risk of complacency which could threaten the safety – and thus the compassionate delivery - of the strategies provided.
Compassionate care should apply equally to the incorporation of complementary therapies within maternity care, especially since these “alternatives” are often required to justify themselves twice over in order to convince the sceptics that they are safe, effective, satisfying and cost-effective. Several maternity units are known to this author where, it could be argued, midwives no longer provide compassionate – or safe – complementary therapies to pregnant and childbearing women because there has been little, if any, on-going updating, evaluation or development. Adapted from Denise’s book Complementary Therapies in Maternity Care, an evidence-based approach 2018 (Singing Dragon).
Today, Denise has chosen to remind us all of the NMC Code in respect of requiring mandatory Covid vaccinations.
The government has decided that all NHS front line clinical staff must be fully vaccinated against Covid by spring of 2022. Of course, there are many who raise the ethical dilemma of effectively forcing all staff to submit to something they may not want - or risk losing their jobs. Then there will be those whose political opinions differ from the government’s and those who see this as one more step away from our democratic or human rights. All of these are issues for the individual and are not the point of my post today.
Healthcare workers have long been required to undergo occupational health assessments to ensure physical and mental fitness to practice. Midwives must be immune to rubella or agree to receive the rubella vaccination. Those exposed to blood products, including midwives using acupuncture in their practice must ensure they are immune to hepatitis B – or receive the vaccine in order to practice. increasingly midwives and nurses are required to have the annual influenza vaccination and others working in particular clinical fields may need to have vaccinations against tuberculosis, hepatitis A and other infectious diseases. Mandatory vaccinations to work in the healthcare professions are not new.
As registrants with the Nursing and Midwifery Council, we are all bound by The Code (2018) which directs nurses, midwives, health visitors and nursing associates towards safe, accountable practice. The NMC’s responsibility is to uphold the safety of the public and to ensure that its registrants are working within the guidelines on which professional healthcare workers should depend. We can apply many of the NMC Code’s clauses to this issue:
Finally, there are two other clauses in the NMC Code that relate directly to discussing this current issue on social media:
Individuals are, of course, entitled to their views on the issue of mandatory vaccinations. However, whilst we welcome your comments on the content of this post, we will immediately delete anything which contravenes these principles. Be Kind!
It's very alarming to see some Facebook pages or websites making suggestions for the use of complementary therapies (CTs) in pregnancy that are completely unsafe. Here Denise discusses when aromatherapy and reflexology should NOT be used in pregnancy and birth.
Complementary therapies offer midwives a range of additional choices to help expectant and birthing parents. Aromatherapy and reflexology can be very effective when used appropriately and cautiously. However it is very worrying that suggestions are often made for using CTs to help with medical or obstetric complications.There are certain situations when aromatherapy or reflexology should not be used at all in pregnancy and birth:
Liver disease or obstetric cholestasis - essentail oils are metabolized via the liver and may exacerbate any existing hepatic issues. Women taking prescribed medication for any major medical issue should also avoid using oils which may interact with the drugs. Reflexology can also compromise drug metabolism or impact on the liver if there is cholestasis or cirrhosis or other hepaticcondition - over-working the foot reflex zone for the liver can accelerate drug metabolism and reduce their effectiveness.
Other major medical conditions including cardiac disease, unstable or insulin-dependent diabetes, epilepsy, thrombosis or clotting disorders or severe thyroid problems - indeed, any condition requiring medication or that is compromised by the pregnancy.
We must remember that aromatherapy and reflexology are intended to complement rather than replace medical treatment. They can have serious adverse effects when used injudiciously by women with more complex pregnancies. Midwives and doulas offering therapies, or.discussing parents' self-administration should be alert to those situations when CTs are inappropriate and possibly even dangerous.
Further, CTs are generally less well accepted by medics and less well researched than obstetrics, but more importantly, less effective than proven medical treatments for major medical conditions. They do not replace medical treatment. Even when used simply for relaxation, they may do.more harm.than good.
Caution is the watch-word here - if in doubt, leave them.out!
Denise was concerned this morning to receive an email from a midwife stating that she has completed two days of aromatherapy training with Expectancy in 2013; she continues to use it in the NHS, and was wondering if she could now use it in private practice.
Denise says: It is really worrying when midwives believe that it is acceptable to continue including complementary therapies (CTs) in their midwifery care for years without any updating.
The Nursing and Midwifery Council Code (NMC 2018) states that registrants must keep up to date in ALL aspects of their practice. Much has changed in aromatherapy since 2013 (indeed, in the last two years) and the context of its use within the NHS has changed too. The law has tightened up, Brexit having required a change to laws and regulations that govern certain aspects of essential oil use.
The NHS is more focused on risk aversion and avoiding litigation than it was in 2013 and several health and safety laws have changed. Medicines management regulation have transferred from individual regulatory bodies to the Royal Pharmaceutical Society. The NMC Code has changed at least twice in this period too, with some clauses having been changed, firmed up or, occasionally, removed. Indemnity insurance issues have also changed and this may also apply to NHS vicarious liability insurance in certain circumstances.
This midwife is in urgent need of updating of her knowledge of aromatherapy in relation to using it in midwifery practice. At Expectancy we recommend updating and reflection on existing practice every two years. This does not have to mean paying for expensive courses – although in this case, I would certainly recommend a full refresher course. However, professional development can be achieved also by many other means. CPD can be achieved by reflecting on situations where aromatherapy has worked well and where, perhaps, it has not been successful or caused adverse effects for individual women, or searching the research literature to ensure you remain contemporary and able to justify your actions in terms of the evidence-base. It is really worrying that midwives believe that a short training course is all they need to incorporate CTs into their midwifery practice - and that is it.
Why do some midwives feel that they do not need to keep updated on aromatherapy, moxibustion, reflexology or acupuncture and that they can just continue to use it in their care of expectant and birthing parents.
These midwives are actually jeopardising their NMC registration and potentially putting parents and babies, as well as staff, at risk.
Denise is often asked by midwives about whether women wanting a vaginal birth after a previous Caesarean section (VBAC) can use complementary therapies and natural remedies to start labour. Obviously these women are desperate to avoid another Caesarean and often try everything they can find to help. Of course, having a nice relaxing massage or reflexology treatment can be good - it reduces the stress hormone, cortisol, and encourages an increase in oxytocin so labour is more likely to start naturally. Hypnotherapy can also help, by encouraging the expectant mum to focus on the positives of the impending birth rather than on the negative feelings about the past Caesarean.
However just because they're natural doesn't necessarily make self-administered natural remedies safe. This applied to all pregnant women but it's a particular risk when those wanting a VBAC start trying every remedy they've heard of - and often all together. More is definitely not better - indeed, using lots of remedies may confuse physiology so much that it actually increases the risk of complications, leading to the need for another Caesarean.
