Introduction

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.

The NMC position

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.

The responsibilities of midwives when mothers wish to self-administer natural remedies

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.

Reflective activity 18.2

Keep a record of how often you are asked for information about raspberry leaf tea, arnica for bruising, or the safety of aromatherapy oils in pregnancy and labour, and consider how you respond to these queries.