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Induction of Labour - The Dilemma for Complementary Therapists Working with Pregnant Clients

by Denise Tiran(more info)

listed in women's health, originally published in issue 184 - July 2011

Introduction
Working with pregnant clients is increasingly a specialist area of practice for complementary therapists. Indeed, it is estimated that almost 87% of pregnant women now use complementary medicine,[1] either by self-administering natural remedies, or by consulting independent practitioners. Receiving relaxation therapies such as massage, aromatherapy and reflexology during pregnancy, particularly as the birth approaches, has been shown to facilitate spontaneous onset of labour, aid progress and reduce pain perception in the first stage and is more likely to result in a normal vaginal birth.[2, 3, 4]

Denise Tiran article

Complementary practitioners are in a privileged position when working with expectant mothers, but it is important to work within accepted professional boundaries. Practitioners need to be adequately and appropriately trained and insured to engage in maternity work and must recognize the limitations of their practice. My experience of communicating with well-trained therapists is that they tend almost to be over-cautious, refraining from undertaking any practices which may compromise the mother's or baby's condition when, in fact, their training has equipped them to extend the boundaries a little further. For example, many therapists decline to treat women in the first trimester, yet there is no real reason why the majority of women cannot receive complementary therapies at this time.

At the other end of pregnancy, most practitioners are aware that it may be inappropriate to provide any treatment or perform specific techniques which are intended to trigger contractions, thus starting labour. However, it can be extremely difficult for therapists whose intention is to act as an advocate for their clients, and whom they have usually come to know well during the pregnancy, and it is easy to succumb to pressure from the women to 'do something to get them into labour', especially when the prospect of medical induction threatens.

Onset of Labour
Normal labour  occurs any time between 37 and 43 weeks' gestation and is the physiological termination of pregnancy, during which the foetus has developed and grown sufficiently to adapt to extra-uterine life. Optimal progress and outcome depends on a combination of efficient uterine contractions, cervical dilatation and descent of the foetus. Common early signs of labour are contractions, a 'show' of mucus and blood from the vagina, or breaking of the bag of membranes (waters) surrounding the foetus. The length of the three stages of labour varies according to whether it is the mother's first baby or not. The first stage, from onset of regular, painful uterine contractions until the cervix is fully dilated, may last up to 24 hours; the second stage, the birth of the baby, usually  takes between 30 minutes and 2 hours; the third stage, during which the placenta and membranes are delivered, takes 5 to 45 minutes.

Several factors trigger the onset of labour. The uterus will only stretch so far and when it reaches its maximum the nerves become irritable and contractions begin. This is one of the reasons why preterm labour (before 37 weeks of pregnancy) may occur in a woman with a very big baby, excessive fluid surrounding the foetus or expecting more than one baby. Maternal hormones, notably progesterone, which has sustained the pregnancy and prevented the uterine muscles from contracting, decrease from about 36 weeks' gestation, and oxytocin, the hormone which causes the uterus to contract, increases. The foetus also produces chemicals from the brain and adrenal glands, which help to trigger contractions. In addition, the foetal head, which is usually down in the maternal pelvis, and the bag of membranes containing the foetus,  put pressure on the cervix to start the process of softening ('ripening'), making it 'stretchy' enough to start dilating.

Induction of Labour
Induction of labour is a medical procedure performed for  specific medical indications, and it is certainly not the role of the complementary therapist to assist a mother who is desperate for labour to start without adequate justification. Although it can be very frustrating for the mother at the end of pregnancy if she is 'overdue', she should be advised not to interfere with the natural process as this can cause complications.

The medical reasons for induction of labour include situations in which continuation of the pregnancy may lead to maternal or foetal compromise, including diabetes mellitus, cardiac, renal or thyroid disease, hypertension and pre-eclampsia. If the foetus is small due to poor placental function during pregnancy, or estimated to be very large if left to progress to term, labour may be started early to enable a vaginal birth, or delivery of as healthy a baby as possible.

