Reflexology has become very popular amongst expectant mothers in recent years, as well as for couples having difficulty with conceiving (see Ch. 8). Many pregnant women actively seek treatment at this time, usually for general relaxation. Some may have had reflexology prior to conception, whilst others request treatment to ease specific pregnancy discomforts. One of the factors welcomed by expectant mothers is the chance to develop a relationship with a professional therapist, especially as there is a severe shortage of some 5000 midwives in the UK. This means that, in conventional maternity care, emphasis is placed on monitoring and treating the mother’s physical condition, whilst her myriad questions and concerns may go unanswered.

Reflexology during pregnancy appears to have profound benefits, although whether this is due to the physical effects of reflexology, the therapeutic value of human touch, or the psychological effects of the client–therapist interaction is debatable. Relaxation reflexology allows the mother to have time for herself, and the ongoing physical and emotional effects of the treatment assist in preparing her for the birth. When physical discomforts occur during the pregnancy, the reflexologist may then be able to use specific techniques to treat the mother for problems such as nausea, backache, sciatica, headaches, carpal tunnel syndrome and constipation. Increasingly too, mothers are requesting practitioners to accompany them during labour, to provide pain relief and emotional support and to act as their advocate by liaising with conventional maternity professionals. Some therapists may already work as doulas (lay birth supporters) whereas others may develop a close relationship with a particular client and wish to support her throughout the childbearing process. Postnatally, reflexology can aid adaptation to parenthood, facilitate breast feeding (or cessation of lactation) and may prevent or reduce the severity of postnatal depression.

Many expectant mothers like to use a range of complementary therapies or natural remedies, such as massage, aromatherapy, and herbal or homeopathic medicines, although there is a relatively limited amount of research evidence on the safety and effectiveness of reflexology in particular, as opposed to manual therapies in general. This apparent lack of evidence has led the National Institute for Health and Clinical Excellence (NICE) to recommend health professionals to discourage women from using complementary therapies during pregnancy or birth (National Collaborating Centre 2008). This is not particularly helpful, nor entirely accurate, but it may mean that some conventional maternity care providers (midwives and doctors) are reluctant to condone women’s alternative treatments by independent therapists. Fortunately, however, this situation is slowly changing, as many midwives now use manual therapies in their own practice, although availability remains slightly ad hoc (Williams & Mitchell 2007). Many maternity units now offer reflexology, massage, aromatherapy or shiatsu (Dhany, 2008, Lythgoe and Metcalfe, 2008 and Mitchell and Allen, 2008), particularly in response to the need to focus on keeping birth normal to avoid medical interventions and reduce an escalating national Caesarean section rate, which is approaching 25%. Indeed, the Department of Health document, Maternity Matters (2007), now appears committed to the concept of providing a ‘full range of birthing choices’, including complementary therapies to ease pain in labour.

Reflexologists who are not qualified midwives or doctors must recognise the limitations of their own professional accountability. Those who wish to specialise in treating pregnant women must have a thorough understanding of pregnancy physiology, embryonic and fetal development, potential maternal and fetal pathology (see Case Study 9.1), the current maternity services and the role and responsibilities of the practitioner, especially when working within an NHS maternity unit.

Whilst core curricula for reflexology training programmes now recommend students to have an introduction to the treatment of pregnant women (O’Hara 2007), this is rarely sufficient to engender confidence in the practitioner. It would be wise for those intending to treat pregnant women to have undertaken continuing professional development to ensure that they can apply generic reflexology principles to the specific physiopathology of pregnancy and that they have a thorough understanding of the maternity services. This should also include knowledge of the first aid treatment that may be necessary in a variety of situations. Examples include: precipitate labour (completed in under 2 hours); antepartum haemorrhage (vaginal bleeding after 28 weeks’ gestation); eclamptic fit (a serious and sometimes fatal consequence of pre-eclampsia, the pregnancy-specific high blood pressure syndrome); or cord prolapse following spontaneous rupture of the membranes (in which the umbilical cord drops below the level of the baby’s head, leading to oxygen deprivation and possible fetal death).

Adequate listening skills are essential, as pregnant women frequently ask for advice and reassurance, but this may sometimes mask a subconscious request for more focused help, for example with sexual problems in pregnancy or domestic violence issues. It is fundamental to good practice that the reflexologist is adequately prepared to answer even the most basic of questions: with antenatal clients this presumes a thorough working knowledge of contemporary, evidence-based information on aspects such as diet and lifestyle, specifically related to pregnancy. It is not, for example, appropriate to attempt to advise women on dietary issues based on inadequate or out-of-date knowledge, and practitioners should be aware of the current Department of Health guidelines on healthy eating (see www.dh.gov.uk).

Practitioners need also to maintain continual updating in both their reflexology skills and in current trends in maternity care which are pertinent to their work. Occasionally, reflexologists incorporate elements of other therapies, such as basic acupressure point stimulation or massage with aromatherapy oils alongside their main therapy, but it is vital to understand fully the application of these additional therapies to pregnant and childbearing women and the potential for interaction between therapies. For example, some practitioners may incorporate essential oils in their reflexology treatment, but many of these are contraindicated during pregnancy and childbirth (see Tiran 2000), as are numerous herbal remedies (Chuang et al. 2006), while stimulation of certain acupressure points is prohibited during pregnancy as this may trigger contractions, causing preterm labour. All practitioners, both conventional and complementary, should be able to justify their actions, supported by research-based evidence where available. It is unprofessional and potentially professionally suicidal, especially in this age of litigation, to act without full knowledge, understanding and experience of the therapies and the client group.

