• mental health

• complementary therapies for the neonate

• conclusion.

Introduction

Becoming a mother, especially for the first time, is a period of psycho-emotional, social and physical adaptation which can be fraught with anxieties and worries. Social expectations to conform to being the “perfect parent”, changes in family dynamics and issues around whether or not to return to work bring additional pressures to bear. Physical recovery from the birth takes time – up to a year in the case of the musculoskeletal system – and extra stress can delay a full return to normal.

Whilst some women will turn to complementary therapies or self-administer natural remedies, some of these strategies can also easily be included in standard postnatal care. They offer options for easing pain and discomfort, aiding recovery from the birth and facilitating adaptation from pregnancy to motherhood. Relaxation therapies reduce stress hormones, aiding breast milk production, improving sleep patterns and enhancing the immune system, thus promoting wound healing and preventing infection.

Research on the value of using complementary therapies in the puerperium appears to be confined largely to lactation issues and wound healing, although some studies address stress reduction. However, there appears to be a wider gap between the use of complementary therapies in the postnatal period and the available evidence to support its professional incorporation into mainstream maternity care than with some aspects of antenatal and intrapartum care. This may be because, once a mother and her baby are discharged from the midwife’s care, there is less contact with the health services and perhaps less inclination to investigate ongoing family use of complementary therapies (except aspects such as infant massage, which is well researched).

Recovery from birth

For pain relief in the early days following the birth, simple hand and foot massage could be helpful, particularly after instrumental or operative delivery (Abbaspoor, Akbari and Najar 2014). A study by Saatsaz et al. (2016) randomly allocated 156 post-Caesarean primiparae to receive hand and foot massage or foot massage alone, or to act as a control. Both massage groups experienced significantly less pain than control subjects for up to 90 minutes post-treatment. Hand and foot bathing has also been found to reduce pain and restore homeostatic balance (Cal et al. 2016).

Reiki (Therapeutic Touch®) could be offered as a pain-relieving strategy, and may be particularly effective when applied over the surgical incision area (Sagkal Midilli and Ciray Gunduzoglu 2016). Midilli and Eser (2015) conducted a randomised controlled trial in which reiki was administered twice a day for two days post-Caesarean section and demonstrated a positive effect on the study group compared to the control group, with less reported pain and a consequent decrease in the use of pharmacological analgesia. Conversely, a Canadian study in which distant reiki was offered to post-Caesarean mothers proved inconclusive (Vandervaart et al. 2011). Listening to music also appears to reduce pain and the need for analgesic medication (Ebneshahidi and Mohseni 2008).

Acupuncture is especially beneficial for holistic recovery from birth. Rather than treating each symptom in isolation (pain, intestinal transit, wound healing, etc.), an assessment of the mother’s internal energies aims to determine the points to be stimulated or sedated in order to treat the whole person. Acupuncture is known to reduce stress hormones, stimulate endorphins and enhance the immune system (Kawakita and Okada 2014), effects which all contribute to physical and psychological recovery. Auricular acupuncture has been found, in post-Caesarean mothers, to lower cortisol levels, thereby easing fatigue and promoting sleep, reducing anxiety and regulating blood pressure and heart rate (Kuo et al. 2016). This could easily and inexpensively be incorporated into midwifery care for women who have had a normal birth. In another study, auricular and general acupuncture were administered to 22 women after Caesarean section; treatment was well tolerated, pain was considerably lessened and women reported satisfaction with the intervention (Hesse et al. 2016). Similarly, TENS may be helpful, especially when applied to the relevant acupuncture points. A study by Kayman-Kose et al. (2014) allocated 100 post-Caesarean section mothers to receive either TENS or a placebo, plus 100 women who had achieved a normal birth without episiotomy into two further groups to receive TENS or a placebo. Women in both TENS groups required significantly less analgesia eight hours after delivery than the women in the placebo groups, suggesting that TENS offers a practical method of relieving pain in the postnatal period.

Lactation issues

Breastfeeding women will normally achieve optimum milk supply by encouraging physiological baby-led feeding. However, when milk supply does not meet demand, galactogoguic (milk-stimulating) herbal remedies or homeopathic medicines may be used by some new mothers to improve lactation. Commonly used pharmacologically active herbal galactogogues include fenugreek, milk thistle and others (Zuppa et al. 2010), whilst the application of cabbage leaves to the breasts is popular to relieve engorgement. There are, however, relatively few studies on the use of herbs during breastfeeding, mostly with small sample sizes, sometimes using multi-herbal preparations and often with variable breastfeeding practices between subjects (Bazzano et al. 2016; Mortel and Mehta 2013).