Unfortunately, most obstetricians almost routinely advise induction when the mother is 'overdue', usually about 10-14 days after the estimated date of delivery. This is based on the traditional belief that the placenta deteriorates after 40 weeks, and the foetal skull bones start to harden, making birth more difficult because the head is less able to adapt to the birth canal. However, if maternal and foetal conditions remain satisfactory in these last weeks, there is no indication for induction. Mothers do have the right to decline, although frequently a degree of 'emotional blackmail' is applied to persuade them to comply with the doctors, and to submit to a procedure which, in itself, poses certain risks. Methods of induction of labour include inserting a hormonal pessary into the vagina to accelerate cervical ripening, artificial rupture of the bag of membranes and intravenous synthetic oxytocin.

'Cascade of Intervention'
Inappropriate induction of labour, performed at a time when the baby is not yet ready to be born, can lead to a 'cascade of intervention' in which one action leads to the need for another. For example, the mother's perception of pain from enforced contractions is often greater than it may have been if labour started spontaneously. This is partly because increased stress hormones produced during induction, particularly cortisol, inhibit oxytocin release, adversely affecting uterine action. Poor contractions, together with pathological, rather than physiological pain, increase the risk of foetal distress. Early requirements for pain relief, such as epidural, which confines the mother to bed, further interfere with contractions; labour progress may be slow, possibly leading to Caesarean section, with all its long-term sequelae. Alternatively, loss of sensation from prolonged epidural use may result in the mother being unable to feel where to push her baby out during the second stage, causing foetal distress requiring forceps delivery, or an episiotomy to enlarge the birth opening, both necessitating perineal suturing after delivery. Operative or instrumental delivery and subsequent pain from wound healing, coupled with emotional distress which this brings to many women, may interfere with lactation, the mother consequently discontinuing breastfeeding at an early stage. Thus, unnecessary induction of labour, merely because the mother has exceeded an artificially determined expected date of delivery can ultimately affect the health of the next generation through cessation of breastfeeding, with risks of potential nutritional deficiencies, obesity and other long-term medical conditions.

Complementary Therapies to Start Labour
Attempting to initiate labour by any means constitutes an intervention in a normal physiological process, which can trigger this 'cascade of intervention'. Therapists should be wary of succumbing to clients' exhortations to 'do something' simply because they are fed up with being pregnant and feel out of control with the unpredictability of labour onset. Certainly, no complementary practitioner should undertake any techniques specifically with the intention of starting contractions, at least until after the mother's due date, and then, only if trained to do so and with the express permission of the midwife or doctor. On the other hand, if the mother is being 'threatened' with medical induction of labour merely because she is overdue, it may be eminently reasonable to attempt to initiate contractions with techniques and remedies which are within the practitioner's qualifications, training and insurance cover.

Acupuncture, acupressure and shiatsu in particular have been found significantly to reduce the interval between the due date and the onset of spontaneous labour.[5,6] Reflex zone therapy can be extremely effective in triggering contractions, but practitioners of generic reflexology should be mindful of the physiology of labour in order to determine which reflex points should be stimulated. The reflex zone for the uterus should never be stimulated as this may cause uncoordinated uterine action and foetal distress; appropriate stimulation of the correct reflex zone for the pituitary gland may, however, successfully start labour.[7]

Gentle relaxing massage or aromatherapy with suitable essential oils, as well as hypnotherapy and other psychological therapies, may be sufficient to normalize the mother's physiology, reducing stress hormones and indirectly facilitating an increase in oxytocin.[8] Homeopaths and medical herbalists may select relevant remedies for the individual, based on a thorough assessment of the mother's physical, mental and psychological state.

However, it is important first to ascertain if the mother is self-administering anything which is aimed at inducing labour, since injudicious or unwitting 'overdose' of a combination of therapies and remedies can result in excessively strong contractions, causing maternal and foetal distress. Hypertonic uterine action, particularly in a mother who has previously given birth, can if left untreated lead to uterine rupture, foetal death and maternal haemorrhage.

