Chapter 18 Complementary therapies in maternity care
Responsibilities of midwives
By the end of this chapter, you will have an awareness of:
There is a huge public interest in complementary therapies (CTs) as an adjunct to conventional healthcare, perhaps due in part to the emphasis on the holistic approach to care in which psychosocial factors are seen to interact with the biological aspects – the body–mind–spirit approach. During pregnancy, women demand more choices and wish to remain in control of their bodies during a period when they can feel very vulnerable. Increasingly, mothers request information and advice on natural remedies since they are often unable to use prescribed drugs to deal with the discomforts of pregnancy, labour and the puerperium. Many women have already consulted independent complementary therapists before conception, either for themselves or for their families, and want to continue to do so once pregnant. Some mothers may wish to seek alternatives to conventional care for the various discomforts of pregnancy, or they may wish to be accompanied in labour by an independent therapist. Enabling women to use CTs empowers them in the childbearing process and provides them with additional resources, which are not only therapeutically effective but also often relaxing and calming. Increasingly, too, midwives wish to incorporate CTs into their own repertoire of tools for assisting mothers during pregnancy, labour and the puerperium.
However, it is essential not to view ‘complementary therapies’ simply as a single ‘add-on’ to maternity care, but to appreciate that there are several hundred different modalities, each with its own specialist knowledge and skills. There are about 20 therapies commonly in use in the UK today and expectant mothers frequently consult practitioners of massage, reflexology, aromatherapy, acupuncture, shiatsu and hypnosis, or self-administer natural remedies, including herbal, homeopathic and Bach flower remedies. Many midwives now train in specific therapies and are tasked with establishing a complementary therapy service, such as aromatherapy or reflexology, in their maternity unit, especially since the development of low-risk birthing units and efforts to normalize birth and reduce soaring caesarean section rates. There are several examples of maternity CTs services which have been set up by midwives (Burns et al 2000, Dhany 2008, Lythgoe & Metcalfe 2008, Tiran 2001). In Oxford, midwives were trained to use a limited number of essential aromatherapy oils for women in labour and offered the service to over 8000 women over a 9-year period (Burns et al 2000). It was found that mothers greatly enjoyed the aromatherapy for relaxation, pain relief and to facilitate progress, and that maternal satisfaction in their overall labour care was greatly enhanced. It was also shown that essential oils decreased the need for conventional pharmacological analgesics and oxytocics, without compromising safety, as there was less than a 1% incidence of side-effects, all minor, and none affecting fetal wellbeing. Furthermore, an unexpected finding was that midwifery recruitment and retention was improved, as midwives actively chose to work in a unit in which they were encouraged to return to the nurturing of being ‘with woman’.
The subject area of complementary therapies in maternity care is a speciality in its own right and is far too complex to cover in a single chapter, especially since many therapies are discrete academic and clinical disciplines, many of which have been covered in depth elsewhere. This chapter therefore explores some of the issues pertinent to the use of CTs in midwifery practice, provides a glossary of terms for the most commonly used therapies, and directs the reader to further sources of information.
Midwives are permitted to advise on or to administer CTs and natural remedies if they are adequately and appropriately trained to do so and can justify their actions. The 2008 code specifically identifies that ‘the use of complementary and alternative therapies must be safe and in the best interests of those in your care’ (NMC 2008:7). Enthusiasm for integrating CTs into midwifery practice must be balanced by comprehensive contemporary knowledge and understanding, ‘based on best available research evidence or best practice’, so that efficacy can be measured and safety can be assured (NMC 2008:7), and any advice on, or suggestions for, healthcare products and services should be evidence-based. Additionally, registrants should work within the limits of their competence and maintain up-to-date practice through ‘appropriate learning and practice activities’ (NMC 2008:7). These guidelines can be interpreted according to whether the midwife is caring for women who wish to administer their own natural remedies, women who wish to seek alternative practitioners outside the conventional maternity services, and who are accompanied in labour by a practitioner of CTs, or if the midwife wishes to incorporate CTs into her own practice.