Maternity professionals - midwives, doulas, doctors - and therapists treating pregnant women should advise those trying for a VBAC to:
* have regular relaxation treatments from a suitably qualified therapist who is insured for maternity work
* avoid self-administering castor oil, raspberry leaf tea, clary sage oil, evening primrose oil and other herbal remedies - and NEVER EVER to take them all at the same time
* inform their midwife or doctor about any complementary therapies they've had, and especially any herbal remedies they've taken or aromatherapy oils they've used.
Here, Denise discusses an issue that arose on a recent aromatherapy course in which a midwife reacted adversely to the oils.
During our aromatherapy course for midwives this weekend, one student had a significant reaction to the essential oils, which we finally identified as being caused by frankincense. The student had already told me she suffered with eosinophilic asthma and I had urged her to be cautious but explained that some reactions cannot be anticipated or attributed to specific oils.
As the midwives were deciding on their preferred blends for the practical massage session, this midwife began to experience tightening in her throat and the beginnings of symptoms indicative of an asthma attack. Fortunately, she was able to move to another room and the oils she and her partner had chosen did not seem to affect her so she was able to engage in the practical work.
I have had several other midwives experiencing adverse reactions to oils during courses, some of which have been quite severe. Different oils have been involved including geranium, rose, clary sage, sweet orange, lavender and now frankincense. Indeed, I have witnessed a far greater number of midwives having negative effects from oils in the last five years than in all the years of teaching aromatherapy before that. Another midwife had such a serious reaction to simply sniffing clary sage from the bottle that we thought we would have to take her to A&E (she declined the offer and eventually the effects wore off). Other symptoms have included midwives being violently sick (from geranium) or developing an acute migraine-like headache (after using chamomile). One midwife reacted so badly to the use, by another midwife, of rose hand cream that she had to go home – she later informed us that she was allergic to roses.
I know of several maternity units where midwives with allergies to citrus fruits are unable to use oils such as orange, grapefruit, neroli or other citrus oils. Another unit has not one, but two members of staff severely allergic to lavender, one having been seriously affected when a mother brought her own lavender oil into the birth centre.
I cannot stress enough that midwives must take care when using aromatherapy in their practice, offering it to birthing parents or using it around other staff. The adverse effects can be unpredictable, severe and long-lasting. It is unethical, unsafe and unprofessional to assume that all people exposed to the oils in a birth centre either like the aromas or can tolerate the chemical effects. Get to know your oils and their benefits and possible adverse effects!
Denise is in Portsmouth again this week, teaching aromatherapy and acupressure for postdates pregnancy. Having had a good first day, the course is having to decamp on Tuesday to another hospital due to lack of room availability. The group was due to use a church hall but a last minute change was required when the church rescinded its booking, claiming that aromatherapy and massage did not fit with its religious ideals. Here, Denise reflects on the attitudes towards complementary therapies.
What a shame that we were unable to use the church hall for the second day of our course due to a possible conflict between religious views and what is sometimes still seen as "new age" therapies. Complementary medicine still has to fight its cause on many fronts. Scientists accuse CTs of being poorly evidenced. Purists feel that "alternatives" have no place in conventional healthcare; obstetricians claim they can interfere with medical interventions (true to a certain extent but they may also avoid the need for medical intervention). Managers sometimes reject them because , they say, there is not enough time to use them. Others claim they are dangerous, illogical or are an element of fringe medicine (or witchcraft).
In almost 40 years of practising, teaching, researching and writing about complementary therapies, I have encountered many views and much opposition. People are, of course, entitled to their views, although it is sad that some are based on lack of knowledge and understanding of what CTs are about, how they work and how they can be used beneficially to enhance maternity care.
We hear a lot, today, about different lifestyles, perspectives and views on everything from sexuality to religion to disability to politics. Everywhere there are pleas for greater inclusivity. Why then does complementary medicine continue to be sidelined by the conventional healthcare and scientific communities? Is it not time that complementary medicine was brought in from the cold and considered equally alongside other forms of medicine and healthcare?
I've seen many posts on social media about the deplorable state of midwifery and the maternity services in Britain but I've also seen similar posts from French midwives where midwifery is possibly even more.medicalised.than in the UK. Midwifery is in crisis in the western world - I would say we are seeing the death of midwifery as we know it unless radical action is taken now.
Blame is heaped on the current government yet this situation has been evolving for decades. It's not the fault of one government or one political party. One government can't cure the problems of fifty year's worth of intervention, control and pathologising of childbirth.
Poor pay is also sometimes raised - but you don't go into midwifery or nursing for the money (that argument is for another day but it's not just the UK that pays its nurses and.midwives poorly). No amount of pay increases will bring more people into midwifery training or stop the deluge of departures from those already working in the system.
I believe the problem lies in the culture and attitudes of the system. Midwives are mainly women and although many obstetricians are now female, they too work in a male dominated, paternalistic - and I would say, sometimes misogynistic - culture and often become part of the problem. Historically women have been moulded into "bodies that have vaginas" (as the recent Lancet referred to) and childbirth has become just another medical problem.
I heard only yesterday of a midwife committing suicide, possibly partly as a result of extreme bullying at work by her colleagues and managers. Bullying is rife in the NHS and possibly worst in midwifery - contributing to midwives leaving the profession for a better work-life balance and as.a.way to protect their own mental wellbeing.
Pressures on the maternity services have risen exponentially with increased population and increased complex needs of those using the services - obesity, diabetes, mental health issues and so on. More users bring higher demands and need more resources - including staff. Yet this means that those with complex needs take priority and those whose pregnancies and births are "normal" are left to get on with it - so they feel dissatisfied. More complex needs mean more emphasis on pathology to the extent that we all begin to see childbirth as a pathological condition.
The problems of midwifery are multifactorial and not easily rectiified. My preference would be to return to a community-based profession with individualised continuity of care and carer -but it's not going to happen easily. I believe midwives should adopt the independent midwifery model but this will be difficult in the NHS which exists for the majority and not for the individual. I feel that unless we do something soon, midwives will become obstetric nurses during birth, antenatal care will focus on the biological and not the psychosocial aspects and postnatal care -well, will there be any at all?
I don't know what the answer is because the situation is so complicated but unless we act soon as a united profession we won't have anything to fight for. Long live midwifery.
If you’re wanting to implement aromatherapy into your midwifery practice, what do you need to learn? Here Denise shares a checklist for midwives and doulas preparing to use aromatherapy for labour care. The list can also be applied to the postgraduate study by aromatherapists wanting to specialise in maternity work.
Essential oils are not a panacea for everything!
Denise comments on continuing concerns about the overuse of aroma therapy oils.
Can you use lavender oil to lower blood pressure if an expectant parent has developed pre-eclampsia?
Is it OK to use tea tree (known to relax.smooth muscle) to stop a threatened preterm labour?
How about treating a skin reaction to one essential oil with another to stop the irritation?
The answer is a resounding NO!
When aromatherapy is used in pregnancy and birth, it should be supportive and can be very relaxing, uplifting, wound healing or immune boosting. However once progress.deviates from the norm, aromatherapy should be DISCONTINUED.