Cabbage leaves have long been used to relieve the discomfort of engorged breasts, and many midwives, doulas and lactation consultants advise their use (Lee 2010). However, as with other traditional remedies, information given to new mothers about cabbage leaves needs to be accurate, comprehensive and, where possible, based on contemporary evidence (Schaffir and Czapla 2012). A recent Cochrane review found that there are some promising findings to support the application of cabbage leaves to the breasts to relieve engorgement (Mangesi and Zakarija-Grkovic 2016); Boi, Koh and Gail (2012) and Saini and Saini (2014) agreed, but concur that more studies are needed.

The mechanism of action when cabbage leaves are applied to the skin of the breasts is unclear, although any effects are local rather than systemic since the active chemical constituents do not appear to be absorbed into the circulation. Many midwives believe cabbage leaves work because of the presence of an enzyme, but equally effective relief can be obtained from using lettuce, geranium or even rhubarb leaves which contain different chemical constituents, suggesting that some other mechanism may be at work. (NB Rhubarb is poisonous; the breasts must be washed before putting the baby to feed and it is probably wise to refrain from using rhubarb at all.) An abstract of an Iranian study was found in which even hollyhock leaves (Althaea officinalis L) were used to good effect (Khosravan et al. 2017).

Cabbage (Brassica oleracea) contains the amino acid methionine, which may increase vasodilatation to reduce engorgement and inflammation, but it is difficult to elucidate from searching the literature the difference between oral consumption and dermal application. It is also possible that the excess fluid is drawn from the breasts through a process of osmosis. If this is so, the fresh, raw cabbage leaves should not be washed prior to use as contact with water will trigger the osmotic action, nor should they be chilled in the freezer, since thawing will cause them to wilt and become wet, again nullifying their potential therapeutic effect. Nikodem et al. (1993) found that women who used cabbage leaves to relieve engorgement in the early puerperium were more likely than controls to be breastfeeding exclusively at six weeks postpartum, but the researchers were unable to clarify the mechanism of action and postulated that the consequent reassurance, reduced discomfort and increased self-confidence in breastfeeding may have contributed to the effects. Most women appear to prefer cold leaves, but there appears to be little difference in clinical effectiveness between chilled or room temperature leaves (Arora, Vatsa and Dadhwal 2008; Roberts, Reiter and Schuster 1995).

The outer leaves should be discarded and any field dirt removed by wiping. It may be necessary to remove the fibrous central stalk of larger leaves to enable them to be wrapped around the breast inside the brassiere. They are left in place until they become wet – they smell like cooked cabbage – and typically takes about 20 minutes but can be as soon as five minutes after application. The leaves are replaced with fresh ones and the process is repeated as many times as necessary until the mother feels some relief. Although the evidence base is limited, there appear to be no risks associated with the practice of using cabbage leaves to relieve engorgement, and it offers an inexpensive, safe and possibly effective method of easing a common discomfort of the puerperium. However, women who are allergic to cabbage and other plants in the brassica family should avoid using the leaves for engorgement.

Chiropractors believe that breastfeeding difficulties associated with fixing the baby on the breast may develop as a result of neonatal spinal subluxations (misalignments) sustained during the birth, especially with instrumental delivery. A systematic review by Alcantara, Alcantara and Alcantara (2015) concluded that misalignments of the fetal neck, cranium and mandible from traumatic delivery contributes to intracranial strain and jaw tension in the infant, making it difficult for the baby to attach to the nipple adequately to draw milk. In this case, chiropractic treatment of the baby may be the best solution to continuing breastfeeding. Indeed, the establishment of a joint midwifery and chiropractic clinic has been shown to achieve exclusive breastfeeding in almost 90 per cent of women who attended (Miller et al. 2016).

Perineal wound healing

Perineal pain following delivery, either from lacerations or an episiotomy, is one of the most common discomforts for women in the early puerperium, yet one for which conventional care has limited options. Prevention of perineal trauma is preferable to dealing with the consequences of tears or episiotomy. Haavik et al. (2016) suggest that chiropractic spinal manipulation during the second trimester of pregnancy may prepare the musculature of the pelvic floor for the birth and result in less perineal trauma at delivery. The practice of perineal massage may also contribute to fewer severe lacerations, reduce the need for episiotomy and lessen the severity of postpartum perineal pain (Beckmann and Stock 2013; Hastings-Tolsma 2014; Seehusen and Raleigh 2014).