Reflective activity 18.1
Brainstorm with a colleague to find out how many different complementary therapies you can name.
Midwives should recognize that women have the right to self-administer natural remedies. If the midwife is unfamiliar with the effects, indications, contraindications and side-effects, she should discuss this with the mother and, if necessary, consult an appropriately trained practitioner of the relevant therapy for advice, or ‘make a referral to another practitioner when it is in the best interests’ of the mother or baby (NMC 2008:5). It would be wise to enquire, when taking the initial booking history, whether the mother uses any natural remedies, such as aromatherapy oils, herbal, homeopathic and Bach flower remedies, in the same way as enquiring about the use of over-the-counter and recreational drugs. Not only does this implicitly give the mother ‘permission’ to discuss complementary therapies, but it will also alert the midwife to any potential problems which may arise, for example, interactions with drugs or exacerbation of existing medical problems. It is, however, necessary for the midwife to have a basic appreciation of the different therapies in order to assist the mother, for example, understanding the difference between herbal and homeopathic medicines.
It is essential that midwives ‘maintain clear and accurate records’ of (any) discussions which they have with the mother about CTs (NMC 2008:8), including recording any questions asked by the mother about CTs or natural remedies. A common subject for discussion is the use of ginger for ‘morning sickness’, with women almost universally (and many midwives) believing, incorrectly, that ginger biscuits offer a suitable remedy to resolve this symptom (personal communications with mothers and midwives). Ginger is not a universal remedy for nausea and vomiting, for whilst it may be effective for some women, it is not safe for those on anticoagulants and other similar medications or for those with blood clotting disorders (Marcus & Snodgrass 2005, Tiran & Budd 2005). In some women the use of ginger will exacerbate their symptoms and may trigger others, such as heartburn. Furthermore, ginger biscuits are not the means by which women should take ginger as there is insufficient real ginger in them to be effective in the long term. Women may obtain temporary relief, but this is mostly as a result of the sugar content of the biscuits increasing blood sugar levels.
Another common question is about the use of the popular herbal remedy raspberry leaf tea to tone the uterus in preparation for childbirth, typically asked by the mother as she is leaving the antenatal clinic. Unfortunately, the way in which midwives often tackle this question demonstrates an example of the ‘Chinese whispers effect’ which pervades midwifery practice, with many midwives having gleaned a little information overheard from colleagues. Some midwives inappropriately interpret this as sufficient ‘learning’ to permit them to provide women with advice on the subject, which is at best superficial, and sometimes incorrect, potentially even dangerous, particularly as herbal remedies act pharmacologically and can interfere with prescribed medication.
It is essential that midwives understand the contraindications and precautions to raspberry leaf prior to giving specific advice to women, and refer to an expert in the event that their knowledge is incomplete. Many midwives advise women to start taking raspberry leaf after 37 weeks’ gestation, a laudable but incorrect precautionary measure to prevent preterm labour. However, if a mother wishes to take raspberry leaf, she should be advised to start taking it earlier, at about 32 weeks’ gestation, to allow time for her body to become accustomed to the effects. She should increase the dose gradually from one cup of the tea or one tablet daily to a maximum of four, taking into account any adverse effects on the Braxton Hicks contractions and, if necessary, reducing the dose accordingly.
The use of raspberry leaf as a routine does pose an ethical question about whether or not it is absolutely essential, since any pharmacological agent taken inappropriately can complicate normal physiology, and it may be preferable to advise women with a history of normal eutocic labour to refrain from taking the remedy. Women with any uterine compromise should be advised not to take raspberry leaf. This includes those with a previous caesarean section scar, history of preterm or precipitate labour, multiple pregnancy, those due to have an elective caesarean, or mothers with major medical conditions for which they are receiving combined obstetrician/physician care (Parsons et al 1999, Simpson et al 2001).
Some mothers wish to self-administer natural remedies during labour, such as essential oils or homeopathic remedies. They have the right to do so and should be facilitated in this wish where possible, but the midwife should record in the mother’s notes and on the partogram when she uses a remedy, even if the midwife is unaware of its action. If the midwife feels, at any time, that using the remedy may be detrimental to maternal or fetal health, the midwife must discuss the situation with the mother, and consult a relevant expert, if possible, to ascertain safety (NMC 2008).
