12 Pregnancy and childbirth
Introduction
Aromatherapy and massage on expectant mothers have proved to be effective throughout their pregnancy, especially where some allopathic medications are contraindicated because of possible adverse effects on the fetus. Aromatherapy can offer a gentler means of achieving optimum wellbeing during the antenatal period and labour, as essential oils can help combat many of the physical and emotional symptoms. This chapter seeks to advise the professional in their safe and effective use, while stressing that aromatherapy is not an alternative to the orthodox care of a pregnant woman, but a complementary aid.
Ethical, legal and safety aspects in pregnancy
Aromatherapy during pregnancy and childbirth has gained enormous popularity in the last decade; many midwives were already using it at the turn of the century (Ager 2002, Reed & Norfolk 1993), as it blends in easily with the one-to-one situation of labour and delivery care and enables both midwives and aromatherapists to provide more holistic care.
Aromatherapy offers a wonderful means of helping women to cope with the physiological symptoms of pregnancy and early parenthood and to ease discomfort and pain in labour.
Only aromatherapists with specialized training in the changing anatomy and physiology of pregnant women should administer essential oils, always liaising with the maternity care team. On the other hand, it is not appropriate for midwives to advise women on the use of aromatherapy unless they have undertaken accredited training, to ensure that the information and care given is accurate, safe and up-to-date (NMC 2002a, b). A cooperative team of experienced professional midwives and aromatherapists can enhance the wellbeing of the mother and add to her overall pleasure and sense of achievement. Protocols may be devised not only to ensure best midwifery practice but also to include the protection of mothers and midwives. Although not actually a safety issue, cigarettes and alcohol are best avoided during pregnancy.
Insurance
Aromatherapists should be well insured for their work, and nurse-aromatherapists should have personal professional indemnity insurance cover in addition to their nursing insurance, which does not cover them for essential oil use. If permission to use aromatherapy within their midwifery practice has been obtained from the employing authority, the Trust’s liability insurance cover will usually apply. Midwives having a private aromatherapy practice should notify the Local Supervising Authority if intending to use essential oils on a pregnant client.
Keeping records
Most women keep their pregnancy notes with them and have access to midwife or consultant comments. The Congenital Disabilities Act 1976 says that notes must be kept for a period of 25 years after the baby is born, in case of any legal claims for error at birth. With this in mind, it would be prudent for a therapist also to keep their consultation and follow-up notes for this same period, giving the expectant mother a copy to keep with her maternity notes.
Safety issues
There is little scientific evidence for or against the safety of essential oils in pregnancy, as it is impossible and unethical to conduct randomized controlled studies on pregnant women; most available evidence comes from anecdotal and empirical knowledge accumulated by practitioners. Antenatal application of a limited number of essential oils is assumed to be safe, based on anecdotal evidence from years of use by pregnant women, currently available knowledge, and the increasing number of research findings (these have been carried out on animals, however, and so are not necessarily relevant to humans). Lists of essential oils contraindicated in pregnancy differ from one authority to the next, emphasizing the need for continual training to ensure that therapists are practising according to current information, whether based on experience or research.
It is standard practice for aromatherapist-midwives or aromatherapists administering essential oils to pregnant and labouring women to use only those that are considered to be safe. They should apply both knowledge of essential oil chemistry and common sense to the physiology and potential pathological complications of pregnancy.
Some aromatherapists, who have taken only a short course or one not recognized by a leading aromatherapy organization, feel they should not treat pregnant women: considering their lack of knowledge and experience, such people should not even be calling themselves aromatherapists (O’Hara 2002).
Emmenagogues and abortifacients
Although some aromatherapists prefer not to use essential oils with emmenagogic or abortive properties on pregnant women, there is only real danger if these oils are used in excess (i.e. 5–10 mL) and/or internally, neither of which a proficient aromatherapist would do. During the first 3 months of pregnancy the developing child is particularly sensitive to chemicals, and remains vulnerable throughout. There is good evidence that different fetal systems are sensitive to different chemicals at specific times (Tisserand & Balacs 1995 p. 110).
Where oils have been reported to cause spontaneous abortion, it has been as a result of ingesting quantities more than 20 times the amount that would normally be used – even in therapeutic aromatherapy, when maternal hepato- or renal toxicity is a far more likely primary outcome (Balacs 1992). Essential oils considered to be abortifacient (such as pennyroyal) are not used during pregnancy (see Ch. 3 Pt II and Appendices B2 and B3 on the CD-ROM).
Emmenagogues
An emmenagogue is a substance that promotes and regulates menstruation, and it is therefore understandable that oils with this property are usually avoided until the end of the first trimester once a woman realizes she is pregnant. Although essential oils with emmenagogic properties are used extensively in aromatherapy for conditions such as polycystic ovaries, dysmenorrhoea, amenorrhea and PMT, such oils should be avoided during pregnancy. There is no conclusive evidence that essential oils can cause a miscarriage, but women experiencing such a loss may look to the oils as a reason and may blame their aromatherapy treatment for their loss, even though the overall risk from essential oils is very small indeed.