It is neither medically appropriate not professionally expedient for midwives and doulas to attempt to rectify medical complications with aromatherapy oils - sometimes DRUGS are needed! And it is not good.practice to attempt to reverse the effects of one oil or blend with another. If a woman has a reaction to an oil or a single chemical in an oil, she may react adversely to other oils containing the same chemical. CAUTION always when using essential oils in pregnancy and birth. Enjoy them but don't abuse them!
Osteopathy and chiropractic offer probably the most dynamic treatment options for expectant parents with lower or upper back pain, pelvic girdle pain or any other musculoskeletal problems in pregnancy such as carpal tunnel syndrome and shoulder girdle pain.
A follow-up study of 115 women who received chiropractic for back pain in pregnancy indicated a 52% improvement after one treatment, with steadily increasing rates of improvement with longer courses of treatment, particularly when continued postnatally for up to a year (Peterson, Mühlemann, Humphreys 2014).
In countries such as Canada, where chiropractic is accepted as being complementary to conventional healthcare, expectant parents with musculoskeletal symptoms can receive care which is genuinely shared between the obstetrician and the chiropractor.
In the UK, osteopathy and chiropractic are highly regarded allied health professions, with all practitioners statutorily registered under the General Osteopaths Council or General Chiropractic Council. Hensel, Buchanan, Brown et al (2015) set up the Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects (PROMOTE) study to evaluate the efficacy of osteopathic techniques for musculoskeletal pain in late pregnancy.
400 expectant parents were randomly allocated to receive standard care, osteopathy with standard care or placebo ultrasound treatment with standard care. Both osteopathy and the placebo treatment achieved some improvement in symptoms reported by participants although osteopathy was significantly more effective.
This was one of the largest trials ever conducted on the effectiveness of osteopathic manipulations in pregnancy, although it was interesting to note a high attrition rate, stated as being due to missed appointments and the onset of labour before 40 weeks’ gestation in some women.
As with much other complementary medicine research, the need to use a standardised treatment regime rather than individually-tailored clinically-relevant programmes of treatment may have affected the ultimate efficacy of treatment.
Some women take herbal remedies to trigger labour, including either black cohosh or blue cohosh.
Black cohosh is thought to have hormonal effects, menstrual and uterine-stimulating effects, but there is little reliable information available on the safety or effectiveness. When taken orally, it can cause gastrointestinal disturbance headache, dizziness, breast tenderness and skin irritation.Women with a history of hepatic or renal disease, epilepsy or vaginal bleeding in pregnancy should be advised to avoid black cohosh.
Blue cohosh is now known to cause significant adverse effects including reports of severe poisoning and life-threatening toxicity in the baby, including stroke, acute myocardial infarction, congestive heart failure, multiple organ injury and neonatal shock and should not be used in pregnancy or for birth.
NB It is essential to differentiate between black cohosh (Cimicifuga racemosa) and blue cohosh (Caulophyllum thalictroides) to avoid confusion and inappropriate administration. It is also important to differentiate between the herbal (pharmacological) and homeopathic (energetic) use of these plants
Aromatherapy oils are like Victoria sponge cakes! Whether you buy your cake from one supermarket chain or another, or from a local artisan bakery, the basic ingredients are much the same. Some cakes may contain more sugar, extra cream, fewer eggs or different flavoured jam than others, so the taste of the end product is affected by the proportion of these primary ingredients.
Essential oils, in principle, are much the same. They all contain the same groups and sub-groups of chemical ingredients, but in widely different proportions. When you examine a list of the "top ten" chemicals in each oil, it's these that give the oil its distinctive aroma and its primary effects - such as being relaxing or stimulating, analgesic or anti-infective and so on. With almost 300 chemicals in each oil, some are found in such minute traces that their physiological effects are negligible.
In pregnancy, we're concerned with avoiding those oils with high levels of specific chemicals particularly, ketones, which may be toxic to the fetus or cause uterine contractions or other maternal complications. Essential oils with only a trace of these chemicals will be much safer than those with significantly higher levels. Conversely, oils with high proportions of ketones should be avoided in pregnancy until term - oils such as jasmine, clary sage, rose or cinnamon.
Have midwives lost the ability to use their common sense because they're caught up in a system that requires ticks in boxes and a "just in case" approach? Why can't the system enable midwives to watch and wait instead of intervening prematurely in what is, after all, a physiological process for both mother and baby?
A friend recently had a lovely son but the pregnancy, birth and first few days were not all.plain sailing. Nothing was wrong medically although the system pathologised.every small.deviation from "normal" and caused extreme anxiety for the parents. The baby was breech at 35 weeks - but ECV was performed instead of waiting to see if he turned - or discussing the option of a breech birth if he didn't. Labour started spontaneously with a very long latent phase - but, surprise, surprise, duration of "established" labour was measured from hospital admission, with mutterings (threats) to intervene if "nothing happened" within a set timeframe. As it happened labour did (of course) progress to the extent that the mum started requesting an epidural - which was arranged immediately instead of spending time supporting her through each contraction and building up her confidence in her body's ability to birth naturally. It was only because the unit was busy that saved her from the possible cascade that goes with epidural - the anaesthetist was unavailable so she laboured, largely on her own with just her partner present, and eventually gave birth to a healthy son. In the postnatal ward, someone saw fit to tell the mum that - on day 1 - she didn't have enough milk and gave her a bottle of milk for the baby. What?!! And then someone decided the baby had not passed urine and mum and baby were kept in hospital until he did - 48 hours later. I can almost guarantee that he will have passed urine in the early hours and that it was missed -but the parents were subjected to.more anxiety (with no explanations) instead of "allowing" them home and having the community midwife visit to check everything was OK.
These are minor incidents in clinical terms but accumulatively worrying for the parents and marred their overall enjoyment of having their first baby. This is also not an isolated case. Midwives are so fearful of losing their registration that they comply with requirements to fit every individual into a system that favours the institution and not each parent. They are so fixated on ticking charts designed to reduce the risk of omission that they forget to think outside the box - and end up missing important cues anyway (this has been proven in research). Lack of understanding of anatomy and physiology and the paternalistic desire of the system to see pathological problems before normality causes more anxiety for parents who are naturally already in need of a confidence boost.
Midwives have lost the ability to be intuitive about pregnancy, birth and the early days of parenthood. This is the fault of pre-registration education which now has so.much content there is hardly any time to learn - and understand - the basics before going on to complications (which, let's face it, are almost more commonly seen than so-called normality these days). It's the fault of a medicalised, paternalistic, risk-averse, litigation-conscious system that exists for the majority and not for the individual. It's the fault of a midwifery profession that has such a culture of bullying - of both staff and parents - that.compassionate midwives are leaving the profession, adding to staff shortages and compounding the whole sitiation. It's the fault of managers who are trying to balance the rotas and budgets whilst also thinking about CQC inspections and national.ratings.And it's the fault of all of us for being complicit in letting it happen.