Essential oils, used in aromatherapy, are extremely popular but should be used cautiously since they can affect everyone in the room. Midwives, other staff and the woman’s partner and relatives may be adversely affected by inhaling the aromas of the oils, since their chemical constituents can cause drowsiness, nausea or headaches. If it is possible to smell the aromas, the chemicals from the oils are present in the air and will be inhaled. It is not acceptable to use vaporizers with a naked flame in an institutional setting, and if the mother brings an electrical vaporizer into the maternity unit, the wiring will need to be checked by the hospital electrician prior to use. Pre-planning is necessary if the mother is to obtain the most effectiveness from the vaporizer, which should be left on for no more than 10–15 minutes at a time. Pregnant midwives should not be exposed to essential oils known to aid uterine contractions, particularly clary sage and jasmine, as well as large doses of lavender, and volatile essential oils should not be used within the anaesthetic room or operating theatre (Tiran 2005).
If the mother wishes to use herbal remedies, which act pharmacologically – and this includes essential oils – care needs to be taken regarding possible interactions with any other drugs the mother may require. For example, pethidine and nutmeg essential oil both have a narcotic effect (Grover et al 2002), which may exacerbate any hallucinatory effect and could compromise respiration, especially in the neonate. Lavender is known to reduce blood pressure (Hur et al 2007; Kiecolt-Glaser et al 2008), so it may be wise to refrain from using lavender oil once the mother has requested epidural analgesia. Clary sage has shown some promising effects on uterine action (Burns et al 2000, Lis-Balchin & Hart 1997), but, by inference, should not be used concomitantly with oxytocics.
Conversely, homeopathic remedies do not act pharmacologically so will not interact with prescribed medications, but need to be used correctly to avoid triggering new symptoms in response to the initial dose (Tiran 2008). Some mothers purchase special ‘childbirth homeopathic kits’ which include brief instructions on use, but midwives should remember that, as labour progresses, the mother may be less able to make an objective decision regarding the most appropriate remedy, for what is, after all, a very dynamic and rapidly changing clinical situation.
Mothers sometimes ask the midwife about visiting an independent therapist, such as an osteopath for backache and sciatica in pregnancy, or a hypnotherapist to prepare for labour. The midwife should record any conversations regarding external therapists and the reasons the mother gives for consulting them.
Practitioners of some therapies can be guaranteed to have received adequate training to treat pregnant women safely. For example, osteopaths and chiropractors, whose professions are statutorily regulated in the same way as midwifery, will have completed a standard nationally regulated pre-registration training which includes reproductive health. However, most therapies are not nationally regulated nor are the training programmes necessarily of the most appropriate academic calibre to prepare practitioners to treat pregnant women at the point of qualification. It is of concern that some therapists presume to treat, even to specialize in treating, expectant mothers without any relevant post-qualifying education (personal communications with therapists). Therefore, midwives should be wary of recommending specific therapies or therapists unless they can vouch for their credentials. It is permissible for midwives to recommend named individuals if they have become acquainted with local reputable and suitably trained therapists, and this may be preferable to leaving a mother to select from advertisements in the local telephone directory. However, if the midwife is not familiar with local practitioners, she should advise the mother to ask about the therapist’s training, experience of, and educational preparation for treating pregnant women and to ensure that the therapist is in possession of personal professional indemnity insurance cover. See also ‘Additional resources’ on website.
A contemporary trend of particular concern is that of mothers nearing term asking therapists to facilitate the onset of labour. This is often before the estimated delivery date and, most commonly, it appears to be reflexologists who are consulted (personal communications with mothers and therapists). Women should be advised that it would be inappropriate to attempt to expedite labour before term and that any intervention, even those which are ‘natural’, could complicate maternal physiology and trigger the cascade of intervention which can occur with a medicalized induction (Tiran 2010). On the other hand, if the mother progresses beyond her expected date and is being ‘threatened’ with prostin or syntocinon, this may be adequate justification for receiving CTs, such as shiatsu or acupuncture, to facilitate cervical ripening and may make the difference between spontaneous or induced onset of labour (Ingram et al 2005, Lee et al 2004). It is, however, important that midwives and therapists liaise to ensure safe care for the mother.
