CHAPTER 2
Commonly Used Complementary
Therapies for Pregnancy and Birth
This chapter provides an overview of the complementary therapies most commonly used in the UK today, including a general description, indications, contraindications and precautions to each therapy, in general and in reproductive health, and some initial debate on the evidence base related to each therapy.
Whilst there are numerous complementary therapies, only about 15 to 20 are commonly in use in the developed world. Some therapies are defined as distinct modalities when, in fact, they derive from other therapies. Some lack any real evidence base and are not generally in common use; others claiming to be clinical therapies fit better into the category of health and wellbeing or even beauty therapy.
In this chapter, 12 therapies appropriate for clinical use in pregnancy, birth and the postnatal period are explored in detail, being those considered to be currently most popular amongst expectant mothers, and of interest to midwives and other maternity workers. Following an introduction to the therapy, the indications, contraindications and precautions and the evidence base are discussed. These therapies are referred to in subsequent chapters, in relation to specific conditions occurring in pregnancy, birth or the postnatal period. Further debate on the research is included in these later chapters.
The following are covered in this chapter:
• introduction
• acupuncture, acupressure and shiatsu
• aromatherapy
• Bach flower remedies
• chiropractic
• herbal medicine
• homeotherapy
• hypnotherapy
• massage
• osteopathy
• reflexology
• reiki
• yoga
• conclusion.
Introduction
Complementary medicine can be classified into several categories. The House of Lords report on complementary medicine (Select Committee on Science and Technology 2000) categorised the main therapies in use in the UK at that time into three main groups. Group 1 included the “top five” modalities, which were the most popular amongst, and sometimes practised by, medical practitioners, namely osteopathy and chiropractic, homeopathy, herbal medicine (relating to herbs indigenous to the UK) and western or “medical” acupuncture. Group 2 listed all the “supportive” therapies, generally thought at the time to be unregulated and lacking an evidence base, although this was challenged vociferously by professionals working in the field. Supportive therapies tend to be those which are not used as discrete systems of medicine in their own right but which enhance other clinical or therapeutic care, both complementary and conventional medicine. This includes massage, aromatherapy, reflexology, hypnosis, hydrotherapy, shiatsu, flower remedies, yoga, stress management, nutrition, reiki, Alexander technique and counselling. Group 3 was sub-divided into traditional systems of (folk) medicine such as Chinese medicine, Indian Ayurveda, Japanese kampo, etc., and alternative diagnostic techniques including kinesiology, radionics and iridology.
There was some controversy regarding these classifications, because the government’s reasons for examining complementary medicine in detail were to move towards better education and training, more formal regulation, a greater evidence base and increased integration into mainstream healthcare. However, at the time, some of the therapies included in group 2 were better researched than some of those included in group 1. Sadly, whilst some advances have been made in the last two decades, the aims of the report were never fully achieved. Regulation continues to be a combination of voluntary self-regulation and unregulated therapies, medical science constantly refutes the evidence of research studies that do not fit with the “gold standard” randomised controlled trial methodology, and integration within the NHS remains sporadic. Other challenges focused around specific therapies. For example, acupuncture: western-style (medical) acupuncture as practised by many doctors was, somewhat politically, allocated to group 1 whilst Chinese medicine, including traditional, holistic acupuncture, was relegated to group 3a. The justification for this was that traditional Chinese medicine includes the use of herbal remedies indigenous to Asia and the import and safe use of these remedies in the UK was difficult to monitor.
Today, we could simply consider the differentiation between com-plementary therapies and natural remedies, as explained in Chapter 1. Alternatively, we could classify the therapies hierarchically from most to least medically accepted or from most to least popular amongst consumers. Therapies can also be categorised according to their mechanism of action, for example pharmacologically active or energy-based modalities, manual techniques or psychological therapies (see also Chapter 1). Several therapies work on more than one level. For example, aromatherapy uses pharmacologically active oils; it is often administered via touch therapy, i.e. massage, and is also thought to work energetically. Erroneously, NICE refers to all therapies as “non-pharmacological” – including aromatherapy. Table 2.1 provides a summary of the various classifications of the main complementary therapies covered in this book and of relevance to maternity care.
Table 2.1 Mechanism of action of commonly used complementary therapies | ||||
Pharmacological | Energetic | Physical | Psychological | |
Acupuncture | ** | ** | * | |
Aromatherapy | ** | * | * applied via massage | * |
Bach flower remedies | ** | ** | ||
Chiropractic | ** | |||
Herbal medicine | ** | |||
Homeopathy | ** | |||
Hypnotherapy | ** | |||
Massage | * | ** | * | |
Osteopathy | ** | |||
Reflexology | ** | ** | ||
Reiki | ** | ** of the aura | ||
Shiatsu | ** | ** | ||
Yoga | ** | * | * | |
Key: ** primary mechanism of action * secondary mechanism of action NB “psychological” refers to the mechanism of action rather than to the effect | ||||
Acupuncture, acupressure and shiatsu
Introduction
The term acupuncture derives from the Latin, acus, for “needle”, and puncture or “pierce”. Acupuncture and acupressure are components of traditional Chinese medicine (TCM), which incorporates other techniques including moxibustion, cupping, Chinese herbs and strong massage called tui na (the word meaning “push and grab”). Acupuncture theory is drawn from Chinese texts, thousands of years old, notably The Yellow Emperor’s Classic of Internal Medicine compiled between 300 and 100BC, which is still regarded as the most authoritative guide to TCM. TCM practitioners would generally use a combination of techniques to treat the person, but a more reductionist way of using acupuncture and/or acupressure alone is used in western medical acupuncture (WMA).
Both systems of acupuncture are based on the principle that the body has energy channels, called meridians, running through it, which link one part of the body to another and help in connecting the whole person. Flowing through the meridians is the individual’s life force, a form of energy called qi (pronounced “chee”). There are 12 major paired meridians running bilaterally through the body, and two single central meridians, one down the front and one down the back of the body. When the body, mind and spirit are in optimal health, the qi flows through the meridians completely harmoniously (homeostasis), but when one or more aspects of the whole are disrupted, illness or disease occurs and the energy becomes static, deficient or excessively strong. Located at intervals along the meridians are focus points (acupoints) which can be stimulated or sedated according to the requirements of the person’s condition. There are over 2000 acupoints, although in modern acupuncture practice only about 200 are commonly used by practitioners.
A further concept in TCM is that of yin and yang, two opposing but complementary forces which help to balance the person. Imbalance in either yin or yang results in disorder, illness or disease. Yang energy is positive, warm and energetic, whereas yin energy is more negative, cooler and passive. Every aspect of life has a yin and a yang feature, and physiological processes can be viewed in terms of their yin and yang characteristics – see Table 2.2 for a few examples. Each organ is said to have an active, warming function (yang) as well as a cooling, moistening function (yin). An imbalance in the yang energy will also affect the yin qi and vice versa. For example, excessive intestinal energy will increase the qi, causing diarrhoea, whereas increased yin energy causes sluggishness and accumulation of waste, producing constipation. In perimenopausal women, night sweats are a symptom of increased yang energy, which in time depletes the yin energy, causing tiredness and fatigue, because yin and yang are co-dependent.
In TCM, practitioners also consider several other principles, namely the opposing features of excess-deficient energy (qi), heat and cold and what is happening on the interior and exterior of the body. Complex tongue and pulse assessments are used to aid diagnosis. For example, sweating, thirst, a red face and perhaps a predominance of anger in the individual’s mood are all yang symptoms and treatment would aim to dispel the excess heat and rebalance the energies by increasing yin energy.