Expectant parents often start eating pineapple as a way of avoiding induction of labour. Pineapple (and to a lesser extent, mango and papaya) contains bromelain, a chemical that affects smooth muscle which is thought to aid uterine contractions. The bromelain is in the central core of the pineapple so it's no good eating tinned pineapple rings. In fact, cooking destroys the bromelain, so pineapple fritters are no good either, nor is drinking pineapple juice. It needs to be fresh, raw pineapple. However, some people are allergic to pineapple and eating large quantities can even lead to anaphylactic shock.
What an incredibly moving and brave article in this month's @MIDIRS by Iris Snowdon on her personal experience of such severe burnout that she walked out of the job she loved - being a midwife. It is a harrowing - but ultimately uplifting - acount of her gradual slide into the deepest depths of despair to her healing journey to a new life. How sad that such a caring and devoted midwife should suffer as a result of complete overload and lack of sympathy from many of her colleagues.
However, Iris is not alone. Many of the midwives who study with Expectancy report similar experiences and some of those have taken the brave step to leave the NHS and do something different. I have met midwives at all levels, from Heads of Midwifery to newly qualified midwives, who have felt unable to continue working in a culture that is unsupportive, ungrateful, bullying and blame-throwing.
A desire to continue caring for expectant parents seems common to all, but often those midwives who have to pay the bills are forced either to stay where they are and put up with the situation or to find another job outside midwifery. Increasingly, midwives are working for themselves, offering maternity- related services such as antenatal classes, complementary therapies, lactation support, birth trauma resolution or tongue-tie division, even though this may mean less income.
It is disturbing, when the NHS is so short of midwives, that it actually isn't really about the money, but about wanting a better work-life balance and about wanting to with families in a caring compassionate way - the way that midwifery care should be.
We often think herbal teas are just pleasant drinks but some are not safe in pregnancy or need to be used with caution
All herbal remedies including teas contain chemicals that act like drugs.
Although chamomile tea can aid sleep, drinking too much can have the opposite effect and over-stimulate the brain.
Peppermint tea can be good for nausea but is a cardiac stimulant and if drunk to excess, can cause palpitations, so should be avoided by anyone with a heart problem.
Raspberry leaf is good for birth preparation but should be avoided by women with a uterine scar from a previous Caesarean.
See Denise's latest book, Using Natural Remedies Safely in Pregnancy and Birth for more information.
New Australian research by Mollart et al 2021 again advocates the need for education on “complementary therapies” to be added to midwifery programmes. Here, Denise comments on the implications of the research:
I am pleased to see an abstract of the latest research by Mollart and colleagues, due to be published in November in the Complementary Therapies in Clinical Practice journal, on the education of midwives on complementary therapies. The results are unsurprising, revealing that just over 50% of midwives have had some “training” in CTs, ranging from being self-taught up to diploma level, primarily in aromatherapy, massage, reflexology and acupressure. The recommendation that evidence-based education needs to be included in pre-registration midwifery education is spot-on but requires some clarification.
First, we need to look at the calibre of the training in CTs that is provided for midwives and students. Student midwives are preparing to practise midwifery not complementary therapies. While they need a basic understanding of the main CTs and natural remedies used by expectant and birthing parents, they do not need, at the point of registration, to be able to practise the therapies or incorporate them into their care of parents. Pre-registration education should provide students with an overview of the commonly-used therapies including – crucially – safety issues. This is particularly pertinent to aromatherapy and natural remedies which are often self-administered, sometimes unsafely. Midwives should be able to answer parents’ questions on safe use of the therapies, rather than be competent in the skills of providing the therapies.
Post-registration midwifery education should offer interested midwives the opportunity to undertake higher level training in therapies of their choice. There is a difference between skills “training” and academic education. Courses for midwives MUST be midwifery-specific and taught at least at academic level 6 so that midwives not only develop skills but also acquire deep knowledge and understanding, with an appreciation of the available evidence, safety issues and the parameters within which they can practise. There are many courses available to midwives that provide only level 4 training – usually based on enjoying a day of massage or blending of aromatherapy oils or learning specific acupressure of reflexology points to treat specific situations in labour.
In addition, it is not appropriate for midwives to train fully in a therapy and then undertake to implement that therapy in midwifery practice, without help to apply the principles of the therapy to maternity care. The use of CTs must be set in the context of the institutional area of practice – the birth centre, main obstetric unit or parents’ own homes. Midwives must appreciate how therapies are regulated within their midwifery practice – by medicines management, health and safety laws and by local, national and international regulations. The use of CTs must also be set in the context of the healthcare services, relevance to the service rather than to individuals, equity of service provision so that as many as possible can benefit from the therapies, evidence-based practice and the need to minimise risk and potential litigation.
Having taught CTs to midwives for almost 40 years, I am, of course, keen that the subject should be included in midwifery education. However, I am concerned – and have written frequently on the subject – that the enjoyment of using CTs often overrides the professional requirements to practise CTs safely. CTs education for midwives should be provided by midwives who are fully qualified in the relevant therapy and experienced in using it within midwifery practice and education. Lecturers should be qualified to teach adult learners and qualified and insured to teach the theory and practice of each therapy. Cascade training is NOT appropriate – students only to retain around 60% of what they learn, so midwives who have themselves only just learned a therapy and then attempt to teach others risk a natural dilution of content and understanding as their learners only retain 60% of what they have provided. Before we can include the subject in the midwifery curricula, we need to concentrate on educating midwifery lecturers and senior clinicians and researchers in order to develop and maintain appropriate standards of safe practice.
We must also remember that the field of “complementary therapies” encompasses many different professional disciplines. Complementary medicine practitioners are increasingly well trained, sometimes to degree level. Their professional bodies have codes of conduct, continuing professional development requirements and disciplinary procedures to maintain standards and safety in the same way as midwifery and nursing. Midwives need to appreciate that lack of knowledge and understanding potentially puts parents and babies, as well as colleagues, managers and their own midwifery registration at risk.
The Alexander technique may benefit expectant mothers with low back pain, sciatica and symphysis pubis discomfort. The Alexander technique aims to teach the woman how to move and use her body mindfully, correcting habitual postures, movements, coordination and balance, as well as patterns of accumulated tension which interfere with the innate ability to move easily and efficiently. Daily activities, - sitting, lying, standing, walking, lifting and other physical activities - become easier by using the body in a more efficient manner, with less risk of pain and discomfort. The Alexander technique is energising because the client learns how to move with less energy expenditure, thus promoting an enhanced sense of wellbeing. Unfortunately, although the Alexander technique is popular amongst actors to assist optimal positioning for voice projection (it was devised by an actor), its use as a general complementary therapy has declined in recent years and it may be difficult for expectant mothers to access a local teacher of the discipline.
If you’re asked by expectant parents about moxibustion for breech presentation, how do you know if it is appropriate or safe for them? The contraindications to moxibustion are the same as for external cephalic version plus hypertension and respiratory conditions such as asthma. These last two reasons are because the heat of the moxa sticks can temporarily increase the blood pressure and the smoke from the burning sticks can cause respiratory irritation.