Some women choose to be accompanied in labour by a lay person who is able to provide complementary therapies. This may be a qualified therapist, or a doula (birth companion) who has acquired some skills in CTs, but who may not always be adequately trained or insured to use them. The midwife remains accountable for the mother’s care and has a duty to ensure that intrapartum care is safe and in keeping with normal midwifery care. It is, of course, preferable to encourage the mother to inform her midwife during pregnancy if she thinks she may have a therapist or doula with her during labour. However, occasionally a mother may present in the delivery suite with her supporter, without prior warning.
The midwife should record in the notes and on the partogram when natural remedies or complementary therapies are being used. Some trusts require independent therapists to sign a disclaimer form stating that the therapist acknowledges that the midwife remains responsible for the mother’s care, that they have independent insurance cover and that, in the event of an emergency, they agree to discontinue CTs and facilitate the midwife to manage the situation. As with other occasions, if the midwife believes that CTs are inappropriate, she should discuss this with the mother and her lay carer and record the outcome of any discussion.
If a midwife wishes to use complementary therapies in her own practice, it is not necessary to be a fully qualified practitioner but it is essential to be able to apply principles of the therapy to reproductive physiopathology and to the use of that therapy within an institutional setting. For example, midwives could learn the chemistry, indications, contraindications and precautions, methods of administration and possible side-effects of a selected number of essential oils for use in labour without needing to be fully qualified aromatherapists, but must also relate their use to health and safety issues within the delivery suite, such as not using a vaporizer with a naked flame to dispense aromas into the air because of the fire risks. It would also be acceptable to learn the skill of moxibustion to turn a breech-presenting fetus to cephalic, without becoming a fully qualified practitioner of traditional Chinese medicine (TCM), but midwives would need to fully understand the mechanism of action, indications and contraindications of the technique and have a working knowledge of conventional management of breech presentation.
It is certainly not acceptable for midwives to ‘dabble’ in complementary therapies, for not only are they jeopardizing the health of women and babies but also they are risking their own professional careers. A genuine desire to act as the mother’s advocate by facilitating her use of complementary therapies has, unfortunately, led to numerous examples of midwives who overhear appropriately trained colleagues giving advice on natural remedies but who then take the information they have heard as accurate and proceed to offer this to other women in their care, without adequate training. Common examples are advice about herbal medicines, such as raspberry leaf to aid labour or cabbage leaves to ease breast engorgement, aromatherapy, including lavender and clary sage for labour, or homeopathy, such as arnica for post-episiotomy pain. Sadly, in this day of frequent litigation, it is essential for midwives to acknowledge the risks of any clinical intervention and be able to justify their actions if they are required to do so in a court of law. It is also vital to recognize that, just because complementary therapies are ‘natural’, this does not mean that they are always automatically safe.
The issues for midwives incorporating complementary therapies into their practice are summarized in Box 18.1.
Obtaining informed consent and maintaining contemporaneous records is vital, as in all other aspects of care, and midwives must appreciate the limitations of their own professional practice. The NMC regulates the practice of nurses, midwives and health visitors, in order to protect the public, but can only regulate midwives’ use of complementary therapies when it relates to their midwifery practice. It is not possible for qualifications in different therapies to be added to an individual’s entry on the NMC register. It is also important for the midwife to undertake continuing professional development, both of her midwifery practice and the relevant complementary therapy.
