Antenatal and Postnatal Initiatives in Complementary Therapies Education

by Maggie Evans, midwife

There is no doubt that Complementary Therapies (CT's) amongst the lay population has become more popular in recent years (Woodham and Peters 1998, Stone 1999). This has resulted in a demand for complementary approaches to care being adopted into the mainstream (The Foundation of Integrated Medicine 1997). Midwives are slowly incorporating CT's into their practice despite difficulties in support, training and finances. (Evans 2002). In tandem with this, pregnant women are also returning to a more naturalistic approach in their birth choices (West 2001, Tiran 2000).

The midwifery profession appears to be divided into two distinct camps. On the one hand, the medicalised model supports intervention, a medical procedure that needs to be executed in the quickest most efficient way (Jowitt 1993). Viewing the mother and the reproductive organs as just a container for the foetus and delivery of the baby, rather than the woman actively giving birth. (Kitzinger 1987). Conversely many midwives are anxious to support and enhance a natural physiological approach, which relies on respecting the woman's instincts, allowing her to trust her body, whilst providing emotional and intuitive support (Hall 2001). Within this model, complementary therapies are often incorporated as they compliment and support many women's wishs to encompass naturalness and nurturing during pregnancy and birth (West 2001). Thus this more holistic, more gentle approach (Douglas 1994), to well being, harnesses the ethos of pregnancy and birth, moving away from the brash harshness of orthodox approaches.

According to eastern philosophy the energetic changes during pregnancy tend towards a going within or yin energy, whilst birth needs to harness a more active source or yang energy (Yates 2003). It is being able to work with these cycles of energy and help to balance them, that is of special benefit for pregnant and birthing mothers.

Complementary therapies also provide women with choices in their care as stipulated by reports such as "Changing Childbirth" (DOH 1993). More recent government policy has emphasised the need to provide high quality health care that is appropriate to people's needs (DOH 1998). Women are faced with many decisions throughout the childbearing year. With the increasing use of care plans, women are encouraged to think about the options they would like to employ for birth, many perhaps will consider complementary therapies for the first time (West 2001).

The use of CT's can also be empowering for birth attendants and partners, as CT's easily allows them to take a more meaningful and active role. Consequently there is birthing bonding for the partner, resulting in a more cohesive and fulfilling experience (Tiran 2000).

Incorporating CT's into maternity care enhances the practice of normal midwifery: the midwife's specialism. Reducing intervention and medical procedures, maximises the release of stress hormones, which are well known to suppress the normal progress of labour (Jowitt 1993). It is important that women are conversant with these basic, but important principles. Education in CT's easily achieves this, as the underpinning philosophy focuses on working with natural processes and holistic values. Utilising CT's encourages the production of natural endorphins which supports normal physiology and mindbody intelligence (Pert 1997). Using CT's provides the midwife with extra/alternative tools to work with, that are supportive of natural physiological processes (Tiran 2000).

However due to the continued scepticism still shown by some of the midwifery/medical establishment, I feel it is important to empower women so that they can achieve their own personal goals for birth especially if they wish to use CT's. This is particularly important as this provides the means by which women can feel in control and well informed and thus achieve fulfilment in birthing.

The midwife is ideally placed to provide health promotion and educational advice to women both one to one and at group sessions (UKCC (NMC) 1998). Therefore there is a priority to include meaningful and correct information for women regarding CT's (Tiran 2000) within these settings, e.g.: parentcraft groups. If women are to be empowered, then they must receive appropriate and safe advice, based on best practice within that sphere or therapy. Most CT's are considered to be "safe", however within most therapies there are cautions particularly in relation to pregnancy. Some essential oils are contra indicated (Tiran 2000) and there are forbidden points for acupuncture and shiatsu (West 2001). Rather than pregnant women dabble with CT's, it is far better to have a sound awareness of safe usage and feel confident in their use, particularly when there are so many fears and anxieties regarding substances or procedures that may harm the foetus.

For this assignment I have chosen to discuss two initiatives that I undertook as part of developing my Shiatsu practice and knowledge. Whilst also furnishing a particular interest in antenatal education and the desire to empower women and their partners. One initiative involved postnatal women, the other initiative involved antenatal women.

The first initiative was to develop a "roadshow" for pregnant women and their partners, introducing them to CT's that may be used for birthing. The main aim was to enhance knowledge, develop simple techniques and answer any queries. It was anticipated that not only would this be useful for birth, but hopefully would be utilised in the future to help cope with daily life episodes (Strauss 1999) and to stimulate more interest in CT's. This session was incorporated as part of an "add on" optional session following on from a traditional parentcraft series. A flier was displayed and interested parties booked with the community midwife leading the parentcraft classes.