Are you allergic to any essential oils? Denise has been allergic to geranium for many years, and is now becoming increasingly intolerant to rose oil.Even a brief exposure to geranium when teaching aromatherapy can cause nausea, and prolonged exposure leads to headaches.Geranium and rose share some of the same chemicals which is why rose is also starting to cause symptoms. Other common oils that can trigger allergic reactions include citrus oils - orange, grapefruit, mandarin etc. Denise has also had midwives react adversely to different oils in class - including one midwife who simply took a quick sniff from a bottle of clary sage and had a major respiratory attack. If you have a reaction to inhaling oil vapours it is vitally important not to continue being exposed to that oil as eventually it can cause anaphylactic shock.We'd be interested to know if you have had any adverse reactions to oils.
Frankincense oil is "the ultimate calmer" and a quick sniff of a single drop on a tissue can be very effective for women in the transition phase of labour. The power of frankincense calms the woman and helps her through that last short period before the birth. It's also useful for helping those who are frightened of having blood taken.
Reflexology is NOT the same as foot massage
When reading research studies on reflexology in labour, it's important to clarify what treatment is being given.
There are several studies that claim to reduce labour pain and duration with reflexology, but most studies use basic foot massage and not reflex points on the feet. It's OK in a clinical sense - foot massage can be a wonderful aid to labour care - but there is very little research using specific reflex points to stimulate contractions or reduce pain.
On the other hand, reflex zone therapy, the style of reflexology taught by Expectancy, can be very effective for postdates pregnancy, latent phase, stalled labour and retained placenta.
How many expectant parents with a breech baby have asked you about moxibustion? This Chinese technique, performed from 34 weeks of pregnancy, is around 68% successful in turning a breech to head-down. But there are certain women who shouldn't try moxibustion. If an ECV is contraindicated, then so is moxibustion. Also, high blood pressure - because the heat of the moxa sticks can raise the BP slightly; and asthma or other respiratory condition - because the smoke from the burning moxa sticks can increase symptoms.
Ginger biscuits are NOT the answer to pregnancy sickness! There's not enough ginger in a biscuit to have any therapeutic effect - and the sugar content causes peaks and troughs of blood sugar that can make sickness worse. Ginger tea, made from half a teaspoon of grated root gjnger, may be better but it's not appropriate or safe for everyone. Ginger contains chemicals that thin the blood so should not be used by expectant parents on anticoagulants including aspirin and clexane, or by anyone with a threatened miscarriage.
It’s great to receive compliments and testimonials!
‘I have really enjoyed studying the Diploma in Midwifery Complementary Therapies. Working alongside Denise has been a real privilege, she is a real inspiration and a transformational midwife. I feel focused and motivated to approach my new midwifery career after being guided, supported and skilled by Expectancy.’ Nicola Rai
‘Dr Denise Tiran is simply the most knowledgeable and experienced authority on the subject of midwifery complementary therapies, and I feel extremely privileged to have been a student with Expectancy.’ Alexis Stickland
‘A professional and academic course with lecturers who are also clinicians who share a passion for alternatives to NHS midwifery care.’ Becky Franklin
‘I have thoroughly enjoyed learning with Expectancy and being part of a like-minded community of midwives to be able to develop myself to offer better support for women.’ Charlotte Williams
‘The Diploma is a holistic course aimed at offering women naturally safe options for both their own and their infants’ wellbeing.’ Nicki Hennighan
Denise saw a question from someone planning a home birth about whether she could have her cat and dog with her. The family also wanted to use an aromatherapy difuser during the first stage. But did you know that aromatherapy oils can be toxic to cats and dogs? If an animal inhales the aromas, or if oil comes into contact with the skin, or if the animal ingests the oil (such as licking it off the skin or drinking spilled oil from the floor) it can cause serious side effects. Cats are particularly badly affected because they lack an enzyme needed to metabolise the oils, so the oils can cause liver problems or cause death. Birds, fish and reptiles can also be badly affected. Denise once had a midwife on one of her courses who had been told by the vet that oils would affect her pet iguana! The most significant oils include tea tree, eucalyptus, cinnamon, ylang ylang, peppermint, citrus oils and others. Don't use diffusers in the areas where your animals go - it could be fatal.
Did you know that homeopathic remedies, such as arnica, are chemically very fragile and can be inactivated by strong aromas from essential oils, moxa sticks, Deep Heat and Vicks vapour rub? Expectant parents using homeopathic remedies during pregnancy should also avoid drinking coffee, using mint flavoured toothpaste and chewing mint gum. Homeopathic remedies should not be stored near aromatherapy oils, microwave ovens or mobile 'phones. Birthing parents wanting to take homeopathic remedies during labour should not use aromatherapy.
It's day 2 of our latest postdates pregancy online course today for an NHS trust, and Denise will be talking about natural remedies before Amanda takes over to teach the acupressure. Denise says:
It's worrying when I hear midwives advising parents to try a whole range of natural remedies to start labour, without giving them any advice about how to use them, and without having assessed whether it is appropriate for the individual. All herbal remedies - such as raspberry leaf, clary sage, evening primrose, castor oil - have their benefits but they also have risks if taken inappropriately. Importantly, they should not be combined - this is likely to cause more problems with labour, not fewer. Searching some Facebook pages this morning, I see women are using up to four times the recommended dose of some remedies - such as evening primrose oil - either because they've been given the wrong information or because they've not been given enough information.
Midwives, doulas, antenatal teachers and other birth workers must offer comprehensive advice to enable parents to make informed choices about natural remedies. This includes information on:
And if professionals cannot give this information they should refrain from advising on the remedies. Continuing to do so without adequate knowledge and understanding is as risky as coercing women into induction when their bodies are not ready - and can equally lead to a cascade of intervention. Giving incorrect or incomplete information jeopardises not only the wellbeing of mother and baby but also the registration of the midwife if their advice leads to complications.
I was concerned this week to have a midwife on one of our online postdates pregnancy courses repeatedly challenge what she perceived as the "negativity" of the session on the risks of self-help natural remedies used by women to start labour (raspberry leaf, clary sage, pineapple, castor oil etc). We were discussing the possible complications of these popular remedies and when not to use them - such as in conjunction with medical induction of labour. The issue was not that she had raised the point but that she did not seem to understand the need for midwives to know about the risks in order to advise parents appropriately.
Of even more concern was that this midwife was a manager, yet all she wanted from the course was a "how to do it" on using aromatherapy and acupressure for postdates pregnancy. This is what, in academic terms, is called level 4 thinking, or being a "knowledgeable doer" without the underpinning theoretical understanding that comes with level 6 learning and evidence-based practice. This attitude is particularly prevalent when it comes to learning about complementary therapies in midwifery and reinforces the incorrect and dangerous belief that "natural" equals "safe". It is not enough for midwives only to learn how to mix and administer oils or use pressure points to stimulate contractions. It is vital to appreciate the safety aspects of what we do - even more so perhaps when it comes to complementary therapies as opposed to other aspects of practice. If something has the power to do good, it also has the power to do harm when not used appropriately. We need to know about the risks, both for our own practice and to ensure the advice we give to parents is correct, comprehensive, balanced and evidence-based, so that they can make informed decisions about whether or not to use the remedies and therapies.