Acupuncture treatment is performed by inserting fine, usually disposable, needles into the relevant acupoints, or by applying thumb or finger pressure (acupressure). A TCM practitioner might also use moxibustion, which involves the application of heat to stimulate points where there is insufficient energy, or cupping, the application of small glass cups over acupuncture points to withdraw excess energy. Moxibustion is increasingly used to turn a breech-presenting fetus to cephalic and is discussed in detail in Chapter 6. Electro-acupuncture, in which leads are attached to the handle of the acupuncture needle, enabling a mild electrical current to pass through the needle to the acupoint, is also widely used by qualified acupuncturists and is similar in principle to transcutaneous electrical nerve stimulation (TENS). Auricular acupuncture, using acupoints on the ears, is also useful for some conditions, particularly when repeated stimulation to certain acupoints need to be carried out manually by the patient over a period of time. Physiological changes which occur during or after acupuncture treatment include changes in blood pressure and cardiac output, blood chemistry, the immune system and peristaltic actions of smooth muscles.
The main difference between TCM acupuncture and western medical acupuncture is that the former uses the full set of opposing principles described above, both to aid diagnosis and to determine the most appropriate treatment. WMA is more focused on anatomical and physio-pathological causes and effects and does not directly consider yin-yang and the concept of qi. The treatment in both styles of acupuncture is similar, using the same acupoints, although WMA practitioners are sometimes said to be practising “dry needling” rather than “acupuncture” per se. However, whilst the more formulaic WMA does not utilise the basic principles of TCM, it is useful for practitioners to have an understanding of them, and in clinical practice, there is often an overlap between the two systems.
It is also necessary here to mention shiatsu, which is similar in concept to acupressure but is a completely separate – and more contemporary – discipline. Shiatsu is a Japanese therapy, only developed in the 20th century, although it evolved from the centuries-old Japanese massage called anma, adapted from the Chinese tui na. The word “shiatsu” means “finger pressure”, and treatment involves pressure being applied to the acupoints (called “tsubos” in Japanese) of the whole body, using fingers, thumbs and palms, although some practitioners claim that shiatsu points are unrelated to traditional Chinese meridians. Treatment and diagnosis are undertaken simultaneously, the practitioner working on each set of points to detect abnormalities in the organs and applying different pressures to restore homeostasis. There are several styles of shiatsu, including tsubo shiatsu, meridian shiatsu and Zen shiatsu, which takes a more spiritual approach than other styles. Treatment can be very relaxing and ease stress-related symptoms, and many practitioners use it also to treat specific clinical conditions. Table 2.3 outlines the differences between acupressure and shiatsu.
Table 2.2 Examples of the Yin and Yang characteristics of some physiological processes | |
Yang | Yin |
Stress/hyperactivity | Relaxation/sleep |
Testosterone | Oestrogen |
Follicular phase of menstrual cycle | Luteal phase of menstrual cycle |
Pre-orgasmic stage of sexual response | Post-orgasmic stage |
Developing fetus | Pregnancy (mother) |
Labour | Post-birth |
Oxytocin | Progesterone |
Table 2.3 Principal differences between acupressure and shiatsu | |
Acupressure | Shiatsu |
Chinese therapy more than 5000 years old – one element of traditional Chinese medicine | Discrete Japanese therapy; evolved from Chinese medicine over centuries, formally recognised in the mid-20th century |
Has its spiritual roots in Chinese Taoism | Has its spiritual roots in Indian Buddhism |
Based on rebalancing vital energy within the meridians – qi (pronounced “chee”) | Based on rebalancing vital energy within the meridians – ki (also pronounced “chee”) |
Acupoints are credited with having specific functions – treatment is usually focused on specific points | Tsubos (pressure points) link the whole body – treatment is generally a full-body massage-type treatment |
Diagnosis prior to treatment via assessments of energy levels, pulse and tongue assessment and an analysis of the “clues” provided | Diagnosis and treatment undertaken together via palpation of pressure points – practitioners “sense” energy variations during palpation |
Pressure applied via the fingers and thumbs | Pressure applied via the fingers, thumbs, palms, elbows, knees |
Treatment may also involve use of acupuncture needles, Chinese herbs, tui na massage, cupping and moxibustion | Treatment focuses on rebalancing the body’s energies by stimulation of the relevant tsubos by leaning into the body, combined with various stretching, holding and manipulative massage techniques |
Treatment increases endorphins and encephalins and reduces stress hormones but is not generally given as a relaxation session; reducing stress hormones is a physiological response to rebalancing of the qi (homeostasis) | Treatment may be given specifically as a holistic stress-reducing session; it is believed that reducing stress hormones facilitates a return to homeostatic balance |
Treatment given on a couch in a clinical setting | Treatment often given with the client on a mat on the floor |
Acupuncture is a popular strategy for pregnant women, particularly those who are well educated and keen to take control of their childbearing experience (Soliday and Hapke 2014). During pregnancy, acupuncture may be useful for the relief of musculoskeletal problems including backache, sciatica, pelvic girdle pain and carpal tunnel syndrome. Gastrointestinal conditions respond well to needling of selected acupuncture points, particularly nausea and vomiting, heartburn, constipation and haemorrhoids. Acupuncture and acupressure/shiatsu offer easy, inexpensive and effective treatments for birth preparation, inducing labour in post-dates pregnancy, augmentation of contractions and pain relief in the first stage, as well as helping with intrapartum complications such as retained placenta. Postnatally, stimulation of certain acupoints can aid lactation, ease recovery from birth and balance the psycho-emotional state.
Shiatsu is more traditionally used for relaxation and to ease fatigue, stress, anxiety and related problems such as insomnia, but has also been used to treat gastrointestinal, musculoskeletal, cardiovascular, urinary and neurological conditions.
Contraindications and precautions
Some women should not receive acupuncture. General contraindications include women with coagulation disorders or those taking anticoagulants because there is a risk of bleeding from the insertion of the acupuncture needles, although a systematic review by McCulloch et al. (2015) disputes this. For similar reasons, women who are prone to infection, for example those with diabetes mellitus, should avoid acupuncture as there is a slight risk of infection entering the needle insertion site; practitioners should not needle near open wounds. Women with any major medical or obstetric complication may not be eligible to receive acupuncture, although this will depend on the severity of the condition and on whether the treatment is given in a community-based setting or in the maternity unit where facilities exist for dealing with emergencies. Shiatsu practitioners usually refrain from treating clients with inflammatory disorders, although acupuncturists may view inflammation as a sign of disordered qi. Certain specific acupoints should not be stimulated in pregnancy, either by needling or by pressure, as they may stimulate uterine contractions; these are called the “forbidden points”. Shiatsu practitioners generally agree, although they may include more points than acupuncturists.
Conducting randomised double-blind placebo-controlled studies of acupuncture can be difficult. Researchers use different methods in their attempts to reduce bias, often comparing acupuncture to a control group which receives only standard care. A common method is to compare true acupuncture, in which the needles are inserted into the most appropriate acupoints for treatment of the presenting condition, with sham acupuncture. Sham acupuncture may involve the use of specially designed needles in which the needle retracts into the shaft of the handle on insertion, so that the subject experiences the piercing sensation but the acupoint is not stimulated to optimum depth (deqi) for a therapeutic response. Less commonly, insertion of a normal needle into parts of the body which do not correspond to specific acupoints may be used. Either method presents difficulties in that, at the very least, there is the possibility of a placebo reaction from the subject as a result of the sensation of the needle puncturing the skin.
