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Importance of Obstetric Knowledge for Complementary Practitioners

by Denise Tiran(more info)

listed in women's health, originally published in issue 131 - January 2007

Expectant mothers are increasingly keen to use complementary therapies and remedies for a more natural approach to pregnancy and childbirth. This is, in part, due to a desire to regain control over a normal life process which has become ever-more technological and medically dominated. Women also crave attention, not just for their physical needs but also for their emotional, social and spiritual wellbeing, during pregnancy and in the early days of parenthood. Some women self-administer natural remedies prior to conception, or have consulted practitioners about their own or their family’s health; according to surveys, as many as 55% of mothers-to-be use herbal medicines,[1-2] perhaps in the mistaken belief that they are ‘safer’ than drugs. Others seek complementary therapies for the first time when pregnant, both for relaxation and for non-pharmacological treatment of discomforts such as nausea and backache, or as alternatives to resolve problems, such as opting for acupuncture for a breech (bottom first) baby.

Increasingly, complementary therapies are recommended by midwives or doctors, and occasionally may be offered as an adjunct to normal maternity care. It is estimated that about one-third of midwives use one or more complementary therapies in their work,[3] and the integration of complementary therapies into maternity  care is well documented, including Aromatherapy;[4] Reflexology;[5-6] and Acupuncture.[7-8] In contemporary maternity care midwifery managers view complementary therapies as a means of maintaining – or perhaps regaining – the normality of childbirth, and also as a cost-effective option, which brings greater satisfaction and extra choices for mothers as well as additional tools to enable midwives to help them.

Pregnancy should not be seen as an illness or medical ‘condition’ – it is a normal life event, but the huge adaptations in the mother’s body and the fact that therapists are effectively treating two clients, requires practitioners to have a good working knowledge of pregnancy and related issues. Bear in mind that over half-a-million babies are born in Britain every year, so it is highly likely that therapists will come into contact in their day-to-day practice with pregnant or newly delivered mothers, or with women trying to conceive. Some of these women may conceive while receiving complementary therapies for other reasons, or may consult a complementary practitioner for treatment of infertility or for relief of pregnancy symptoms. Some maternity units now welcome complementary practitioners to contribute to the care of childbearing women, for example accompanying clients in labour. The growth of the doula movement, in which lay women offer physical, emotional and practical support to labouring women and act as their advocate to help them achieve a satisfying birth experience, also focuses on the value of various therapies for relaxation and as an alternative or an adjunct to conventional pain relief.

However, therapists sometimes decline to treat women once they become pregnant for fear that they may do ‘something wrong’ which may lead to complications. For example, there is currently no universally-approved list of ‘safe’ essential oils that can be used in the pre-conception or ante-natal periods, although there is more evidence available on the safety of whole plants, as used in medical herbalism, and a growing body of knowledge on the possible dangers of herbs in pregnancy, especially when combined with conventional drugs.  There is also a widely held misconception amongst practitioners of many therapies that treatment should be withheld in the first three months of pregnancy in case they (the therapists) ‘cause’ a miscarriage. Nevertheless, it can be stated categorically that complementary therapies, used accurately and appropriately, will not cause miscarriage, which is a reaction of the mother’s body to a pregnancy which is not meant to be.

Education – Knowledge and Skills to Increase Competence and Confidence


This, however, is just the issue – Complementary Therapies must be used accurately and appropriately. Practitioners must have a comprehensive understanding of the ways in which their therapies interact with the physiology and potential complications of pregnancy, labour and the early post-natal period. For example, Aromatherapists must appreciate how ante-natal changes in the skin and sense of smell affect absorption and the effects of essential oils; massage therapists must acknowledge how hormonal effects on the musculoskeletal system may impact on the positioning of the mother; Reflexologists must understand that pregnant women can have profound responses and that shorter treatments may be required. If therapies are combined it is important to be aware of the possible implications of each aspect of treatment. For example, the masseuse who integrates Shiatsu/Acupressure points into a full body massage needs to know which points to avoid in pregnancy, as they may stimulate premature labour, and the yoga teacher who advises Bach flower remedies to reduce stress should take into account their ‘onion peeling’ effect which in pregnancy can trigger release of repressed emotions.