Several Middle Eastern studies support the use of intrapartum perineal massage, and a systematic analysis by Karaçam, Ekmen and Calis¸ir (2012) concurred. However, the choice of medium used in some of these studies is concerning. It is generally thought that a light, non-greasy vegetable oil such as grapeseed should be used for perineal massage. A study by Harlev et al. (2013) attempted to determine the most appropriate oil, but this trial is flawed because the two oils used in the study are not suitable for all women. The oils used were jojoba liquid wax, which is not necessarily the best consistency, and a combination of olive oil with sweet almond oil, the latter of which potentially causes allergic reactions in some people. Demirel and Golbasi (2015) used glycerol during the first and second stages of labour, and Geranmayeh et al. (2012) used Vaseline™, which is intended for external use only. Using petroleum jelly on moist mucous membranes tends to linger and can encourage an increase in bacteria, leading to infection (Brown et al. 2013). Many of these Middle Eastern studies appeared to demonstrate a reduction in the need for episiotomy compared to control groups. On the other hand, episiotomy is performed routinely in many of these countries, and positive results may simply have been due to the lack of standard surgical intervention in the study group, irrespective of the use of perineal massage.

In the UK, a case is known to this author of a woman who self-administered a commercial steroid-based cream to massage the perineum during pregnancy in the belief that it would thin the perineum and encourage stretching at delivery. Unfortunately, the cream caused complete breakdown of the perineal tissues in labour when the presenting part exerted pressure on the pelvic floor. Essential oils (aromatherapy) should not be used for perineal massage during pregnancy or labour. Many chemical constituents in essential oils potentially cause irritation in this delicate mucosal area and it is unsafe for the baby to come into contact with the oils at birth.

Another Iranian study (Sheikhan et al. 2012) compared lavender essence to normal care (betadine), and although the results were less conclusive, the team considered that “lavender” was a preferable treatment. However, essential oils are the extracted volatile oils from plants, whereas the definition of essences is more indistinct and often refers to fragrant oils, which may be synthetic, or used as flavourings in foods. Similarly, Vakilian et al. (2011) compared lavender oil with povidone iodine, demonstrating reduced erythema and oedema. However, topically applied povidone-iodine, in itself, can cause skin and mucosal irritation and sensitisation in susceptible women and, again, any improvements may have arisen from the omission of standard care rather than the inclusion of a natural oil treatment.

Several inappropriate practices in relation to the use of lavender for perineal healing have come to the notice of this author in recent years. Some midwives are known to advocate adding neat drops of lavender essential oil to a sanitary pad, in a line equivalent to the suture line, or making a lavender spray in a water bottle for the mother to spray onto the perineal wound. These are both inappropriate methods. In the first example, essential oils should rarely be used neat but, in any case, adding them to a sanitary pad is an expensive waste of money since the pad is specifically designed to draw fluid away from the skin. In the second example, mixtures of essential oil in water will chemically last only 24 hours before oxidation alters the chemical composition. The bottle should therefore be labelled with a use-by time and date. Further, the use of a plastic bottle is inappropriate because the organic oil chemicals interact with the synthetic chemicals in the plastic, causing further oxidation (deterioration) of the essential oil, thus changing the original chemicals to others which may be more hazardous, possibly causing irritation.

Tea tree essential oil has also been used in the bath, either alone or in combination with lavender oil. Tea tree (Melaleuca alternifolia) is particularly valuable as an anti-infective agent and has been researched extensively since the 1970s in relation to many different pathogens. There is some evidence to suggest it can be useful for wound healing (Chin and Cordell 2013; Edmondson et al. 2011), but whether this is due to a direct effect on granulation or an indirect effect through the prevention of wound infection is not clear. However, tea tree oil can cause serious skin or mucosal irritation in some women and should therefore be used or advised with caution, ensuring good dilution and low doses. It is possible to obtain tea tree oil rich in terpinen 4-ol, which is thought to reduce the incidence of irritation, but this is more expensive and there does not appear to be any evidence to support its use for wound healing above the use of standard tea tree oil.

Homeopathic arnica is well known as a remedy for shock, trauma and bruising and is often used by newly birthed mothers to ease pain and reduce bruising to the perineum and buttocks following episiotomy or lacerations. It can also be used after operative or instrumental delivery and is particularly effective for wounds with pain, swelling and tissue bruising. A localised patch containing arnica can also be used for small wounds such as needle puncture or epidural cannula bruising (Barkey and Kaszkin-Bettag 2012), although this would not be appropriate for perineal healing.