Complementary therapies are often denigrated as not being sufficiently evidence-based or not fitting with conventional maternity care options. There is some truth in this although I would not have been teaching the subject to midwives for all these years of I didn't feel we could overcome that and promote the therapies as adding beneficial elements to the care of expectant and birthing parents. However, whilst even midwifery managers remain ignorant of the need to balance the benefits of complentary therapies with some understanding of the risks, we are not going to validate the subject as worthy of being part of standard midwifery practice and safe care of parents. We also risk parents' and babies' wellbeing by not knowing where to draw the line between enjoying the therapies and enjoying them so much that we cause harm.
I have written before about compassionate care and the Human Factors issues in relation to complementary therapies. It is not compassionate or caring to use complementary therapies in a "doing" way without understanding the risks of inappropriate use. Midwives need to get past the "niceness" of introducing complementary therapies into their care and start appreciating the balanced and caring approach that an understanding of possible contraindications, precautions, side effects and complications if therapies are not used correctly.
That midwifery manager needs to re-evaluate her managerial responsibilities to staff for whom she is responsible and for parents in her care to ensure midwives are able to offer complementary therapies safely in her unit.
Here Denise explores some of the issues of teaching birth preparation for expectant parents via the original "hypnobirthing" method.She says:
I recently read a Facebook post from a midwife questioning whether "hypnobirthing" could contribute to birth trauma rather than reducing it. I have to agree with her that the emphasis on expecting birth to be pain-free is not helpful to those in labour who actually DO feel pain despite having learned "hypnobirthing". The essential intense, repetitive, increasingly powerful muscular contractions of the uterus aid the birth process, and like any exercise, everyone experiences it in different ways. Labour is a biological process that, whilst being natural, is a rite of passage for women that CAN be painful - and has been since time immemorial.
What contributes to birth being perceived as more painful than it might be is the psychosocial impact of western society, the medicalisation of childbirth and the contemporary emphasis on "doing it right". "Pain" is a dirty word in "hypnobirthing" classes which sometimes focus so much on imbuing a sense of denial of pain that it can be a real shock when labour is found not to be quite what the parents expected. This can lead to emotional trauma that may have long term consequences including mental ill health, poor bonding with the baby and fear of embarking on another pregnancy.
Further, "hypnobirthing" can place a barrier between mothers and midwives that is unhelpful and unnecessary. Midwives are there to work in partnership with parents, to be their advocates and to guide them through a life event that can make them feel out of control, especially in hospital. Parents enter labour already viewing the midwife as "the enemy", which increases their stress and further contributes to perceiving birth as painful. Some "hypnobirthing" teachers are so anti-establishment that they increase parents' fear of the birth process and the (lack of) care they may receive from midwives.
Birth preparation classes started in the 1950s when Grantly Dick-Read introduced his "birth without fear" principles - and those of "hypnobirthing" are very similar. I have every support for these principles. I taught them myself as a community midwife in the 1980s, long before Mongan coined the now-trendy name of "hypnobirthing" - which is something of a misnomer since it is not actually hypnosis.
Other companies have come along more recently with "new" approaches to birth preparation - but they are all the same under the skin. They provide information and advice, suggestions for physical and mental preparation for birth and parenthood and, in groups, an opportunity to meet other expectant parents. Unfortunately, the demise of much NHS provision of antenatal classes has meant midwives are more and more excluded from birth preparation - which has given these companies inroads into teaching commercially-labelled systems.
There is nothing inherently wrong with any of these systems but let's be honest about what it is we're trying to do - to help expectant parents. Let's stop being divisive, with "hypnobirthing" teachers implying that they have all the answers to a failing NHS maternity service which no longer has time to address the fears and anxieties of its "customers".
Many midwives are moving away from the inflexibility of the original "hypnobirthing" method, adapting the basic principles to be more individualised, and dismissing the notion that birth can always be pain free. We should be honest about birth and help parents to learn strategies to cope with the pain, not to imagine that there will be none. Pain in labour is NOT a negative issue - it is the way we deal with it that is negative. We need to look closely at the long term adverse impact of unrealistic ideas and consider ways that enable parents to embrace birth and to feel a sense of achievement of having coped with whatever happens, whether it is painful or not.
Did you know that seaweed was previously used as a means of dilating the cervix in postdates pregnancy? Laminaria is an algae from seaweed, also known as kelp or kombu. It wastraditionally used to facilitate labour, and remains popular in the USA.
Laminaria has the ability to form a viscous gel in water, and laminaria "tents" are inserted intra-cervically to absorb ambient moisture, gradually swelling to 1 cm diameter over 4-6 hours. This may be due to the presence of a foreign body in the cervix initiating prostaglandin release, or possibly due to a high content of arachidonic acid, a prostaglandin precursor.
However, it can cause pelvic cramping and cervical bleeding and has been associated with fetal hypoxia and intrauterine death. Also, the “tents” can fragment and be retained in the cervical or vaginal canal, causing cervical wall rupture and infection.
Reearch on laminaria shows it is not significantly effective although it may reduce the need for medical induction. The new NICE guideline on induction of labour states that there is insufficient evidence to support its use in postdates pregnancy.
The number of midwives - and NHS trusts - considering complementary therapy training is at an all-time high.
The interest in incorporating aromatherapy, acupuncture, reflexology, hypnosis and moxibustion into midwifery care appears to be a direct consequence of the out-of-control medical management of pregnancy and birth.
But how do you know whether the complementary therapy courses you find are adequate and appropriate for midwives? It's certainly not necessary to be fully qualified in a therapy - and to be honest it's a bit of a waste of time and money to learn how to use aromatherapy, acupuncture or other therapies for non-pregnant women, for men, the elderly or people with cancer. On the other hand, remember that each therapy is a professional discipline in its own right, and midwives cannot expect to know everything after a short introductory course. More importantly, midwives must set the use of complementary therapies in the context of midwifery practice, the NHS and the laws and directives that govern our practice as midwives.
So here's our top ten tips to choosing an appropriate course so you can include complementary therapies in your midwifery care:
1) Is the course accredited by the Royal College of Midwives or other relevant organisation such as the Federation of Antenatal Educators? (It does not have to be accredited by the therapy's regulatory body)
2) Are the teachers experienced midwives, fully qualified in the therapy, with teaching qualifications that provide them with insurance to teach the therapy? (check where, and with whom, they themselves trained)
3) Do the teachers have at least five years' experience of practising the therapy in midwifery, including having implemented the therapy into an NHS setting, as well as at least five years' experience of teaching the therapy to midwives?
4) Is the course taught and assessed at academic level 6 so you understand how to apply principles of the therapy to midwifery practice? (This is very different from an academic level 4 course that just teaches you skills without ensuring understanding)
5) Does the course include the relevant physiology and other sciences (eg chemistry, anatomy, neurology) to aid your understanding of the therapy, especially in pregnancy and birth?