Although many of the investigations into acupuncture are naturally published in Chinese language journals, there is an increasing amount of work published in English-language complementary therapy journals and conventional medical, nursing and midwifery journals. There has been a vast amount of research undertaken on the effectiveness of acupuncture for a range of clinical conditions. Whilst there appears to be less evidence to demonstrate safety, acupuncture is generally considered relatively safe, except for the possible risks highlighted by the principles for safe practice (contraindications and precautions). Retrospective systematic reviews of large numbers of cases perhaps offer the most reliable evidence of safety (MacPherson et al. 2001; White 2004; White et al. 2001; Witt et al. 2009).
There is an emerging body of evidence on the mechanism of action of acupuncture. Early work by the North Korean scientist Bong-Han (cited by Soh, Kang and Ryu 2013) appeared to demonstrate the existence of the acupuncture meridians flowing subcutaneously throughout the body, both within and outside blood vessels and lymphatic channels and on the surfaces of organs. More recent work involving injections of radio-opaque dye has shown the structure of the meridians throughout the body, the whole of which has been termed the “primo-vascular system” (Soh et al. 2013). It is known that this primo-vascular network is crucial to the cardiovascular system, and is now thought to channel the flow of energy and information around the body, relayed by electromagnetic waves of light (biophotons) and by the DNA. Computerised tomography has also shown the branching tree-like structure of the acupuncture channels (Chen et al. 2013), with clear differentiation between the sites of acupoints, corresponding to the original charts of Chinese acupuncture meridians, and non-acupuncture areas. Chinese studies tend to focus on determining the mechanism of action and physiological effects, although much of this work is still evolving (Wang, Chen et al. 2016; Wang, Yang et al. 2016).
Research on shiatsu is often misrepresented as acupressure, making it difficult to elucidate the specific techniques used. It is for this reason that shiatsu has been included in this section on acupuncture and acupressure, since searching the research databases usually reveals a mixed list of abstracts on both therapies, and in practice the same pressure points are commonly used. An Italian study compared shiatsu with amitryptiline for refractory headaches and found a benefit of manual treatment over the drug (Villani et al. 2017), but a prolonged search of several complementary therapy databases indicated that almost all other studies refer to “acupressure” rather than “shiatsu”. On the other hand, there are numerous studies on acupressure for a range of conditions, particularly for symptoms such as pain and nausea.
In reproductive health, acupuncture can be helpful for couples experiencing fertility problems (Cochrane et al. 2016) and menopausal symptoms (Avis et al. 2016). In pregnancy, numerous studies have shown that stimulation of the Pericardium 6 acupoint on the wrists can be an effective treatment for nausea and vomiting, either by needling or acupressure (Can Gürkan and Arslan 2008; Shin, Song and Seo 2007; van den Heuvel et al. 2016) (see Chapter 4). Several studies have also been undertaken on the stimulation of acupoints to induce labour (see Chapter 7). Labour pain responds well to acupuncture (Liu et al. 2015) and may reduce the duration of labour (Asadi et al. 2015) (see Chapter 8).
Aromatherapy
Introduction
Aromatherapy is a scientific therapy in which highly concentrated aromatic essential plant oils are administered in various ways to enhance health and wellbeing. Essential oils are produced naturally and act as a protection for the plant from infection and extremes of temperature. The huge number of chemicals within the essential oils affects the fragrances of each plant so that the appropriate insects are attracted for pollination. These chemicals are also pharmacologically active, possessing a range of physical and emotional effects that can be harnessed in clinical practice for therapeutic benefits – but which can also be harmful when used inappropriately.
Essential oils enter the body primarily via respiratory inhalation. This occurs irrespective of the clinical method of administration, but inhalation can be used as a means of administration in its own right. Inhaling the aromas causes the chemicals within the essential oils to disperse around the body via the systemic circulation and also to travel via the olfactory system to the limbic system in the brain, where they impact on the mood. Oils can also be administered via the skin through massage or in water (in the bath or as a compress). Some medical practitioners, notably in France, administer essential oils as drugs via the mucous membranes, rectally as suppositories, or vaginally as pessaries, as well as via the gastrointestinal tract, but these methods are not appropriate in maternity care (and in the UK it is not possible to obtain indemnity insurance cover if oils are prescribed for oral administration). It is a combination of the physiological action of the chemicals, the method of administration and the psychological impact of the aromas which provides a therapeutic treatment according to the client’s needs. See Tiran (2016a) for more in-depth information on aromatherapy in pregnancy and birth.
Indications
Aromatherapy treatment is generally relaxing, especially when the oils are administered via massage, the most popular and commonly used method in the UK. Specific essential oils also have pharmacologically relaxing effects, including common lavender oil (Lavandula angustifolia) (Sayorwan et al. 2012). Conversely, peppermint (Mentha piperata), grapefruit (Citrus paradisi) and black pepper (Piper nigrum) oils are stimulating to specific organs (Butt et al. 2013; Nagai et al. 2014; Oh, Park and Kim 2014). Lavender and clary sage (Salvia sclarea) oils lower the blood pressure (Seol et al. 2013), but others, such as rosemary (Rosmarinus officinale), will raise it (Fernández, Palomino and Frutos 2014). A predominance of certain chemicals means that some oils are analgesic, for example lemon (Citrus limon) (Ikeda, Takasu and Murase 2014) and common lavender (Hadi and Hanid 2011). All essential oils contain chemicals which are anti-bacterial; some are also anti-fungal or anti-viral – thus aromatherapy also offers useful substances to prevent or treat certain infections (Ziółkowska-Klinkosz et al. 2016).
Contraindications and precautions
Many essential oils should not be used before, during or immediately after pregnancy or may be contraindicated for women with medical or obstetric complications. Women should be advised to avoid self-administering essential oils in the preconception period and during the first trimester, although treatment from an appropriately qualified professional is not, in itself, a contraindication at these times.
Aromatherapy should be used with extreme caution, or avoided altogether, for any woman with a medical condition or obstetric complication. As a general rule, those who are eligible for a home birth or the midwife-led birthing centre can usually receive aromatherapy. Epilepsy is a complete contraindication as the aromas may trigger fits, especially since the woman may have had to change her medication and/or the epilepsy may have become unstable during pregnancy. In addition, some specific oils are known to be neurotoxic, including clary sage and common sage (Salvia officinale).
If the woman requires any medication, aromatherapy is usually contraindicated or should be used with caution only under the direction of a dual-qualified practitioner (e.g. midwife-aromatherapist). Drug and essential oil metabolism is similar and there is a risk of interactions or potentiation of either the prescribed medication or the essential oil. Women on anticoagulant therapy or with clotting disorders should avoid essential oils that may have an anticoagulant effect. Those who are admitted to the antenatal in-patient ward are not usually eligible to receive aromatherapy (and if a woman is able to receive treatment, care should be taken not to expose other women in the ward to the aroma vapours which may jeopardise their condition). All other women should be assessed carefully to ensure that the oils used are appropriate and safe. These contraindications apply equally to anyone else in contact with the aromas. See Tiran (2016a) for a more in-depth analysis of the contraindications and precautions.
As with any pharmacological therapy, aromatherapy treatment should be determined by the individual’s condition, and administered in the correct dosage and by the most appropriate method. Side effects may occur if the oils are used inappropriately, in too high a dose or for a prolonged period of time. Side effects differ from a healing reaction, although the symptoms may be similar. Common symptoms, which are usually dose-dependent, include headaches, nausea, dizziness, lethargy and loss of concentration. Skin sensitivity is a very common adverse reaction, either due to contact with specific chemicals in the oils or to a pre-existing sensitivity to chemicals, including reactions to over-exposure to sunlight’s ultraviolet rays.