Fortunately, emergencies are rare, but it is also important to know what to do if problems arise, and equally to be able to recognize when it is inappropriate to treat expectant mothers, for example in the event of severe frontal headache in late pregnancy,  which may be a symptom of impending fits related to pre-eclampsia (gestational hypertension).The benefits and potential risks of using complementary therapies in pregnancy and childbirth must be balanced, based on currently available research evidence, in order to provide women with information and care which is not only effective and satisfying but also safe. A particular area of concern is the current trend for an apparently increasing number of therapists to agree to help women start labour, yet rarely do these practitioners recognize that induction of labour is a medical treatment for a specific medical problem, and that artificially attempting to force the mother’s body into labour before it is ready can frequently lead to a cascade of complications.

Very little theory and practice in relation to pregnancy, is included in the majority of pre-registration courses for therapists. Although courses now require a specified number of tutorial hours to be dedicated to pregnancy, students do not have adequate knowledge, competence or confidence at the point of qualification to be able to treat pregnant women safely. Even where techniques can specifically be applied to pregnant women, training approaches these from the therapy perspective but fails to take into account the issues relevant to women being cared for within the conventional  maternity services (whether NHS or private). An example of this is moxibustion, the increasingly popular Chinese technique for turning breech babies to head first. Whilst acupuncturists would argue that moxibustion will only successfully turn the foetus if conditions are favourable, their training does not equip them to ascertain whether or not the foetus remains breech before the technique is used, nor if there are any precautions or contraindications to using it in specific individuals, such as a placenta lying low in the uterus, which will not only prevent the foetal head from presenting first, but may trigger torrential haemorrhage and, ultimately, foetal death if it is artificially encouraged to turn.

Legal and Ethical Issues


Furthermore, certain other issues need to be taken into account, not least the legal ones. It is important for therapists to have an understanding of the conventional maternity services and their role and responsibilities within them. In UK law, only a midwife or doctor is legally allowed to take sole responsibility for the care of pregnant and labouring women, except in an emergency. Indeed, there have been occasional legal cases where husbands have been prosecuted for carrying out plans to deliver their partners at home without a professional being present. Any therapies used during pregnancy and childbirth must be Complementary rather than Alternative to normal maternity care, and Complementary Practitioners should liaise with the mothers’ midwives. Additionally, accurate comprehensive records are required to be maintained by midwives and retained for up to 25 years in line with the Congenital Disabilities Act, since a child damaged by a birth-related event can pursue a legal case for compensation up to adulthood. It might, therefore, be wise for therapists who treat pregnant women, or accompany them in labour, to arrange to keep their own records for this length of time.

There is also an ethical point to consider when treating pregnant women. Although women have self-administered natural remedies, and practitioners have provided Complementary therapies ante-natally for decades with little apparent (i.e. documented) evidence of adverse effects, there is minimal formal research evidence of safety, less alone efficacy. As a result, the NICE guideline on Routine Care of the Healthy Pregnant Woman[9] recommends that they should be actively discouraged from using complementary therapies or natural remedies until more research studies have been undertaken. The validity of this recommendation has been challenged[10] but one would question whether, in fact, it is ethical to subject women and their unborn babies to techniques and substances which are as yet generally untested. Conversely, however, maternity-complementary therapies research data are available. The largest clinical trial on aromatherapy was undertaken at the John Radcliffe Hospital in Oxford where essential oils are provided for women in labour to ease pain, relieve nausea and reduce anxiety.[11] Previously a randomized-controlled study on the use of lavender oil for post-natal perineal wound care was conducted by midwives in Cambridgeshire,[12] Reflexology for ankle oedema has been explored by Mollart[13] and Ingram et al[14] have recently investigated the use of shiatsu in reducing the need for induction of labour. There are also numerous studies on the value of massage in pregnancy which have been undertaken at the Touch Research Institute in Miami.[15-16]

Conclusion


Caring for pregnant, childbearing and newly delivered mothers is a specialist area which requires Practitioners to have undertaken continuing professional development once qualified.

The Complementary Practitioner with specialist knowledge and experience can play an invaluable part in supporting women during this momentous life event, which often causes anxieties and fears that may not be revealed to the Midwife providing normal maternity care. Furthermore, some Practitioners may be privileged to be invited to provide complementary therapies for women in labour, which can be an exciting professional challenge. The emotional and physical support to be gained from judicious use of Complementary Therapies in labour cannot be under-estimated, particularly as the practitioner may be the sole professional who provides continuity of care throughout a long labour. It is important to acknowledge the parameters of the complementary practitioner’s role when caring for women in labour, and to develop the ability to apply enhanced knowledge appropriately, in order that the therapist can gain competence and confidence to enjoy offering treatment to childbearing women.  Incorporating complementary therapies into orthodox maternity care provides opportunities to gather evidence, and to undertake risk-benefit analyses, while better communication between orthodox maternity professionals and complementary practitioners will promote safer care for women, and increase collaboration and advocacy.