6) Will you learn enough about the safety - contraindications, precautions, side effects, complications and institutional Health and Safety regulations - to give you the confidence to practise the therapy safely?
7) How much attention is given during the course to the Nursing and Midwifery Council Code, other relevant midwifery documents such as medicines management, and the process of change management to help you implement the therapy appropriately?
8) Is there an emphasis on evidence-based practice - do the teachers have experience of researching complementary therapies in relation to pregnancy and birth?
9) What requirements and provisions are there for continuing professional development in the use of the therapy in midwifery, in accordance with the NMC Code?
10) If you want to offer the therapy in private practice, does the course accreditation provide you with the option to obtain appropriate personal professional indemnity insurance? (This is different from the RCM's medical malpractice insurance)
Today, Denise was asked by a midwife who had completed Expectancy’s aromatherapy training, if it’s acceptable to give a telephone consultation to another midwife, not trained in aromatherapy, to enable the non-trained midwife to blend and administer aromatherapy to a birthing person. Denise says:
The answer, I’m afraid, is a resounding “NO”. Midwives need to think about this in the same way as medicines management, their Nursing and Midwifery Council registration and the trust’s vicarious liability insurance. Midwives would not provide a ‘phone consultation to a midwife about a birthing woman she has not met, then prescribe drugs and allow another midwife to dispense and administer them – and the same applies to aromatherapy oils. If you are actually on-site you could do a face to face consultation with the mother, prescribe and blend the oils, leaving a non-trained midwife, student or support worker to administer them under your direction. You cannot be on the community (off-site) or off duty (invalidates your right to vicarious liability insurance) – you must be accessible in case the mother has an adverse reaction so you can deal with it. YOU are accountable for the use of aromatherapy oils (chemicals in the workplace, classified under Health and Safety regulations). If the non-trained midwife makes a mistake, it is YOUR NMC registration that may be in jeopardy as well as theirs. Midwives who are not trained in aromatherapy are NOT permitted to choose (prescribe) or blend (dispense) the oils. The best thing is for those midwives not yet trained to use just carrier oil and provide basic massage, although they must be trained sufficiently to understand any contraindications and precautions and how to record the massage treatment in the notes.
Denise continues to challenge NICE on its inaccuracies when it comes to complementary and alternative medicine. She says:
Having recently seen the revised NICE guideline on induction of labour, currently out for national consultation, I was disappointed - but not surprised - to see a paltry single paragraph on the use of more natural methods to aid labour onset. Basically their stance is that there is insufficient evidence to support the use of almost all complementary therapies (CTs) although they singularly fail to include aromatherapy, one of the most commonly-used methods of encourage contractions, despite a growing body of randomised controlled trials to support its use.
Further, NICE erroneously refers to CTs as “non-pharmacological”. The term “pharmacological” refers to the uses, effects and modes of action of drugs and other chemical substances. Manual therapies such as reflexology and massage, energy-based modalities including acupuncture and homeopathy, and psychological therapies such as clinical hypnosis ARE non-pharmacological as they have different mechanisms of action. However, ALL herbal medicines and aromatherapy oils act in exactly the same way as medicines, being absorbed, distributed, metabolised and excreted, and are, therefore, definitely “pharmacological”. They can interact with drugs and other herbal remedies, and can have serious toxic effects in some cases.
Not only is NICE wrong, but this continued use of terminology that belittles the clinical power of complementary modalities, that do not fit with the politically powerful medical profession’s dominance, is potentially unsafe. Until the medical and allied professions, including midwives, nurses, paramedics, physiotherapists etc, understand the risks of herbal medicines and essential oils when used inappropriately, we will continue to encounter real clinical issues. For example, overuse of raspberry leaf tea has a dose-dependent effect that prolongs rather than shortens pregnancy, and excessive use of clary sage oil in labour can cause cessation of contractions rather than facilitating them.
For more information see Denise’s book, Using Natural Remedies Safely in Pregnancy and Childbirth (2021).
WHO IS RESPONSIBLE FOR PROVIDING ESSENTIAL OILS WHEN MIDWIVES OFFER AROMATHERAPY FOR BIRTH? Denise was very concerned today to hear from a midwife working in a trust in which aromatherapy is offered in the birth centre, but whose community midwives apparently have to purchase their own oils if providing aromatherapy for home births. She says:
Midwives are permitted to use aromatherapy in their practice if they have had adequate training and keep updated, have the trust’s permission and local clinical guidelines – this means they are protected by the trust’s vicarious liability insurance. Chemical substances in the workplace – including aromatherapy oils - are regulated by the Health and Safety at Work Act and Control of Substances Hazardous to Health regulations. Aromatherapy oils must also be used in accordance with the same principles as medicines and must be of good enough quality for safe clinical practice. It is the trust’s responsibility to supply the oils and to ensure they are purchased from a reputable supplier, that expiry dates and batch number are centrally recorded and that there is a system in place to monitor midwives’ practice and record any adverse effects on parents, babies, visitors or staff.
Midwives’ attending home births must remember that the home setting is their place of work and that all the regulations relevant to the birth centre or maternity unit also apply in the community. The oils must be the same brand as those used in the hospital, the individual oils must be included in the trust aromatherapy guideline and midwives must also comply with requirements for safe storage. Asking individual midwives to provide their own oils is not only unethical, it is potentially unsafe. It is akin to asking midwives to purchase their own paracetamol rather than dispensing the trust’s approved brand of the drug.
Compare this situation to a trust in which midwives visiting parents at home are required to request that no one in the home smokes for at least two hours prior to the visit, since the home becomes the midwife’s workplace. The midwives asked me if the same should apply to the use of aromatherapy in the home, especially when parents often use oils to aid contractions during home birth, which may be dangerous for midwives in early pregnancy. In principle, the same cautions should apply to aromatherapy oils as to cigarette smoking. I would far rather the midwives were ultra-cautious like this, than irresponsibly maverick as in the first trust.
Midwives studying our Diploma and preparing for private practice through our Licensed Consultancy scheme had a great "finance" webinar last night with the wonderful Joanne Bell from Bell's Accountants in southeast London. We discussed starting up in business and what expenses you can claim, dealing with HMRC, completing self-assessment returns, VAT and Corporation tax and much more.
If you're thinking of moving into private practice, there's so much to learn. On our business training module we include everything you need to know about starting and growing your business, advertising and marketing, legal and professional aspects including avoiding conflicts of interest for midwives continuing to work in the NHS and much more. It's a whole new world when you step outside the comparative safety of the NHS to become self employed!
Now the lockdown is being lifted it seems that midwives are keen to get back to working in ways that enhance care. We've been inundated with enquiries for training in maternity units and birth centres, with requests for everything from aromatherapy and postdates pregnancy to hypnosis and acupuncture. Denise comments:
The interest in using complementary therapies for labour and birth is at an all-time high. It's as if the plug has been pulled on the pandemic and midwives are desperate to provide holistic care for expectant parents so that their birthing experiences are memorable for all the right reasons.