When working in an employment situation, rather than as an independent practitioner, midwives wishing to implement CTs within the unit will also need to develop and gain approval for the relevant guidelines and protocols. These should state clearly the rationale for incorporating the specific elements of CTs into midwifery practice, supported by contemporary research or authoritative references. The guidelines should state which midwives are eligible to use the therapy, based on having acquired the relevant initial knowledge and skills and maintaining these via continuing professional development. They may also state which midwives should not use the therapy; for example, it may be advisable to exclude pregnant midwives from using uterotonic essential oils in the labour ward. The guidelines should also identify which mothers may receive the therapy and those for whom it is inappropriate. An example might be the establishment of a reflexology service within the delivery suite, from which mothers with medical or obstetric problems may need to be excluded. Other specific information regarding the use of a particular therapy may be included in a precise protocol, for example moxibustion for breech presentation.
If a midwife is appropriately trained in aspects of complementary therapy and has the permission of her employing authority to incorporate this into her practice, the Royal College of Midwives’ and the Royal College of Nursing’s personal professional indemnity insurance schemes provide suitable cover. However, the vicarious liability cover of the employing authority will be invalidated unless the midwife has gained permission of the relevant authorities to use complementary therapies in her work. If the midwife also chooses to practise independently as a therapist, she should at present arrange additional insurance cover through one of the complementary therapy organizations; the Royal College of Nursing indemnity insurance covers midwives wishing to use complementary therapies in private practice, but the Royal College of Midwives does not (2010).
Acupuncture is based on the principle that the body has energy lines, called meridians, running through it, which link one part of the body to another. There are 365 meridians with over 2000 focus points where energy is concentrated – acupuncture points. When the body, mind and spirit are in optimum health, energy flows along the meridians unimpeded, but disorder or disease causes blockages (stagnation) or over-stimulation (excess) of energy at specific points. Acupuncture needles may be inserted to rebalance the body’s internal energy and facilitate a return to homeostasis. Acupressure involves the use of thumb pressure to stimulate or sedate the acupuncture points. Acupuncture and acupressure have been effectively used for ‘morning sickness’ and induction of labour (Can Gürkan & Arslan 2008, Gaudernack et al 2006, Helmreich et al 2006, Selmer-Olsen et al 2007, Shin et al 2007).
Aromatherapy, an aspect of herbal medicine, involves the use of highly concentrated essential oils extracted from plants, the chemical constituents of which have various therapeutic purposes. The therapeutic benefits – or possible risks – of aromatherapy are due to a combination of the chemistry, the effects of the aromas on the limbic system in the brain and the method of administration, most commonly massage, but also added to water, for example in the bath, or used in compresses, suppositories, pessaries, creams, lotions or inhalations. Oral use is not encouraged and, with very few exceptions, oils should not be applied to the skin neat because the chemical constituents may cause skin reactions. Many essential oils are contraindicated during pregnancy, labour and breastfeeding and are contraindicated completely in neonates. Some essential oils are known to raise the blood pressure, others lower it; some potentiate the action of certain drugs or alcohol; all have a range of anti-infective properties. Many oils are relaxing and some contain chemicals that are analgesic. (See Tiran 2000, 2005.)
Bach flower remedies (BFRs) are liquid preparations prepared from 38 flowers using minute doses similar to homeopathy, but prepared differently. This form of vibrational medicine aims to treat the emotional symptoms associated with disease and disorder. Rescue Remedy, the best known, is a combination of five of the 38 remedies and is used for stress, panic and nervous tension, which could be useful for women in the transition stage of labour. There is limited research into BFRs but there is some suggestion that they may have a part to play in relieving pain through psychophysiological effects (Howard 2007), whereas any impact on stress, anxiety and panic is attributed to the placebo effect (Walach 2001).
Chiropractic is statutorily regulated by the General Chiropractic Council and is concerned with the relationship of the nervous system to the mechanical structure of the body and places emphasis on spinal joints as well as related muscles and ligaments. It is particularly appropriate for musculoskeletal conditions of pregnancy, especially symphysis pubis diastasis and sacroiliac joint pain (Leboeuf-Yde et al 2002, Lisi 2006).
Herbal medicine involves the medicinal use of plants and works pharmacologically in exactly the same way as drugs, which poses the potential problem of interactions with other medication; there is an immense body of research evidence to demonstrate this. Many herbal preparations are contraindicated during pregnancy as they may affect embryonic development, cause miscarriage, or affect the mother’s systemic wellbeing, for example raising the blood pressure or interfering with clotting mechanisms (Dugoua et al 2006a, 2006b, 2008).