Within the 2 hour session I devoted some time to Shiatsu, which is what I shall focus on. (appendix 1 ) Shiatsu is an ideal therapy that can be used as an adjunct to conventional maternity care or as the main supportive therapy a woman may wish to use. Its other main asset is that it will enhance both physical and emotional domains; this lends itself to the special needs of labouring women (Jowitt 1993). Simple techniques can also be taught to partners antenatally, which gives them a positive role in labour and birth, knowing that they are contributing to the experience in a meaningful way (Yates 2003).

The Shiatsu session focused on delivering a concise introduction to the therapy with the aid of flipcharts and exercises, and practice of simple techniques that the partner could use in labour, ( appendix 2).
Firstly, I gave a very brief introduction to shiatsu, lasting just a couple of minutes. To introduce some fun and variety we then all participated in a group exercise which included breathing and stretching (metal stretch, standing stretch and complete breath). We then moved on to some do-ing, explaining that we were energising the body via the meridians, whilst also stimulating the circulation. Finally we spent a little time massaging the Hara, whilst I explained the importance of this area (the centre of our being, during pregnancy and for the practice of shiatsu). To finish I demonstrated with the partners the cat stretch and the knee-chest position discussing it's advantages for encouraging the baby into a favourable position for birth (Yates 2003).

Following this a short talk, supported with handouts, (appendix 3 and 4) about the general principles of shiatsu was given to consolidate important information; to build on the little knowledge of most people present and to prepare for the practical session. I then proceeded to demonstrate on one of the midwives present, consolidating the information again as I was doing the shiatsu. The partners were then encouraged to practice, taking time to ensure that they were comfortable and to use the techniques in different positions. I circulated amongst the group giving practical advice, support to the partners and receiving feedback. Finally general feedback from the group revealed that most of the women enjoyed the hands on, although some of the men were a little apprehensive about whether they were doing it properly. A few couples were aware of changes in temperature and sensations as they were working the points. I explained that this corresponded to energy being over abundant or diminished (Bullock 2002). Shiatsu helps to balance the flow of this misplaced energy via the meridian pathways (Jarmey 1992).

Generally the session went well and I was pleased with the participation and motivation of the group. As always evaluation of the session provides sound educational principles of reviewing objectives as a means for improvement. I would involve some minor modifications for the next group to improve the delivery of the practical part.

A month later a little feedback gained via the community midwife regarding one couple was very encouraging. Although they couldn't remember all that I had included on the roadshow, they had incorporated a few techniques. The sacral work, particularly the sacral grooves had been very helpful in labour, together with stroking down the back and legs and working K1 as part of a simple foot massage.

The second initiative that I undertook was in conjunction with a community midwife employed on the "Surestart" programme. She felt that in pregnancy women received a plethora of information and attention as apposed to the postnatal period, whereby women often felt isolated and attention was focused primarily on the baby. The midwife had already set up a postnatal group to bring recently delivered women together, initiated baby massage classes and was looking for other interesting ideas, particularly targeted at the women themselves. Hence I devised an introductory session on Shiatsu.

The main objectives were to provide valuable and practical advice that could be utilised in every day life (Strauss 1999), plus to create a session that would be practical and a relaxing experience for the women. The session needed to be able to accommodate the fact that young babies would also be present and so needed to be sensitive and flexible to their needs too.

The community midwife had attended an introductory course in shiatsu for midwives, so was able to help with the practical aspect of this venture after some revision of the principles with me.

The session commenced with asking the group if any one had knowledge of shiatsu and a brief review of what we would be doing. No one had previous experience of Shiatsu. Handouts were distributed to support a general explanation of the main principles of oriental medicine (appendix 3 and 4). The group then participated in some breathing and do-ing exercises, finishing with massaging the Hara and a brief neck massage on each other (appendix 5). I gave explanations throughout this session, reinforcing what had already been discussed - the importance of the hara; that we had been activating some of the meridian lines and also the neck massage to prepare them for some hands on experience of shiatsu.

Some individual work was then facilitated to explain the positioning and practice of shiatsu prior to being worked on later. Key points for the postnatal period were selected, whereby the women worked these points for themselves. Explanations were given regarding the significance of these points as we proceeded. (appendix 6).

I then talked briefly about the Chinese view of the postnatal period. There is often a weakening or loss of Ki (life force or energy) due to the extra requirements needed for labour, birth and delivery of the placenta, consequently the vessels become empty (Yates 2003, West 2001). This then leaves the blood and Yin energy weakened, which can cause many problems such as tiredness, depression, inability to breastfeed successfully, bleeding and slow involution. Therefore, working on specific meridians will encourage and strengthen the flow of Ki and nourish the body to cope with the demands of the postnatal period. (West 2001,Yates 2003).