Respiratory reactions are increasingly common, mainly due to a general over-exposure to chemicals in the environment, our food, toiletries and cleaning products. Severe respiratory effects can be unpredictable, the chemicals in fragrances and aromatic substances such as essential oils causing bronchial and alveolar inflammation resulting in dyspnoea, hyperventilation, air hunger or extreme hayfever-like symptoms. It is for this reason that aromatherapy should never be trivialised by midwives and doulas and the oils should be considered as drugs that need to be prescribed by appropriately trained professionals.
Adverse reactions to essential oils can affect anyone who is exposed to them, including clinicians and any companions of the pregnant woman. Prolonged exposure, for example, when caring for a woman during a long labour, may trigger headaches, nausea, loss of concentration or respiratory reactions in the midwife, doula or birth partner. Use of certain essential oils in labour – notably clary sage (Salvia sclarea) – can also cause menorrhagia for attendants who are menstruating. Midwives and others with specific medical conditions may need to decline to use aromatherapy if the oils required are contraindicated. For example, oils to facilitate labour should not be used by midwives who are pregnant, trying to conceive or breastfeeding, and any staff member who has a major medical condition may need to avoid using, or being exposed to women who are using, aromatherapy oils. Table 2.4 summarises the principal contraindications and precautions to the use of aromatherapy in pregnancy, birth and postnatally.
Table 2.4 Contraindications and precautions to the use of aromatherapy in maternity care | |
Contraindication/precaution | Justification |
Respiratory reactions | • Avoid use of vaporisers, diffusers and burners in institutions such as maternity unit, birth centre – exposure of everyone in the vicinity to the chemicals is unsafe and unethical; burners present a fire risk • Women with history of asthma, hay fever or existing respiratory condition – caution • Women with respiratory reactions to specific oils or perfumes containing these oils – avoid relevant oils, caution with others |
Skin reactions | • Avoid oils high in chemicals known to cause skin reactions, e.g. phenols • Avoid specific oils which cause skin reactions in individuals, caution with other oils: common oils include chamomile, tea tree, black pepper • Caution with women with skin conditions, e.g. eczema, psoriasis, or with sensitive skin • Avoid exposure of skin to strong sunlight after administration of citrus oils and others that trigger photosensitivity |
Specific oils contraindicated in pregnancy | • Avoid all essential oils in pregnancy, birth or postnatal period unless there is reasonable evidence/anecdotal experience of using the oil without major adverse effects |
Clary sage oil (Salvia sclarea) | • Consider clary sage as “nature’s Syntocinon” • Before 37 weeks gestation – contraindication • Labour, contractions well established – contraindication • Mother requiring drugs, e.g. Syntocinon, prostin, Propess, or taking other natural remedies to stimulate contractions – contraindication • Excessive vaginal lochia or retained products of conception in puerperium – contraindication • Attending staff or birth companions who are pregnant or trying to conceive – contraindication • Attending professionals who are menstruating – caution |
Medical conditions | • Epilepsy – absolute contraindication • Major cardiac disease – contraindication • Liver disease – contraindication – oils metabolised via liver • Those taking anticoagulants or with coagulation disorder – contraindication • Women on other medication – precaution • Some oils affect blood sugar, causing hyper- or hypo-glycaemia – caution if woman or attendants have diabetes mellitus |
Obstetric conditions | • Current vaginal bleeding, placental issues – contraindication • Mild to moderate hypertension – precaution; fulminating pre-eclampsia – contraindication • Twin pregnancy – precaution; triplets or more – contraindication |
Neonates/babies under three months of age – absolute contraindication | • Baby’s skin is sensitive and permeable to essential oils, may cause severe skin irritation • May predispose child to allergies in later life • Baby partially dependent on sense of smell to recognise mother – oil aromas may mask this • Bronchial or sensory hyper-reactivity may occur from inhalation of essential oil vapours – never use room vaporisers near babies • Oils are metabolised via liver – neonatal liver is too immature to cope • Newborn immune system is immature: antibacterial properties of all essential oils could compromise immune system, with potential for lifelong difficulties in fighting infection |
Homeopathy | • Women using homeopathic remedies should avoid concomitant use of aromatherapy oils by any method of administration because the strong aromas can antidote (inactivate) the chemically fragile homeopathic preparations (see section on homeopathy below) |
Evidence base
There is a vast array of evidence to demonstrate the anti-infective properties of essential oils, although many studies involve oils not commonly used in clinical aromatherapy. Tea tree has been shown to be anti-bacterial, anti-viral and anti-fungal. Research on tea tree oil has been ongoing for over 30 years, much of the work being done in Australia (where tea tree grows) (Carson, Hammer and Riley 2006; Hammer, Carson and Riley 1998, 2012). More recent studies by other researchers often replicate or expand on previous studies (Bona et al. 2016; Liu et al. 2016). One of the largest and most significant studies on the use of aromatherapy for pain relief in labour was conducted by midwives at the John Radcliffe Hospital in Oxford, UK, between 1990 and 1999 (Burns et al. 2000) (see Chapter 8). Wound healing with essential oils, notably lavender (Lavandula angustifolia and other types), has also been studied. Episiotomy healing is of particular interest, but caution should be taken because the methods of application, types of lavender and doses differ between studies. Whilst it is possible to generalise that aromatherapy, or individual oils, may be effective in aiding wound healing, the specific clinical application should be considered, and the potential for side effects also taken into account with individual women. See Chapter 9 for further debate on aromatherapy for perineal wound healing. Several studies have explored emotional wellbeing, stress, anxiety and pain.
Bach flower remedies
Introduction
There are several types of flower remedies, including Bach from the UK, Bush from Australia, orchid essences from Scotland and others from the Far East, but Bach remedies are by far the most well known, particularly in the UK. Bach flower remedies (BFRs) are liquid plant essences thought to have a positive effect on the emotions and on psychological wellbeing. They were devised by Dr Edward Bach (1886–1936), a Welsh microbiologist and pathologist, who became disillusioned with orthodox medicine and its focus on purely physio-pathological aspects of illness. He became interested in the possible impact of the emotions on the human body and the psychology of disease. Whilst working at the London Homeopathic Hospital just after the First World War, he surmised that medicine should treat the whole person, not merely the disease, and that, by working on the emotions through a system of energy-based remedies, this would stimulate the individual’s self-healing capacity, a feature of many complementary medical modalities.
Bach (pronounced “batch”) developed 37 remedies from different plants, and one from spring water (rock rose), plus Rescue Remedy, which is a combination of five of the original 38 remedies and is a first aid/stress reliever. The remedies are produced by putting freshly picked sun-exposed flowers into spring water. They are said to be similar in principle to homeopathic remedies, although they are prepared quite differently – there is no succussion and dilution, so many homeopaths dispute this claim (see Homeopathy, below). However, as with homeopathy, Bach remedies do not act pharmacologically: they are based on vibrational energy.
Complementary practitioners who use BFRs in their practice are not medically qualified, and although some focus entirely on the remedies as their primary modality, the remedies are mostly used in combination with other therapies such as homeopathy. They are freely available to purchase in health stores and it is relatively simple to self-administer them. The most common method of administration is to use the purchased stock bottle, dilute a few drops in bottled still spring water and then use this as the main remedy source, usually taking two or three drops, perhaps three to four times a day – but this does, of course, depend on the individual’s precise symptoms and the reason for using the remedies.
Indications
Rescue Remedy, in liquid form, is used for panic, hysteria and acute anxiety (but is not usually appropriate for prolonged or chronic stress-related conditions). The dose is three to four drops neat on the tongue but it is also available in a spray and a cream for dermal application, as well as lozenges for oral use. However, whilst Rescue Remedy is very effective in acute situations, for example pre-examination nerves, it should not be seen as a panacea for all emotional issues. It is particularly useful for situations in maternity care such as acute anxiety during venepuncture, the transition stage in labour and distress after being given bad news. It is also possible to use a blend of up to seven BFRs to treat more chronic emotional conditions and this would be taken three to four times daily for up to two weeks. Table 2.5 gives some examples of how the full range of 38 BFRs could be of use in pregnancy, labour and the puerperium.