Homeopathy involves the use of minute doses of substances which, if given in their full dose, would actually cause the problems they are attempting to treat. It does not work pharmacologically but is a powerful form of energy medicine, and should not be considered harmless. Remedies must be individually prescribed according to the precise symptom picture, but also take into account the individual’s personality and factors that exacerbate or inhibit symptoms. The popular remedy arnica is used to combat bruising, trauma and shock (Oberbaum et al 2005, Seeley et al 2006).
Hypnotherapy is the clinical use of deep relaxation to access the subconscious mind, often likened to daydreaming, and can be used to change behaviour, such as habitual and addictive behaviours. It has been used to good effect to alter women’s perceptions of labour pain (Cyna et al 2006, VandeVusse et al 2007).
Massage is the applied use of touch and is effective for relieving stress, aiding relaxation, reducing blood pressure and inducing sleep. Touch impulses reach the brain more quickly than pain impulses; therefore massage is effective in easing discomfort in labour (Chang et al 2006, Kimber et al 2008, McNabb et al 2006). Massage can also work to stimulate areas of the body, including excretory processes and the circulation. Baby massage has become increasingly popular and has been found to be of particular benefit for preterm babies (Lahat et al 2007; Mendes & Procianoy 2008).
Moxibustion is an element of TCM in which sticks of dried compressed mugwort, a herb, are used as a heat source to stimulate acupuncture points where energy is deficient. It is best known in maternity care for effectively turning breech presentations to cephalic (Cardini et al 2005, Neri et al 2007, Tiran 2004, Vas et al 2008).
Osteopathy is statutorily regulated by the General Osteopathic Council and aims to restore and maintain balance within the body, particularly in the relationships between the neural, muscular and skeletal systems and by examining and maintaining the biomechanical functioning of the body. It is particularly effective for the treatment of back pain in pregnancy but can be useful for other problems, for example heartburn or carpal tunnel syndrome (Krueger 2006; Tettambel 2007).
Reflexology is based on the principle that the feet (and hands) represent a map of the rest of the body, so that by working on specific areas of the feet, other distal parts of the body can be treated, and is thought to be related to acupuncture meridians. Reflexology is not simply foot massage, but a very powerful therapy which should be used with caution in pregnancy unless the practitioner has a thorough working knowledge of physiopathology (see Tiran 2002).
Shiatsu is a contemporary Japanese form of acupressure incorporating the use of simple pressure and holding techniques combined with gentle stretching. Touch is used as a means of adjusting the internal energies of the body, in both treating and preventing energy imbalances (see references for acupressure).
Traditional Chinese medicine (TCM) is a complete system of traditional medicine involving acupuncture, including cupping (placing special cups over acupuncture points to draw out heat), moxibustion, special massage (tuina) and Chinese herbs (Dengfeng et al 2007, Li 2007; see also references for acupuncture and moxibustion).
Yoga involves learning a series of postures and positions, often in conjunction with meditation and breathing techniques, for relaxation and relief of symptoms. It encourages flexibility, suppleness and strength and is valuable for preparing for labour (Chuntharapat et al 2008, Narendran et al 2005).
Conclusion
Mothers increasingly turn to complementary therapies to expand their options during pregnancy, labour and the puerperium, for relaxation and for specific physiological discomforts. As the general public’s use of CTs has risen, so too has the possibility that pregnant women will ask their midwives about the use of CTs. Midwives are in an invaluable position to facilitate women’s desires but must balance their enthusiasm for the benefits of CTs with an appreciation of the potential safety issues, and recognize their own professional boundaries when advising mothers. Whilst all midwives should have a basic understanding of the principles, the use of complementary therapies within midwifery is a specialist area of practice. In the same way as some midwives specialize in obstetric ultrasound scanning, parent education, or caring for women with high-risk pregnancies, so too should CTs be seen as a broad subject area which requires in-depth knowledge and skills.
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