Midwives and doctors are legally required to retain maternity notes for 25 years. This is because, under the Congenital Disabilities (Civil Liability) Act of 1976, any claim for negligence can be taken to court by a child allegedly damaged by care during birth, for up to 25 years after the event. There is an expectation that childbirth in the Western world of the twenty-first century is safe: the death of a baby – or occasionally a mother – is so much more emotive than the death of someone who is elderly or seriously ill. Cases involving alleged maternity negligence account for almost 60% of claims dealt with by the NHS Litigation Authority and over £1 billion has been paid in compensation for maternity cases since 2001 (Independent newspaper 4-3-07).

Although there is no legal obligation on the part of therapists to retain their records for the full 25 years, it may be wise to do so, as any professional involved in the mother’s care may be called to give evidence and it would be extremely difficult to remember details after so long a period of time. If the therapist feels unable to store all the documentation, she or he can request that notes on pregnant clients are sent to the maternity unit responsible for the mother’s care, to be inserted into the individual mother’s conventional maternity records. It is not permissible for the reflexologist to write in the conventional maternity notes when recording treatments but a copy of the reflexology record could be inserted in the back of these notes. This provides a reasonable means of communication between the therapist and the midwife caring for the mother, although more direct communication is wise on occasions. Since the potential for litigation is high when treating pregnant and/or labouring women, it is also important to ensure that the therapist has adequate and appropriate indemnity insurance cover; some companies providing insurance for complementary therapies do not cover the treatment of pregnant or labouring mothers.

Midwives are the principal maternity care providers, caring for women during pregnancy and for up to 28 days after delivery, and acting as the lead professional for approximately 70% of births. Midwives are the experts in caring for women with normal pregnancies and are trained to recognise when complications are developing, at which point they refer the mother to an obstetrician. Obstetricians are doctors who specialise in caring for women with problems in pregnancy and labour. If all is well, a mother does not need to consult a doctor at all, although a few choose to receive antenatal care from their general practitioner.

It is illegal for anyone other than a midwife or doctor, or one in training under supervision, to take sole responsibility for the care of expectant and labouring women, except in an emergency. There are, of course, occasional situations in which a baby arrives unexpectedly quickly and the mother will be glad of any help available. However, it is illegal for someone to plan to attend a mother during childbirth without having the requisite qualifications; indeed, there have been cases involving prosecution of men attending their partners during delivery, without the midwife being present. This is a growing contemporary problem, fuelled by public dissatisfaction with the maternity services, a severe shortage of midwives in some areas of the country and women’s desire for more control over the childbearing experience. A new trend from the USA, ‘unassisted birth’ or ‘free-birthing’, means that some women are actively choosing to labour without professional support.

The reflexologist should therefore determine whether the mother is booked for conventional maternity care, either with the NHS or privately, with a midwife or a doctor. One way of confirming this is to ask to see the mother’s maternity notes, which she keeps with her for the duration of the childbearing episode. If she is unable to produce these on demand, especially in later pregnancy as the birth approaches, the therapist may be alerted to the possibility that the mother intends to labour without professional help. In this case he or she should decline to provide maternity reflexology in order to protect his or her professional status.

Confidentiality is, of course, important in respect of all clients. However, it is very easy when caring for pregnant women to forget the need for discretion, especially as the outcome is usually so positive and exciting. Reflexologists should take extra care that colleagues with whom they discuss cases are only given information on a ‘need to know’ basis. When home visits are provided, consideration should be given to the mother who does not wish her neighbours to know that she is pregnant, especially in the early weeks – this may, for example, require a coat to be worn over the uniform, if one is worn.

Therapists intending to offer their services within an NHS maternity unit will need to have a Criminal Records Bureau check prior to working with pregnant women and their babies. Even those who do not enter the maternity unit but who choose to treat pregnant women and their babies would be wise to obtain this check privately. Some NHS trusts may also request reflexologists to sign an indemnity form, confirming that they have personal professional indemnity insurance cover and that, in the event of a case for negligence, they will not attempt to use the trust’s vicarious liability cover (which only applies to employees of the trust). Further, practitioners may be asked to sign that they acknowledge that the midwife and/or doctor retains overall responsibility for the mother’s care and that they agree to ‘step back’ if it is deemed no longer suitable for a mother to receive reflexology; this applies particularly to labour care. On occasions, this request may be made by the midwife, perhaps because of her lack of understanding of the therapy, even though the reflexologist may feel she or he still has a part to play. It is not appropriate to debate the situation at length in front of the labouring mother at this time, but a post-birth ‘debriefing’ between the two professionals can be helpful for both the midwife and the therapist and may strengthen their relationship for the future.

Antenatal care may be provided in the home, the GP’s surgery or health centre and in the hospital maternity unit, both on the NHS and privately: some women choose to contract with an independent midwife whom they pay direct (average cost for pregnancy, labour and postnatal care is about £3500, rising to £6000 in London). Women may give birth at home (currently approximately 3–5% in most areas), in a midwife-led, low-risk birthing unit or in the consultant-led obstetric unit (maternity unit), depending on their choice, maternal and fetal health and local availability.