Table 2.5 Examples of situations in maternity care in which Bach flower remedies may be useful | ||
Remedy | General indication | Examples |
Agrimony | Mental torment behind a “brave face” | Over-cheerful mother who may be developing postnatal depression |
Aspen | Fear of unknown origin | Primigravida frightened of giving birth but unsure why |
Beech | Intolerant | Labouring woman who can’t stand being touched and becomes irritable |
Centaury | Finds it difficult to say “no” | Professional working woman whose pregnancy suffers because she continues to work at her pre-pregnancy pace |
Cerrato | Lack of judgement, constantly seeking reassurance | Mother who constantly asks questions, lacks confidence in mothering ability |
Fear of mind giving way, as if she is going to “lose it” | Woman in labour who is becoming “out of control” | |
Chestnut bud | Keeps repeating the same mistakes, does not learn from experience | Woman who has different relationships with similar, perhaps abusive, men |
Chicory | Over-concern for others, controlling | Mother who constantly double-checks the condition of her baby, unable to pass care to others |
Clematis | Little interest in what is happening, day-dreaming | Mother who does not attend to her baby, possibly developing postnatal depression |
Crab apple | Unable to accept self-image, constantly cleaning | Woman who is overly conscious of the smell of lochia |
Elm | Overwhelmed, depressed, too much to do | Woman with several small children, who is overwhelmed by responsibilities |
Gentian | Easily discouraged when faced with difficulties | Woman who is discouraged by her slow progress in labour |
Gorse | Extreme hopelessness and despair | Labouring woman who feels complete misery, unable to anticipate the birth with joy |
Heather | Preoccupied with herself, talkative, demanding attention | Woman after a miscarriage, constantly “de-briefing” her experiences with people |
Holly | Feelings of envy, jealousy, suspicion, hatred | Partner who feels jealous of the time that the baby demands from mother, particularly during breastfeeding |
Honeysuckle | Over-attachment to past memories, can’t let go of the past | Pregnant woman who is constantly worrying about a previous emergency Caesarean |
Hornbeam | Mental weariness, “Monday morning” feeling | Midwife at the end of a 13-hour shift |
Impatiens | Impatient, easily irritated | Labouring woman who irritably tells the midwife not to touch her |
Larch | Lack of self-confidence | Older, highly professional woman, used to being in control, who lacks the confidence to care for her baby |
Mimulus | Fear of known things | Woman with needle phobia |
Mustard | Depression, deep gloom for no known reason | Postnatal depression |
Oak | Exhaustion, burn-out, workaholic, over-achiever | Midwife trying to juggle clinical, academic and personal commitments |
Olive | Lack of energy, fatigue | New mother not getting much sleep; midwives on long shifts |
Guilt, self-reproach, apologetic | Woman feeling guilty about leaving other children at home while she is in hospital | |
Red chestnut | Worried, over-concern for others | Mother who constantly checks that her baby is breathing |
Rock rose | Fear, terror | Woman requiring “crash” Caesarean section for severe fetal distress |
Rock water | Self-denial, perfectionist | Mother who is constantly striving to be the perfect parent |
Scleranthus | Indecision, usually between two choices | Woman trying to decide whether or not to have external cephalic version |
Star of Bethlehem | After effects of trauma, post-traumatic stress | Woman who is completely shocked by an unplanned pregnancy |
Sweet chestnut | Extreme despair, hopelessness, anguish | Following loss of baby or birth of baby with abnormalities |
Vervain | Over-enthusiastic, hyperactive | Student midwife who does not listen because she is so over-enthusiastic |
Vine | Domineering, inflexible, aggressive, bullying | Partner in domestic violence situation |
Walnut | Protection from outside influences, adaptation to change | Woman needing to adapt to the role of being a mother |
Water violet | Proud, aloof, lonely, anti-social | Woman in parent education class who keeps herself to herself and does not interact |
White chestnut | Mind constantly going over problems and worries | Woman unable to sleep because she is constantly worrying that the baby will be all right |
Wild oat | Uncertain of correct path, unable to plan and make decisions | Midwife trying to decide on direction of career |
Wild rose | Apathy, loss of motivation, resigned to current situation | Midwife suffering “burn out” but without energy to resolve it |
Willow | Resentment, self-pity | Woman who resents the interfering help of her mother-in-law |
Contraindications and precautions
Although BFRs are generally considered safe to use in pregnancy, the liquid remedies are preserved in aqueous alcohol (brandy), so should be avoided if there is a history of alcohol-related or hepatic disease or if the woman is taking large amounts of medication or herbal remedies that are metabolised via the liver. Occasionally, Rescue Remedy has been reported to cause drowsiness, so women should be advised to try it at home first in order to assess how they respond to it.
Where there are deep underlying psychological issues, care must be taken to assess the woman carefully and observe her closely over a course of treatment. BFRs are said to have an “onion peeling” effect, in which the most dominant emotion is stripped away by the initial administration of combined remedies, often revealing deeper psychological issues hidden below the surface. It is important that practitioners using BFRs also possess good counselling and listening skills and know when to refer to a professional who is more experienced in dealing with women with mental health problems.
Evidence base
There is little robust evidence for the effectiveness of BFRs and, as far as is known, none relating to safety. Rescue Remedy is the most studied of the remedies, mainly focusing on situations such as pre-examination or pre-operative stress (Armstrong and Ernst 2001; Walach, Rilling and Engelke 2001). Ernst (2010) conducted a systematic review of seven flower remedy trials, six of which were placebo-controlled, but none of the studies conclusively demonstrated effectiveness. Similar conclusions were drawn from Thaler et al.’s systematic review (2009). One study explored the use of the remedies for children with attention deficit hyperactivity disorder but, again, found no greater benefit of the remedies than with placebo (Pintov et al. 2005).
More recently, Rivas-Suárez et al. (2015) conducted a small placebo-controlled trial of 43 patients awaiting surgery for carpal tunnel syndrome who used Rescue Remedy cream for 21 days. The results appeared to indicate that it could be helpful in relieving pain, possibly due to a reduction in the emotional perception of pain. Howard (2007) also considered the use of BFRs to relieve pain and surmised that patients’ coping abilities were potentially improved through a better mental outlook on the pain, although it is difficult to determine the extent of the placebo effect in this study. Rescue Remedy cream has also apparently been found to control blood glucose and cholesterol levels in rats (Resende et al. 2014), possibly providing evidence of physiological effects.
One old obstetric study (von Rühle 1995), a summary of which was found on the Bach Flower Centre’s own website, investigated the use of BFRs on primigravidae with a post-dates pregnancy, with three groups receiving individualised flower remedies, additional care and attention or standard care. Although there were no direct effects on the time to onset of labour or mode of birth and results were not statistically significant, the researchers found that women in the flower remedy group appeared to have a perception of less labour pain and nausea and possibly required less intervention than women in the other two groups. It would, however, be difficult to replicate this study since the remedies were individualised to each subject within the original study, a factor that detracts from the robustness of randomised controlled trials.
The general conclusion in most studies is that there is a placebo effect, a factor which is increasingly recognised as a powerful therapeutic response in itself (Ernst 2010). BFRs are very popular amongst certain sections of the public. However, taking into account the lack of any real investigative support, there is little direct cross-referencing to BFRs in the condition-specific chapters in this book as they seek to examine the evidence base for the use of complementary therapies for each condition.