Women increasingly find suggestions in magazines and on the Internet, designed to facilitate  labour onset, often with potentially disastrous consequences. Popular remedies in current vogue include the aromatherapy essential oil, clary sage, a powerful oil which can indeed stimulate contractions when used cautiously but which may, if used inappropriately, trigger excessive contractions and cause foetal distress (personal communications).

Homeopathic caulophyllum may be appropriate for some, but not all mothers, sometimes having a reverse effect and slowing down normal contractions.[9] Its herbal counterpart, blue cohosh (Caulophyllum thalictroides) should be completely avoided as it has been linked to cardiac arrest and congestive heart failure in the newborn when used in labour[10] and its use by medical herbalists has been discontinued in the UK. Pineapple, popularly eaten for supposed uterine-contracting properties of its bromelain content, is more likely to cause diarrhoea or severe allergic reaction than to trigger contractions, especially since the bromelain is focused in the central core of the fresh pineapple, and it would be necessary to eat about 8 pineapples to obtain sufficient bromelain to stimulate contractions.[11]

Conclusion
Treating pregnant women in your practice can be enjoyable, rewarding (and lucrative!) but it is vital that you work within the limitations of your training and insurance. Whilst it can be tempting to try to comply with women's wishes regarding their pregnancy and labour, therapists should not undertake any actions which may be inappropriate. Induction of labour is a specific obstetric intervention and is not to be undertaken lightly. However it is important to remember also that any means of attempting to start labour in any way other than allowing it to commence spontaneously, is an intervention in the same way as drugs, drips and pessaries used by obstetricians. Therapists should encourage women to understand that the baby will be born when s/he is ready, and any efforts to expedite the baby's  arrival before this time can lead to complications and can, on occasions, be disastrous.
 
References
1. Hall HG,  McKenna LG and Griffiths DL. Complementary and alternative medicine for induction of labour. Australian College of Midwives. Elsevier Ltd. 2011. www.sciencedirect.com/science/article/pii/S187151921100028X
2. Burns E, Zobbi V, Panzeri D, Oskrochi R, Regalia A 2007 Aromatherapy in childbirth: a pilot randomised controlled trial BJOG. 114(7):838-4
3. Field T  Pregnancy and labor massage Expert Rev Obstet Gynecol. 5(2):177-181. 2010.
4. Mc Nabb MT, Kimber L, Haines A, McCourt C  Does regular massage from late pregnancy to birth decrease maternal pain perception during labour and birth? A feasibility study to investigate a programme of massage, controlled breathing and visualization, from 36 weeks of pregnancy until birth Complement Ther Clin Pract 12(3):222-31. 2006.
5. Ingram J, Domagala C and Yates S.  The effects of Shiatsu on post-term pregnancy. Complement Ther Med 13:1115. 2005.
6. Lim CE, Wilkinson JM, Wong WS, Cheng NC.  Effect of acupuncture on induction of labor  J Altern Complement Med. 15(11):1209-14. 2009.
7. Tiran D.  Reflexology for Pregnancy and Childbirth Elsevier Edinburgh. 2010.
8. Evans M  Postdates pregnancy and complementary therapies Complement Ther Clin Pract 15(4):220-4. 2009.
9. Smith CA  Homoeopathy for induction of labour. Cochrane Database Syst Rev. (4):CD003399. 2003.
10. Dugoua JJ, Perri D, Seely D, Mills E, Koren G.  Safety and efficacy of blue cohosh (Caulophyllum thalictroides) during pregnancy and lactation Can J Clin Pharmacol. 15(1):e66-7. 2008.
11. Tiran D.  Complementary therapies: Use of pineapple for induction of labour. Pract Midwife. 12(9):33-4. 2009.

Resources
www.expectancy.co.uk - Expectancy - the Expectant Parents' Complementary Therapies Consultancy - provides advice for women, including downloadable information sheets, telephone and face-to-face consultations, and accredited professional education for therapists, midwives and birth supporters.

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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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