Other studies use arnica in combination with other homeopathic, herbal or synthetic substances. For example, Castro et al. (2012) studied the effect on rats of arnica compared to homeopathic hypericum and in combination with microcurrent stimulation, finding that the use of a microcurrent enhanced the benefits of both homeopathic remedies. Simsek et al. (2016) used a cream containing arnica and an anti-inflammatory analgesic, which was found to reduce oedema and bruising after rhinoplasty. Conversely, van Exsel et al. (2016) found no statistically different reduction in bruising or swelling following blepharoplasty compared to a placebo cream, and a systematic review by Ho, Jagdeo and Waldorf (2016) concluded that there is insufficient evidence to support the use of topical arnica or bromelain (see below) for post-operative oedema.

A single-blinded study of biofeedback taught by physiotherapists to mothers for home self-administration showed no real benefit, but the researchers postulated that the mothers find it difficult to allocate sufficient time to perform the technique (Peirce et al. 2013). A Cochrane review of localised cooling (East et al. 2012) found limited evidence of analgesia, wound repair and oedema compared to other natural and conventional clinical strategies, although many women report satisfaction.

Mental health

Stress, anxiety and lack of confidence are common emotions amongst newly birthed mothers, which can predispose them to more significant postnatal “blues” which, for some, may develop into clinical depression. Lack of sleep often exacerbates symptoms in susceptible women, while those who experience emotional trauma during pregnancy, as well as those with pre-existing depression, are much more likely to develop postnatal mental health problems because of the hugely fluctuating hormone levels and the immense social changes wrought by having a new baby. Several aspects of complementary medicine have been explored, both for the prevention and treatment of depression, with some being more acceptable than others. It must be stressed however that complementary therapies cannot replace conventional medical care when women are severely clinically depressed and caution must be employed when advising women at risk of depression or with a pre-existing mental health condition on natural remedies or aspects of other modalities.

Placentophagy

In an American study, Schuette et al. (2017) investigated women’s and professionals’ attitudes to, and knowledge of, placentophagy. Approximately two thirds of women and almost 90 per cent of midwives and doctors had heard of the practice but most knew very little about its benefits and risks. Gryder et al. (2017) conducted a randomised placebo-controlled trial to investigate the claim that encapsulated placenta is a rich source of iron for women who are iron deficient. Whilst encapsulated placenta contained significantly more iron than a placebo (beef), it was not sufficient to meet the recommended daily amounts for lactating mothers, and the authors expressed concern that women whose only source of iron came from the placenta may not receive a sufficient amount. Abstracts of some very old papers were found online and claimed variously that placentophagy increased breast milk production (Hammett 1918) and the protein and lactose content of breast milk (McNeile and Lyle 1918) and eased pain (in rats) following birth (DiPirro and Kristal 2004). No studies appear to have been undertaken on the possible risks of eating the placenta, although Hayes (2016) suggests that infection, thromboembolism from oestrogenic tissue and accumulation of environmental toxins are possible.

Touch therapies

Touch therapies such as massage, aromatherapy and reflexology may be helpful in aiding relaxation and facilitating sleep in women with postnatal “blues”. However, touch therapies should be used with caution for mothers with clinical depression, whether pre-existing or antenatally or postnatally manifested. This is because deep relaxation may be inappropriate for some women, perhaps precipitating a serious emotional release, a fact that reinforces the need for counselling and listening skills in professionals who provide massage.

It is also possible to combine the massage with essential oils. Imura, Misao and Ushijima (2006) offered women a single 30-minute aromatherapy massage on the second postpartum day and found improved anxiety and depression scores compared to a control group. However, this may have been due more to the interaction with caregivers, or a positive reaction to the massage, than specifically related to the essential oils. Conrad and Adams (2012) provided a more realistic programme of 15-minute treatments with rose (Rosa centifolia) and lavender (Lavandula angustifolia) oils, administered either by inhalation or via a hand massage. The Edinburgh Postnatal Depression score and Generalized Anxiety Disorder scale evaluations were significantly improved in both the trial groups compared to a control group.