Chiropractic
Introduction
Chiropractic was founded in the 1890s by the Canadian Daniel David Palmer, a magnetic healer. Since 1994 it has been a statutorily regulated profession in the UK in the same way as medicine, nursing and midwifery. Chiropractic deals with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system and the effects of those disorders on neurological functioning and on general health and wellbeing. Treatment normally involves manual manipulation and/or adjustment to rebalance the whole and to help the person regain and maintain homeostasis. It is similar in principle to osteopathy but has some differences in philosophy and the management of conditions. See Table 2.6 for a summary of the similarities and differences between chiropractic and osteopathy. See also Osteopathy, below.
Table 2.6 Similarities and differences between chiropractic and osteopathy | |
Similarities | |
• They share a common history and philosophy • Both work on the musculoskeletal system, including bones, joints, ligaments and tendons • Both work on the neurological system and blood supply to influence other bodily systems • Both use observation and touch as part of the diagnostic process | |
Differences | |
Osteopathy | Chiropractic |
Osteopathy was founded 21 years earlier than chiropractic | Chiropractic was developed from the principles of osteopathy by a group of osteopaths with opinions that differed from their colleagues |
Takes a more holistic approach, considers the body as a whole, aims to improve function by correcting the overall structure of the body | Focuses mainly on realignment of the spine to treat pain, preventing neurological system compromise |
Treats a wide range of functional conditions including circulatory and digestive system disorders | Treats primarily musculoskeletal issues |
Diagnosis is by history-taking and physical examination, referral for other diagnostic tests as necessary | Diagnosis may include X-rays, MRI scans, urinary analysis and blood tests as well as history-taking and clinical examination |
Treatment involves a wide variety of techniques including muscle and soft tissue work, such as massage, joint articulation and manipulation | Treatment involves more manipulative techniques to aid adjustment of the vertebrae and facilitate optimal nerve transition |
Treatments may be over a prolonged period to allow for holistic assessment and therapy, with appointments being spaced out to facilitate recovery | Treatments are often short but frequent |
The primary concept of chiropractic is that joint subluxation (dislocation) is the cause of disorders within the body and that spinal manipulation assists in correcting the relationship of the joints, ligaments and tendons in order to treat the consequent illness. Spinal manipulation involves high-velocity, low-amplitude manual thrusts applied to spinal joints, which cause extension of the joints beyond the physiological range of motion. This is different from the spinal mobilisation used in physiotherapy in which manual force is applied to the joints without thrusting movements and within the normal passive range of motion.
Chiropractic is used to treat a wide range of illnesses, including stress, respiratory conditions such as asthma, to irritable bowel syndrome, cardiovascular problems and, of course, musculoskeletal issues. In pregnancy, backache, particularly lumbosacral pain, sciatica, pelvic girdle pain and carpal tunnel syndrome appear to respond well, but chiropractic can also be used to treat soft tissue conditions including nausea, constipation, heartburn, oedema and even pelvic floor problems (Bernard and Tuchin 2016; Haavik, Murphy and Kruger 2016; Henry 2015; Tuchin 1998).
Contraindications and precautions
Women with coagulation disorders or taking anticoagulants should not receive chiropractic, especially the high-velocity manipulations which can occasionally induce internal tissue tearing. Chiropractic is also contraindicated in those with osteoporosis, malignant or inflammatory disease, fractures or spondylolisthesis. It is important that expectant mothers seeking treatment inform the chiropractor of their pregnancy because X-rays are often used to aid diagnosis. It does, however, seem to be safe during pregnancy and for the treatment of neonates (Todd et al. 2015).
Evidence base
Research into chiropractic commonly revolves around treatment of backache and other major spinal disorders. A systematic review by Blanchette et al. (2016) found that chiropractic appears to be at least as effective as physiotherapy for the treatment of low back pain (in non-pregnant patients) and that it is relatively safe. Unfortunately, many of the papers involve small studies or comprise single case reporting (Howell 2012). Conversely, studies on pregnant women with back pain show good results (Murphy, Hurwitz and McGovern 2009; Peterson, Mühlemann and Humphreys 2014). A systematic review by Close et al. (2014) indicated similar results for both chiropractic and osteopathy, although methodology was considered to be of variable quality and it was suggested there was an element of bias in the studies reviewed. An additional problem is that many studies have been undertaken in Canada, the “spiritual home” of chiropractic, implying that there may be an expectation by clients of its potential success (Sadr, Pourkiani-Allah-Abad and Stuber 2012). See Chapter 5 for further discussion on back pain in pregnancy.
Introduction
Herbal medicine (phytotherapy) is the therapeutic use of plants and plant substances. Plants contain numerous chemicals which, when administered correctly, work synergistically to facilitate homeostasis. Although still not accepted by the medical professions, there is a great deal of research ongoing by pharmaceutical companies keen to harness the therapeutic properties of individual constituents so that they can be isolated and produced synthetically as drugs. Commonly used drugs which have been derived from plants include aspirin (from willow bark and meadow sweet), digoxin (from foxglove), cannabis (from opium) and quinine (from the bark of the cinchona tree), used for malaria. Plants have been used as medicines for centuries all around the world, particularly for childbirth problems.
Indications
Women frequently use herbal remedies, including herbal teas, to treat physiological disorders such as nausea and vomiting, constipation and other gastrointestinal discomforts in pregnancy. Use in pregnancy is often unrelated to previous use (Nyeko, Tumwesigye and Halage 2016), with older, better educated primigravidae being the most likely to use herbal remedies (Forster et al. 2006). Antenatal use is also common in developing countries, especially in rural areas with little access to conventional healthcare (Yemele et al. 2015). Women may also attempt to treat what they perceive as “minor” complaints with herbal medicines, including the rather worrying use of cranberry for urinary tract infection or St John’s wort for clinical depression (Frawley et al. 2015; Izzo et al. 2016).
Expectant mothers’ use of herbal remedies increases as they approach term, with many using herbal medicines specifically to prepare for and initiate labour (see also Chapter 7). Self-administration tends to decline during the early postnatal period, although some women take substances such as fennel or fenugreek to stimulate milk production. Traditional Chinese medicine is of particular concern in the UK because it can be difficult to elicit precisely what remedies have been prescribed; a survey of 54 Chinese medicine shops in London (Teng, Shaw and Barnes 2015) indicated potentially misleading information and unsubstantiated advertising claims that could lead to inappropriate consumer choices. Of more concern is the sometimes injudicious use of herbal teas to calm babies, especially, but not exclusively, in developing countries (Abdulrazzaq, Al Kendi and Nagelkerke 2009; Savino et al. 2005; Sim et al. 2013).
Contraindications and precautions
The most important factor which conventional healthcare professionals need to take into account is that all herbal remedies, including herbal teas and essential oils, act pharmacologically, their metabolism being the same as for other medication, whether prescribed or recreational. The risk of adverse effects is probably greater than with any other complementary or alternative therapy (Langhammer and Nilsen 2014). Women perceive herbal remedies as being safer than drugs and do not consider any potential risk to fetal development when taking natural remedies, although ironically their approach to prescribed medication is more cautious (Petersen et al. 2015).
One of the major problems of inappropriate use is the potential for overdose, side effects and interactions with other herbs or with prescribed or recreational drugs. As with drug medication, it is imperative that herbal remedies are taken for the correct purpose, in the correct dosage and frequency. Many side effects occur because of the public’s widespread misconception that plant remedies are safe because they are natural.