Complementary therapies offer so many ways to help, not just for relaxation, but for pain relief and aiding progress, for dealing with all those symptoms of pregnancy and sometimes for treating problems that occur. When used appropriately and cautiously, complementary therapies can make the difference between a home or hospital birth or between a physiological or medically managed birth.
However, whilst the NHS website and NICE guidelines are right to advise caution, their reliance on evidence to support the use of CTs - and consequent advice to parents to use them as.little as possible is missing the point. Expectant parents ARE using CTs, they want them to be available for birth and are prepared to pay for therapies during pregnancy.
This means that midwives have a duty to know more about CTs and natural remedies so they can advise parents about using them safely. Yet the revised 2020 education standards for.midwifery from the Nursing and Midwifery Council have removed any overt mention of CTs to be included in pre-registration midwifery programmes.
From a national, regulatory perspective CTs continue to be marginalised and disregarded. From the parents' perspective, this is something they want, sometimes without understanding the possible risks of misuse - so midwives have a duty to help. Conversely, we only have to look at the number of maternity units wanting to offer CTs to see that grass-roots midwives are trying to respond to the demand. Isn't it about time the NHS accepted this and took steps to accommodate the public's desire to use CTs whilst still advising caution?
Whilst around 5% of expectant parents experience excessive nausea and vomiting in pregnancy, with dehydration and weight loss, even more suffer mild to moderate sickness which does not normally require medical attention or hospital admission. Many women cope with mild symptoms but it is those caught in the middle, with ongoing vomiting and constant nausea who may need support which is not readily available. Midwives and GPs are ill equipped to help them and often make inappropriate suggestions such as the ubiquitous advice to “try ginger biscuits”, which is neither universally appropriate nor safe. Therapeutic doses of fresh root ginger (about 1gm daily) may help some but should be avoided by those with any bleeding or who are taking anticoagulant drugs such as heparin, enoxaparin or even preventative aspirin. Travel sickness bands may help – these are based on an acupuncture point on the inner wrist. Or try the Morningwell™ app which uses sound pulsations that bounce on the balancing centre in the ear to reduce nausea. Even more effective is acupuncture or homeopathy from a qualified practitioner. Aromatherapy oils are not always effective and may make symptoms worse if the nausea is exacerbated by smells.
Denise and Amanda were teaching our popular online course on complementary therapies for post dates pregnancy this weekend. Reflexology can be useful to start labour, but there are some concerns about inappropriate treatments. Denise says:
Many practitioners believe that contractions can be stimulated by massaging the area of the foot that represents the reflex area for the uterus - on the inner heel. However this is incorrect and potentially dangerous as overzealous stimulation of these areas may lead to placental separation. Labour contractions need oxytocin from the pituitary gland to activate the uterus, so it is more appropriate to work on the reflex zones for the pituitary gland - on the big toes.
However, my research over many years suggests that the pituitary gland reflex zone is not where many practitioners traditionally position it. I place the pituitary reflex zone on the outer side of the big toes, nearest to the second toe. I also found that the reflex zone on the right foot reflects the anterior pituitary gland while that on the left corresponds to the posterior pituitary gland.
Further, this relocation was confirmed in my research on using reflex points to detect stages of the menstrual cycle. It is possible to use these points to work out which ovary is active, estimate where in the cycle the woman is, and then to predict the next menstrual period. This process can then be applied to pregnant women, to predict the imminence of the onset of labour.
Denise was contacted today by a midwife concerned to see an Instagram post from a US midwife who advocated placing an opened bottle of essential oil to the nose of a newborn to calm the baby (and to promote a particular brand of oils). Here is Denise’s reply:
Newborn babies should not be exposed to - and especially not treated with - essential oils for five very significant physiological reasons: 1) the skin is very sensitive and dermal contact may cause severe skin irritation 2) the aroma masks the baby's ability to use their sense of smell to recognise their mother 3) all essential oils are metabolised via the liver and the neonatal liver is immature – inhaling oil chemicals could risk increased jaundice, possibly even kernicterus 4) the neonate has an immature blood brain barrier - inhaling oils causes rapid, potentially toxic absorption to the brain, risking jitteriness 5) all essential oils are antibacterial - neonatal exposure to oil vapours could interfere with the maturation of immune system, which could lead to a lifelong difficulty in fighting infection
In this interesting video, academics, researchers and medics discuss homeopathy and the presumed "placebo" effect.
Denise comments: Homeopathy is a little-understood complementary modality that can be useful in pregnancy and birth. Highly diluted and agitated (shaken) substances release energetic potential to treat "like with like". If a substance is completely inert, it will have no effects at all - but this is not the case with homeopathy. Remember, if something has the power to do good, it also has the potential to do harm when not used correctly. Excessive or inappropriate homeopathic use can trigger the symptoms the remedy aims to treat. Homeopathic arnica, can be useful to reduce perineal trauma and bruising after birth, but excessive use may trigger a reverse effect, leading to systemic bruising. This is NOT a placebo effect. For more on homeopathy and herbal remedies, see Denise's book Using Natural Remedies Safely in Pregnancy and Childbirth (2021).
Did you know that using too much clary sage aromatherapy oil to aid labour contractions can have the opposite and actually stop labour? Here, Denise discusses the growing incidence of hyperpolarisation arising from misuse of clary sage oil in labour.
Clary sage is one of the most misused aromatherapy oils for labour. There is no doubt that it can aid the onset of labour when a woman is overdue. It may also help to accelerate the latent phase, encouraging contractions to become well established. However, both parents and professionals are over-using clary sage to the extent that I now receive reports on a regular basis of situations where labour has slowed down or even stopped despite the use of clary sage. Clary sage oil should be considered to be aromatherapy’s equivalent of oxytocin and should only be used when there is a justification to use it to aid contractions; it is, of course, completely contraindicated until term pregnancy (37 weeks).
Prolonged use, excessive doses or continual environmental diffusion of clary sage oil can, in the first instance, cause excessively strong uterine contractions, possibly leading to fetal distress. However, continuing to use clary sage oil, administered either by inhalation or via the skin, may eventually cause a situation in which contractions slow down and eventually stop. This is a condition called hyperpolarisation, an effect that can occur with any pharmacological agent, including drugs, herbal remedies and aromatherapy essential oils. When a drug / oil is commenced, it triggers an action potential of the neurons in the relevant organ to make the body receptive to the substance (this process is called depolarisation). In the case of clary sage oil, it stimulates an action potential to encourage the uterine muscles to contract. Eventually, a stage of optimum effect is reached, after which the oil becomes less effective (repolarisation). Ultimately, a state of hyperpolarisation is reached, in which the clary sage oil will start to have the opposite effect, namely relaxing the uterine muscles and interfering with the progress of physiological labour.
To prevent clary sage oil causing hyperpolarisation and leading to reduced or no contractions, midwives should:
Is It Unethical To Use Fragrance To Attract Custom?
Knowledge is Important
Self Care for Midwives
Individualisation Is The Key To Diversity
Embracing Complementary Therapies
Old Books For New:
Z is for ZuSanLi
Y is for ylang ylang