Finally a relaxing hands on shiatsu sequence was performed by myself and the community midwife on the women, mainly concentrating on the back meridians plus points for the post natal period. (appendix 7). I did not focus on some of the key meridians for the postnatal period (Penetrating vessel and The conception vessel) within the group session, as this may have been a little intimidating for some women, especially with their first exposure to Shiatsu. However in a one to one session this would of course be more appropriate, therefore I chose to work mainly on the Governing vessel and the Bladder meridian. It was important too not to make the hands on session too lengthy in case the mothers became distracted if their babies required attention.

The community midwife and myself carried out all of the hands on massages consequently this ensured that there was always someone (the other mothers who were awaiting or who had had their massage) available to look after the babies whilst the mothers were being massaged in turn. Thus all the mothers were able to get full benefit from the shiatsu by not worrying about their baby's needs not being attended to.

Evaluation of the session revealed that the women had gained a lot of new information and felt as though they had been "pampered". One baby fell asleep whilst holding his mother's hand when she was receiving her massage. This had a huge impact on the group, which they concluded was a very positive aspect of shiatsu, by experiencing the benefits themselves they could identify how this had come about. The women also commented how it had made them more relaxed and some had felt changes in temperature and sensations indicative of energy imbalances during their session.

A couple of mothers seemed interested in knowing more about Shiatsu for themselves and their families. I commented that there were plenty of books available and I showed them the introductory book of my own as an example. I also commented on the benefits of Shiatsu for babies too. I do believe that facilitating empowerment for people and sharing knowledge is paramount if CT's are to be accommodated within the public domain. This process also results in networking amongst people which further distributes the benefits and holistic aspects of CT's. This in turn initiates people to move forward in controlling their own health and well being, and adopting an alternative philosophy of health consciousness.

This session provided some challenges as I had envisaged, there were interruptions from the babies for feeding or comfort from their mothers, so I was pleased I had woven in some flexibility and informality to the session. Also the decision that the hands on massage would be done by the two midwives and not expecting the women to practice on each other was appropriate. This therefore achieved the objective of the women receiving something for themselves and thus feeling pampered. On reflection there is little I would do to modify this session for next time.

In conclusion the experience of planning and facilitating the two initiatives has provided me with the means to consolidate and utilise the theoretical and practical aspects of shiatsu in a meaningful and useful way. It has also empowered me to achieve a personal goal, that of empowering others (mothers and midwives) to an awareness of the value of CT's in contemporary maternity care.

There are further sessions planned and other midwives are interested in incorporating the "roadshow" into their parentcraft programmes. Further input into the Surestart initiatives is also underway with more sessions for postnatal groups and antenatal support for young and unsupported mothers. Shiatsu for the younger/unsupported pregnant groups will require a different approach, with the focus on informality and fun whilst incorporating simple, relaxing techniques. Also the younger element often tend to be inhibited about touch and expressions of spirituality, so again a flexible approach and care with terminology will need to be considered carefully for these sessions.

The impetus for change and response to the needs of women during pregnancy and birth has never been more apparent. It comes at a time of great financial restraints and reductions in staffing levels within midwifery, whilst also trying to accomplish goals set by government bodies. A medicalised model of care also subscribes to reductionist strategies that influences the uptake of CT's. However, CT's provide ways of circumventing some of the difficulties, many therapies do not require expensive equipment or resources (Shiatsu is a prime example) and many lend themselves to self-administration given correct advice and information. Due to the economical short fall, CT's can be cost effective alongside conventional treatments.

Shiatsu like many CT's fosters a holistic approach, which encompasses mind, body and spiritual aspects. I feel it is particularly pertinent to initiate a concept of wholeness at a time of new life and expectancy. Not only does this allow women to feel in control and empower them to achieve a more meaningful experience, but it also enables women to get in touch with their more sensitive and spiritual side, which is suppressed within a medical model of care. By empowering women and midwives through education, of the role of CT's there is a way forward to initiate changes to keep pregnancy and birth normal and to create a more fulfilling and holistic culture within maternity care.

References
1. Bullock R. (2002) Essential Traditional Chinese Medicine. Caxton Editions, London.
2. Douglas M. (1994) The construction of the physician: a cultural approach to medical fashion. In: The Healing Bond. (Budd S and Sharma U eds) Routledge, London.
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5. The Foundation of Integrated Medicine (1997) Integrated Healthcare: A Way Forward for the Next Five Years. London Royal Society of Medicine.
6. Evans M. (2002) Complementary therapies in midwifery - Establishing a database. The Practising Midwife. Vol 5, 3, page 25 (March 2002).
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8. Jarmey C. (1992) Thorsons Introductory Guide to Shiatsu. Thorsons, London.
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20. United Kingdom Central Council (NMC) (1998) Midwives' Rules and Code of Practice, UKCC, London

Appendices

- 1, Plan

- 2, Shiatsu introduction - plan

- 3, Yin and Yang

- 4, Meridians

- 5, Exercise and Breathing sequence

- 6, Postnatal Shiatsu

- 7, Relaxing Sequence