References


1.    Factor-Litvak P, Cushman LF, Kronenberg F, Wade C and Kalmuss D. Use of complementary and alternative medicine among women in New York City: a pilot study. Journal of Alternative and Complementary Medicine. 7(6): 659-66. 2001.
2.    Pinn G and Pallett L. Herbal medicine in pregnancy. Complementary Therapies in Nursing and Midwifery. 8(2): 77-80. 2002.
3.    NHS Confederation. Complementary medicine in the NHS: Managing the Issues. Birmingham. 1997.
4.    Ager C. A Complementary Therapy Clinic – Making it Work. RCM Midwives’ Journal. 5(6): 198-200 2002.
5.    Tiran D. Complementary strategies in ante-natal care. Complementary Therapies in Nursing and Midwifery. Ch 7: 19-24. 2001.
6.    Tiran D. Using reflexology in pregnancy and childbirth. In: Mackereth P and Tiran D (eds). Clinical Reflexology: a Guide for Health Professionals. Elsevier Science. London. Ch 7. ISBN 0-443-07120-9. 2002.
7.    Budd S. Traditional Chinese Medicine in Obstetrics. Midwives Chronicle and Nursing Notes. 105: 140. 1992.
8.    West Z. Acupuncture within the National Health Service: a personal perspective. Complementary Therapies in Nursing and Midwifery. 3(3): 83-6. 1997.
9.    National Collaborating Centre for Women’s and Children’s Health/National Institute for Clinical Excellence. Guideline No. 6 Ante-natal Care: routine care for healthy pregnant woman. London. 2003.
10.    Tiran D. Complementary Therapies in Pregnancy: NICE guidelines do not promote clinical Excellence. Complementary Therapies in Nursing and Midwifery. 10(4): 50-2. 2004.
11.    Burns E, Blamey C, Ersser SJ, Lloyd AJ and Barnetson L. The use of aromatherapy in intrapartum midwifery practice: an observational study. Complementary Therapies in Nursing and Midwifery. 6(1): 33-4. 2000.
12.    Dale E and Cornwell S. The role of lavender oil in relieving perineal discomfort following childbirth: a blind randomized clinical trial. Journal of Advanced Nursing. 19(1): 89-96. 1994.
13.    Mollart L.  Single-Blind Trial Addressing the Differential Effects of Two Reflexology Techniques Versus Rest on Ankle and Foot Oedema in Late Pregnancy. Complementary Therapies in Nursing and Midwifery. 9(4): 203-8. 2003.
14.    Ingram J, Domagala C and Yates S. The Effects of Shiatsu on Post-Term Pregnancy. Complement Ther Med. 13(1): 11-5. 2005.
15.    Field T, Hernandez-Reif M, Hart S, Theakston H, Schanberg S and Kuhn C. Pregnant Women Benefit from Massage Therapy. J Psychosom Obstet Gynaecol. 20(1): 31-8. 1999.
16.    Field T, Hernandez-Reif M, Taylor S, Quintino O and Burman I. Labour pain is reduced by massage therapy. J Psychosom Obstet Gynaecol. 18(4): 286-91. 1997.

Further Information


For information on university-approved courses for Complementary Therapists on Caring for Pregnant Clients, which can be delivered in your own institution, as well as consultancy services and educational resources, contact Tel: 08452 301 323; www.expectancy.co.uk; 

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About Denise Tiran

Denise Tiran MSc RM RGN ADM PGCEA, a practising midwife, university lecturer, complementary practitioner and author, is an acknowledged international expert in maternity complementary medicine, and Director of Expectancy Ltd. Previously, Denise worked as a midwifery tutor and then as Principal Lecturer at the University of Greenwich, London, where she developed one of the UK’s first practice-based degree programmes on complementary medicine. Her unique complementary therapies NHS antenatal clinic at Queen Mary’s Hospital in Sidcup, southeast London (1994-2004) was “Highly Commended” in the 2001 Prince of Wales’ Awards for Healthcare in London.

Denise has written several professional textbooks and over 40 journal papers, as well as two books for expectant mothers. She is regularly consulted by the Royal Colleges of Midwives and of Nursing on complementary medicine. She was a member of a joint Royal College of Nursing / FIH working party on midwives’ and nurses’ Fitness to Practise complementary therapies. She has recently been appointed Chair of the Education and Standards Committee of the Federation of Antenatal Educators and its Consultant on maternity complementary therapies. She may be contacted via info@expectancy.co.uk       www.expectancy.co.uk

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