Concern has been expressed by numerous authorities about the use of herbal medicines in the preconceptional period and during pregnancy, childbirth and lactation (Boltman-Binkowski 2016; Budzynska et al. 2013; Johnson et al. 2009; Sim et al. 2013; Teoh et al. 2013). In pregnancy, the main issues centre on the impact of harmful chemicals on the mother and fetus and on the progress of pregnancy. Some plants are genuinely known to cause side effects, but others will only cause problems if taken to excess, and the difficulty in differentiating these two aspects further confuses the picture. The evidence for safety in pregnancy can be scarce simply because the individual herb has not been studied, or because there is no evidence of risks such as miscarriage or fetal anomalies in relation to the remedy. However, this does not mean that phytomedicine is safe in pregnancy – an absence of evidence of risk is not the same as proof of safety (Tiran 2012).
Research undertaken to elicit therapeutic effects in order that active constituents can be isolated and extracted for the development of drug manufacture can also be applied. For example, if a study finds that a herb has a hypertensive effect, it is obvious that caution should be taken in pregnancy even if there is no evidence of direct reproductive toxicity. In addition, there is a need to apply knowledge of the mechanism of action of the relevant herb to the physiology of pregnancy; for example, juniper berry may decrease blood sugar (Orhan et al. 2011), cause urinary tract irritation and even epileptiform fits if taken in excess and may significantly interfere with drug metabolism (Tam et al. 2014).
Medical practitioners rightly take a cautious approach to the use of herbal remedies in pregnancy, although this is mainly through lack of any in-depth knowledge. The general public takes the opposite approach, believing that herbal remedies must be safe (or safer than drugs) because they are natural. Conflicting information and evidence on individual herbal remedies abounds, even in relation to those which are very popular such as ginger, echinacea, chamomile and St John’s wort (Cuzzolin et al. 2010). Although the proportion of harmful chemicals tends to be less than in commercially prepared herbal remedies, excessive consumption of herbal teas can also lead to complications such as hepatotoxicity, as reported in a (non-pregnant) case related to rooibos (red bush) tea (Reddy et al. 2016), or airborne allergic reactions to chamomile tea (Anzai, Vázquez Herrera and Tosti 2015; Benito et al. 2014).
It is safest to advise women that herbal medicines should be avoided completely in pregnancy unless they have been prescribed by a qualified practitioner. This commonsense approach extends to the preconception period as many herbal remedies may interfere with fertility or early embryonic organogenesis. This applies across most cultures and in almost every country in the world. Women should avoid any plant remedies which are not essential during the first three months of the pregnancy, since many are known, even anecdotally, to trigger miscarriage; this rule is even more essential if there is a history of difficulty in conceiving or recurrent miscarriages. Certain remedies are, however, very commonly used in later pregnancy, not least those which are thought to prepare the woman’s body for labour.
Numerous plant remedies have strong anticoagulant effects and should be avoided by anyone, pregnant or otherwise, with haemorrhagic or coagulation disorders, or who is taking warfarin, aspirin or other drugs or herbs with anticoagulant effects (McEwen 2015). There are numerous published papers expressing concern about the effects of herbs on blood clotting, sufficient to prompt some anaesthetists to advise discontinuation of all herbal remedies at least two weeks prior to elective surgery (Leite, Martins and Castilho 2016). This practice should extend to women due to have an elective Caesarean section, to reduce the risk of haemorrhage during or after surgery.
There are several hundred herbal remedies used by qualified medical herbalists. Table 2.7 highlights some of the common herbs considered unsafe, in therapeutic doses, to use during the childbearing period as they may cause birth defects and are systemically toxic or utero-tonic (NB this list is not exhaustive). The key points are that herbal medicines act pharmacologically and can interact with prescribed medications, with each individual remedy having its own indications, contraindications and precautions in the same way as pharmaceuticals. Women should be advised to be extremely cautious in using herbal remedies, including excessive consumption of herbal teas or individual culinary herbs, during the preconception, antenatal, labour and postnatal periods.
Table 2.7 Herbal medicines considered unsafe to use before and during pregnancy, labour and breastfeeding | ||
Plant | Reason | Reference |
Aloe vera (oral) | May cause birth defects, miscarriage and have strong purgative effect on bowel May cross to breast milk | Ulbricht et al. 2007 |
Basil | May cause miscarriage, preterm labour May affect blood glucose; avoid with diabetic medication Small amounts suitable for culinary use | Mohammed et al. 2016 |
Black cohosh | May cause miscarriage, preterm labour Avoid in hepatic conditions, or with antidepressants or sedatives Possibly acceptable in labour (see Chapter 8) | Blitz, Smith-Levitin and Rochelson 2016 |
Blue cohosh | May cause miscarriage, preterm labour; developmental abnormalities in fetus Major vascular problems in neonate NOT to be used for natural induction of labour Avoid completely in pregnancy and labour (see Chapter 8) | Dugoua et al. 2008 |
Strong uterine stimulant, may cause preterm labour, hypertonic uterine action in labour, postpartum haemorrhage Avoid with oxytocics, antidepressants, alcohol (see Chapter 8) | Anecdotal evidence – personal experience and communications with midwives (see Tiran 2016a) | |
Comfrey | May cause miscarriage, preterm labour Hepatotoxic | Stickel and Seitz 2000 |
Dong quai (angelica) | May cause miscarriage, preterm labour, diarrhoea, sensitivity to sunlight Avoid with bleeding, coagulation disorders, anticoagulants | Chuang et al. 2006 |
Fennel | May cause miscarriage, preterm labour, dermal irritation May inhibit strong antibiotics | Trabace et al. 2015 |
Fenugreek | Large amounts may cause miscarriage, preterm labour Consumption immediately prior to delivery may cause baby to have unusual body odour similar to that with maple syrup urine disease Avoid with anti-diabetic medication, bleeding, coagulation disorders, anticoagulants | Ouzir, El Bairi and Amzazi 2016 |
Feverfew | May cause miscarriage, preterm labour May cause nausea, diarrhoea, constipation, headache, abdominal pain, bloating Avoid with bleeding, coagulation disorders, anticoagulants | Yao, Ritchie and Brown-Woodman 2006 |
Ginger | Use in small amounts for no longer than three weeks Anticoagulant effects – avoid with bleeding, coagulation disorders, anticoagulants | McEwen 2015 See Chapter 4 |
Ginseng, Asian | May cause fetal abnormalities Avoid with bleeding, coagulation disorder, anticoagulants, anti-diabetic medication, immunosuppressants, alcohol, caffeine | Seely et al. 2008 |
Juniper berry | Toxic to kidneys, may cause difficulties with conception, miscarriage Avoid with anticoagulants, renal complications | Butani et al. 2003 |
Motherwort | May cause miscarriage, preterm labour Avoid with antihistamines, drugs with sedative action | Ernst 2002 |
Mugwort | May cause miscarriage, preterm labour; may contain lead traces NB mugwort sticks for moxibustion are safe as not used orally; see Chapter 6 | Aziz et al. 2016 |
May cause miscarriage, preterm labour, thrombosis, hallucinations, changes in consciousness Avoid with pethidine or similar-acting drugs | Ernst 2002 | |
Parsley | May cause miscarriage, preterm labour, birth defects Avoid with anticoagulants, aspirin, anti-diuretics Culinary use acceptable in small amounts | Ciganda and Laborde 2003 |
Passiflora (Also known as passion flower) | May cause miscarriage, preterm labour Avoid with sedatives | Boeira et al. 2010 |
Pennyroyal | Toxic to liver, kidneys May cause dizziness, bloody vomiting, delirium, fits, raised blood pressure, blood clotting disorders May cause miscarriage or preterm labour | Jalili et al. 2013 |
Sage | May cause miscarriage, preterm labour, postpartum haemorrhage May affect milk supply postnatally Avoid with anticonvulsants, anti-diabetic medication | Ernst 2002 |
Senna | Long-term frequent use may cause laxative dependence, liver toxicity Purgative effects may cause miscarriage, preterm labour, abdominal pain, cramps, nausea, diarrhoea Avoid with other laxatives, anticoagulants | Vanderperren et al. 2005 |
Squaw vine (also known as partridge-berry) | May cause miscarriage, preterm labour; use only under supervision of medical herbalist | Chevalier 2016 |
St John’s wort | Mechanism of action similar to antidepressants and may cause same side effects Not a replacement for antidepressants | Moretti et al. 2009 |
Thuja (also known as arbor vitae) | May cause miscarriage, preterm labour Can cause epileptiform fits; avoid with anticonvulsants, antibiotics, antidepressants | Naser et al. 2005 |
Evidence base
There is a phenomenal amount of good quality research evidence to support the benefits and risks of herbal medicine. Many studies have been undertaken by pharmaceutical companies wanting to isolate active ingredients in order to develop and patent drugs. Whilst this gives us some relevant information about the mechanism of action of specific herbal remedies, it is the isolation of active constituents and the production of a synthetic form to be patented which is likely to lead to the appearance of side effects in patients taking the drugs. However, there is no clear evidence as to the safety of specific herbal medicines in pregnancy since it is impossible to conduct appropriately designed research studies on pregnant humans. Much of that available focuses on the risks to embryonic/fetal development and is usually performed on animals or in the laboratory. Other evidence is anecdotal and arises from reports of adverse effects, often from poisoning through inadvertent misuse.