Certain individual constituents, e.g. ketones, are claimed to stimulate uterine contractions, although this may depend on the isomer present in the particular oil; it may be wise to refrain from using oils containing ketones, particularly for women with a history of preterm labour. On the other hand, ketones can be useful at the end of pregnancy as they stimulate contractions and so reduce the time spent in labour.
Abortifacients
An abortifacient is a substance which can provoke an abortion (Collin 1993 p. 2). It is necessarily powerful as it has to fight nature, not help it. Essential oils known to be abortifacient should not normally be used in general practice – savin, tansy, juniper and pennyroyal have all been considered abortifacient. However, work using the isolated human uterus shows that the essential oils of these plants have no direct action on uterine muscles (Gunn 1921). There appears to be no clear evidence that any essential oils present an abortifacient risk, as far as external use in aromatherapy is concerned (Tisserand & Balacs 1995 p. 112).
A note on photosensitivity
Although photosensitizing oils are not a major problem in aromatherapy because possible ill effects are ineffective within 2 hours of administration (see Ch. 3), pregnant women should take extra care as they have an increased production of melanocytic hormone, which may make them more prone to being affected if the minimum waiting period of 2 hours is not observed before going into direct sunlight. Citrus oils, expressed or distilled, contain furanocoumarins, which trigger phototoxicity (Naganuma et al. 1985). Women who develop chloasma (the butterfly-shaped facial pigmentation of pregnancy) have higher circulating levels of melanocytic hormone and should not apply such oils on parts of the body most likely to be exposed to the sun. However, citrus essences and essential oils are otherwise considered relatively safe during pregnancy (see also Ch. 3 Pt II).
Aromatherapy and massage during pregnancy
Choice of oils and methods of use
The selection of essential oils can only be made in conjunction with the mother, following assessment of her condition at the time of the treatment. The oils suggested below are given as a general guide. Aromatherapy used to relieve specific physiological disorders in pregnancy offers mothers, midwives and aromatherapists additional tools to treat the unwanted symptoms which can present during the 9 months, as well as making the birth itself much easier. Most methods of use can be employed, although oral use (see Ch. 9) is the most effective way of treating digestive disorders, should the mother request it: it should not be used for any other problem. Not enough schools teach this aspect, so it is best used on the prescription of an aromatologist working with a medical practitioner. Regular antenatal aromatherapy, whether by massage, inhalation or self-application, is a pleasant way of enhancing the mother’s wellbeing by aiding relaxation, sleep, and easing physiological discomforts.
Massage during pregnancy reduces stress hormones such as cortisol and may contribute to a lower incidence of antenatal, intranatal and postpartum complications (Field et al. 1999), as well as being invaluable for treating oedematous ankles, constipation, backache and headaches etc.
See Ch. 8 for help in positioning a woman advanced in pregnancy for massage, in order to avoid supine hypotension, especially in later pregnancy, and to prevent discomfort.
Case Study 12.1 Massage throughout pregnancy treatments
Assessment
Ms E, age 38 – pregnant with non-identical twins (her first baby had died at 11 months old 7 years previously).
Recent diagnosis of gestational diabetes – under control. A history of polycystic ovaries was diagnosed in her early 20s, she experienced bad PMT, mood swings and had a 45-day cycle. She is emotionally tender over losing her first baby and is feeling tired, often aching.
Intervention
(1% blend in sweet almond oil used for all treatments)
Aim: to help Mrs E to feel relaxed, more confident about pregnancy and help dispel feelings of fear. Full body massage was given and the following oils selected:
• Citrus sinensis – calming, sedative, aids sleep
• Santalum album – cardiotonic, general tonic
• Citrus aurantium var. amara flos – calming, neurotonic, aids sleep
The same blend of essential oils given in a lotion to apply on shoulders each night.
2nd treatment – 3 weeks later – Mrs E had been sleeping better
Assessment: her sacroiliac area was painful and she was congested, with excess mucus.
Aim: To decongest system and relieve muscular aches and pains
• Boswellia carteri – analgesic, anticatarrhal, anti-inflammatory, energizing, expectorant, immunostimulant
• Pelargonium graveolens – analgesic, anti-inflammatory, relaxant
• Myrtus communis – anticatarrhal, expectorant, decongestant
The same blend was given for local application morning and night at home.