In another study (Kianpour et al. 2016) anxiety, stress and depression were significantly lower in the postpartum women who received lavender inhalation, even up to three months after delivery. The methodology involved women inhaling three drops of lavender essential oil from the palms of their hands, eight-hourly for four weeks. However, as with many other Iranian trials, the lavender was specifically prepared at a local laboratory and the research paper does not specify the type of lavender. Further, no mention was made of any woman experiencing skin irritation from the dermal application or respiratory adverse effects from the inhalation, although one woman withdrew from the study because she did not like the aroma of the lavender. It is interesting to note that a systematic review by Perry et al. (2012) found that, despite limited evidence for Lavandula angustifolia as an anxiolytic, oral consumption of a tea made from lavender (i.e. as a herbal remedy rather than as an aromatherapy treatment) may have some value in reducing anxiety.

Mindfulness

Mindfulness techniques such as guided imagery impact positively on the mood, and help to reduce stress (Beattie et al. 2017), particularly that experienced by mothers whose babies are in the neonatal intensive care unit (Howland et al. 2017). Learning mindfulness techniques during pregnancy can be especially effective in the postnatal period (Roy Malis, Meyer and Gross 2017), and women explicitly at risk of mental health disorders may benefit from mindfulness yoga before and after delivery (Muzik et al. 2012). Group sessions can help some women, although the logistics of arranging these and gathering newly birthed mothers together must be considered. A study by Buttner et al. (2015) found that when depressed new mothers participated in yoga sessions, with 16 treatments over eight weeks, there were improved depression and anxiety scores and enhanced quality of life for 78 per cent of the trial group. It is however difficult to elucidate whether the yoga was the primary means of improvement or the fact that women were in a dedicated group setting, presumably allowing for interactions between participants.

Ko et al. (2013) initiated an exercise programme, based on yoga and Pilates principles, to help new mothers to lose weight, ease fatigue and prevent or reduce depression. A course of 12 one-hour weekly sessions was provided. Fatigue levels pre- and post-course were not significantly different, but there were noticeable reductions in body weight, fat mass and basic metabolic rate. When measured in terms of women’s quality of life there was considerable improvement. Although the primary aim of the study was to investigate exercise for postnatal weight loss, it was concluded that improved body image contributed to enhanced emotional states and that group exercise programmes could contribute to a reduction in postnatal depression.

St John’s wort (SJW) (Hypericum perforatum) has long been known as an herbal remedy for treating mild to moderate depression and may be one of the most commonly used remedies in the postnatal period (Budzynska et al. 2012). It is often used orally for mood disturbances, including premenstrual syndrome, menopausal symptoms, seasonal affective disorder and other mental health issues, whilst topical application aids wound healing. SJW has been found in numerous clinical trials to be more effective than placebo in reducing depressive symptoms and is at least as effective as tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) including sertraline, fluoxetine and paroxetine (Apaydin et al. 2016; Linde, Berner and Kriston 2008; Rahimi, Nikfar and Abdollahi 2009). Short-term use seems to be particularly effective (Linde and Knüppel 2005), the active constituents being hypericin and related chemicals, which appear to regulate serotonin, noradrenaline and dopamine and reduce cortisol (Schüle et al. 2001).

General side effects to SJW include gastrointestinal disturbance, insomnia, headaches, photosensitivity and skin rashes. More serious adverse reactions include manic episodes and suicidal tendencies, as well as serotonin syndrome if administration is discontinued abruptly. SJW should not be taken concurrently with antidepressants with similar actions and may inhibit the use of the contraceptive Pill, anticoagulants and certain drugs used in cancer and HIV treatments (Jiang et al. 2006; Murphy et al. 2005). It may also possibly induce psychotic episodes in women who take it injudiciously (Ferrara, Mungai and Starace 2017).

The safety of SJW in pregnancy and breastfeeding is still under discussion. Although researchers and medical professionals were of the opinion in the late 20th and early 21st centuries that SJW should be completely avoided in the preconception, antenatal and breastfeeding periods, cautious approval has been forthcoming in recent years (Dugoua, Mills et al. 2006; Moretti et al. 2009) with apparently little neonatal risk (Klier et al. 2006). However, women should be advised to seek medical advice before changing from prescribed antidepressants to SJW and that any change should be gradual and preferably under medical or herbalist supervision to avoid the risk of side effects. Similarly, withdrawal from SJW should also be gradual. As a point of interest for post-puerperal use, concomitant use of SJW with the contraceptive Pill can trigger breakthrough bleeding and reduced contraceptive efficacy (Berry-Bibee et al. 2016).