Homeopathy
Introduction
Homeopathy is a gentle system of healing developed in the 18th century by Dr Samuel Hahnemann who became disillusioned with the medical practices of the day, for example blood-letting, purging or using toxic substances, which often caused severe side effects. Hahnemann discovered that, rather than treating people with opposites (such as treating constipation with laxatives), the principle of “treating like with like” was gentler and more effective. He challenged the popular belief that quinine from cinchona bark cured malaria due to its diuretic properties: after self-administering quinine he discovered that it produced malaria-like symptoms, which led him to the theory that “like cures like”. He later experimented with ever-smaller doses and realised that an infinitesimal dose worked even more effectively, especially when it was shaken vigorously – a process called succussion. Essentially, he discovered that when the person’s individual symptom picture is matched to a remedy (this is termed a proving), that same remedy, in extremely diluted form, will actually treat the same symptoms. Examples include a remedy derived from coffee (coffea) that may treat insomnia, or one from arsenic (arsenicum) that may ease profuse vomiting. The remedy resonates with the body’s vital force (internal harmonising capacity) to raise its energetic vibration, facilitating healing. This concept of the vital force is similar in principle to that of qi, as harnessed in traditional Chinese medicine.
Sceptics argue that because homeopathic remedies are so dilute, their action is purely a placebo effect. However, homeopathy does not work pharmacologically (i.e. chemically) but through a process of quantum physics in which the vibratory (dynamic) structure of a substance can be altered by violent shaking (succussion). For most physiological conditions in pregnancy and postnatally, a single tablet, taken three to four times daily for no more than four days, should be sufficient to resolve or lessen the symptoms. Taking an inappropriate remedy for longer than this can cause a “reverse proving”, in which symptoms intended to be treated by the remedy develop in addition to existing symptoms. For labour, a more acute phase, one tablet of 200C may be effective or, for more prolonged symptoms, one 30C tablet every one to two hours. It is the frequency of administration which affects the dose, not the number of tablets taken at each administration. If the correct remedy has been selected, the mother may initially feel worse (an anticipated healing aggravation) but her condition should then improve within a few days.
Indications
The essential method of diagnosis employed in homeopathy aims to determine ways to treat the whole person. Every aspect of the individual’s symptom picture is vital to choosing the most appropriate remedy. Different women with the same condition – for example, nausea and vomiting in pregnancy – may be prescribed different remedies because their overall symptom picture may differ. Conversely, the same remedy may be used to treat several different conditions because the underlying characteristics of the remedy match the symptom pictures. Women who are familiar with the principles of homeopathic remedy selection will often choose to self-administer remedies for the various physiological conditions of pregnancy and the postnatal period, including nausea, constipation, oedema and lactation issues. In labour, homeopathy can be useful for pain relief and to stimulate contractions, to help women overcome anxiety, fear and the various emotional changes occurring as labour progresses; it can also be effective for critical problems such as retained placenta. However, given the acute nature and possible dangers of a mismanaged third stage of labour, this would need to be prescribed by an experienced homeopath and should not be attempted by novices, particularly when midwives have access to other, proven, pharmacological and surgical treatments. Whilst the use of homeopathic remedies can be helpful, labour is a dynamic, constantly changing event and it can take some skill to identify the most appropriate remedy for each woman.
Contraindications and precautions
Homeopathic medicines are chemically very fragile, and although they will not interact with drugs, some medicines, such as antacids and certain strong antibiotics, can inactivate the remedies. Remedies must be stored carefully to avoid being inactivated by other chemicals or the environment, including exposure to bright light, radiation such as microwaves, televisions and mobile telephone energies, mint and other strong flavours and aromas (including aromatherapy essential oils), coffee, eucalyptus and embrocations for muscle pain such as Deep Heat™.
A healing reaction is a very common effect of treatment when the correct remedy has been selected. This is not the same as an adverse (side) effect of a pharmacological therapy such as herbal medicine or aromatherapy. In homeopathic medicine, the presentation of symptoms following administration of a remedy is more commonly known as a homeopathic aggravation and needs to be distinguished from adverse effects arising from inappropriate administration, such as taking the wrong remedy, or taking the right remedy too frequently or for too long. For example, a reverse proving can occur if a woman takes arnica tablets excessively frequently after delivery, causing her to develop severe systemic bruising.
Parents familiar with homeopathy often use remedies to treat their children, believing that it is gentler than pharmaceutical drugs. However, in the USA, over 400 reports of adverse reactions of infants given homeopathic teething granules or gels have been received by the Federal Drug Administration (FDA) since 2011 (Abbassi 2017). The reports included infants suffering convulsions, dyspnoea, drowsiness, coma and gastrointestinal complaints, and ten deaths. The FDA has advised parents not to use the products, several companies have voluntarily withdrawn stock from sale and one company issued a recall on a homeopathic teething product found to contain inconsistent amounts of belladonna; analysis by FDA laboratories found excessive levels of belladonna in another product. The FDA investigation continues at the time of going to press but this is likely to be another setback for the acceptance of homeopathy. However, as with any therapy, there is a correct method of administration and a correct dose to which people should adhere. It is probable that many of these children either suffered severe reverse provings or that some had underlying medical conditions which would make the use of the specific remedies inappropriate at that time. Unfortunately, as with herbal remedy adverse effects, problems with homeopathy most likely occur with inappropriate use due to lack of knowledge and understanding. Box 2.1 outlines the criteria for effective and appropriate use of homeopathic remedies.
BOX 2.1
Criteria for effective use of homeopathic remedies
• Avoid food, drink, toothpaste or cigarettes in the mouth for 15 minutes before or after taking the remedy.
• Avoid substances which antidote remedies: aromatherapy essential oils, coffee, strongly spiced foods, peppermint, mint-flavoured toothpaste or chewing gum, eucalyptus, decongestants, Olbas™ oil, mobile telephones, metal spoons, X-rays, microwaves.
• Avoid with drugs which block homeopathic action: analgesics, antacids, antibiotics, aspirin, steroids, laxatives, decongestants, cough lozenges.
• Remedies should not be taken prophylactically – await the occurrence of the condition.
NB It is particularly important prior to an elective Caesarean to avoid taking remedies such as arnica in advance of surgery as prolonged administration will cause a reverse proving.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