Assessment
Having frequent Braxton–Hicks contractions; was told not to overdo it, to drink more water and to rest. Mrs E was not sleeping well again, this time because it was difficult to get comfortable; her feet were swollen and tight. Heartburn was a regular occurrence. Scan showed twins gaining weight, so no worries. The oils selected were:
• Chamaemelum nobile [Roman chamomile] – calming, sedative (aids sleep), carminative, digestive
• Citrus paradisi [grapefruit] – digestive (indigestion), diuretic
• Citrus limon [lemon] – calming, carminative, digestive, diuretic (oedema)
• Lavandula angustifolia [lavender] – balancing, calming, cardiotonic, carminative
The blend was given for home application twice a day
Last treatment – before caesarean section booked for 2 weeks’ time
Assessment
Babies have dropped so heartburn has eased. Mrs E excited but nervous. Has had medication altered to combat insulin dropping sharply after meal times. Feeling fed up and very tired!
Aim: To energize Mrs E and relieve her anxiety
• Boswellia carteri – energizing, immunostimulant
• Citrus limon [lemon] – calming, diuretic, pancreatic stimulant
• Pelargonium graveolens – antidiabetic, relaxant
• Thymus vulgaris ct. thujanol [sweet thyme] – hormone-like (diabetes), immunostimulant, neurotonic
Firm sacral massage on a woman with a history of preterm labour must be avoided, as inadvertent stimulation of the acupuncture points in the intravertebral foramen may trigger uterine contractions. Additionally, there are certain points on the feet that should be avoided, for example massage of the area between the heel and the inner ankle is contraindicated in early pregnancy as this is the reflexology zone for the uterus (Price 1999 p. 55).
Essential oil use
A 1% dilution is recommended during all stages of pregnancy – for application, compresses and baths; it is advisable not to use the oils neat during this time, except in an emergency, such as a burn. As a woman’s sense of smell can change dramatically during pregnancy (see morning sickness and Box 12.1), always involve the client in the choice of oils and blends. It would perhaps be prudent to use a seed oil such as sunflower or grapeseed in case the client has a nut allergy.
Box 12.1 Taste and smell in pregnancy
A report by Nordin et al. (2004) showed that abnormal taste and smell was reported by 76% of 187 pregnant women tested, typically believed to be caused by their pregnancy. Increased smell sensitivity was common during the early stages of pregnancy (67%), occasionally accompanied by qualitative smell distortions (17%) and phantom smells (14%). Smell abnormalities occurred less in the later periods of pregnancy and were virtually absent postpartum. Abnormal taste sensitivity was fairly commonly reported (26%), often described as an increase in bitter and a decrease in salt taste. The authors conclude that pregnancy smell and taste disorders relate to fetal protection mechanisms to avoid poisons and increase salt levels for the expanded fluid levels.
Common problems in pregnancy
Blood pressure
Blood pressure is monitored closely in pregnancy and is checked at each antenatal visit – some women may suffer from hypertension throughout their pregnancy. If pre-eclampsia (a serious condition involving oedema, high blood pressure and protein in the urine (Collin 1993 p. 278)) is present, or if the mother-to-be is already on medication for high blood pressure, the authors do not advocate the use of aromatherapy; however, elevated blood pressure in the parameters of what is considered normal can be treated effectively with massage using hypotensive essential oils. Those reputed to lower blood pressure include: Cananga odorata [ylang ylang], Citrus aurantium var. amara (flos) [neroli], Citrus limon [lemon], Lavandula angustifolia [lavender] and Melissa officinalis [melissa].
Digestive disorders
Digestive disorders such as constipation, diarrhoea and indigestion, even if not directly connected with pregnancy, are likely to occur at some stage (see Table 4.6, which gives essential oils for all types of digestive disorder.
Alternatively, should internal use not be considered advisable, 15 drops of the blended essential oils should be added to 50 mL lotion for self-application. Aromatherapists familiar with Swiss reflex treatment (see Ch. 8) can massage the whole area of the arches of the soles of the feet with the relevant oils, in a clockwise direction, to stimulate the digestive system reflex zones, especially those of the large intestine.
Constipation
The hormonal action of progesterone relaxes the digestive system, which can result in the slowing down of peristalsis. It is often made worse by high doses of iron supplements to alleviate anaemia symptoms. A diet rich in fruit and vegetables and at least 2 litres of water a day will assist defecation. Essential oils which can help constipation include Citrus aurantium var. amara per. [bitter orange], Citrus reticulata [mandarin], Piper nigrum [black pepper], Rosmarinus officinalis [rosemary] and Zingiber officinale [ginger]. Coriandrum sativum [coriander seed] and Elettaria cardamomum [cardamon] aid a sluggish digestion, which may in turn aid constipation.
Clockwise massage over the abdomen can bring relief, but would have to be very light to be comfortable in later pregnancy (see above).
Diarrhoea
Diarrhoea can be helped by the following oils (see also Table 4.6): Citrus limon [lemon], Cupressus sempervirens [cypress], Melaleuca viridiflora [niaouli] and Pelargonium graveolens [geranium].
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