Here is the reading to be completed before your workshop
This document has been constructed purely as a supporting resource and is not intended to represent or replace formal training or education. As a therapist you are responsible for your own education and the decisions you make with your clients. This document simply highlights some important factors to consider when working with pregnant clients. The information provided is by no means comprehensive.
The below information has been sourced from the text “Nurturing Massage for Pregnancy” A Practical Guide to bodywork for the perinatal cycle by Leslie Stager. ISBN – 13: 978-0-7817-6753-8.
MASSAGE DURING PREGNANCY
As a Massage Therapist working with a woman through her perinatal cycle have an exciting and unique opportunity to share in what is often the most life changing and important experience of a woman’s life. Massaging pregnant women can be extraordinarily different from working with other clients. Over the space of 9 months, a massage therapist will observe and feel both the subtle and dramatic changes the body goes through.
Throughout a pregnancy a woman often experiences important changes emotionally, energetically and spiritually. If working regularly with a pregnancy client you will begin to notice a change in the woman’s identity and ultimate transformation into a mother.
One of the most amazing opportunities that we are privileged is to work on two people at once, whilst only touching the skin of one person. Each time a pregnant woman is massaged, the baby in utero, as well as the mother is affected energetically and physically.
BENEFITS OF MASSAGE DURING PREGNANCY
Improved physiological function: massage improves venous blood flow and oxygen perfusion whilst assisting removal of cellular waste by increasing lymphatic flow. In pregnancy this helps decrease non pathological edema, reduce blood pressure, and relieve headaches. With this improved circulation, especially through the large vessels of the inguinal region, the occurrence of edema and muscle spasms related to poor circulation can be reduced.
Musculoskeletal Pain Reduction: Massage helps decrease strain on joints and muscles that are impacted by the extra weight gain of pregnancy, reducing muscle tension and back pain.
Improved Posture: Massage sessions are a great opportunity to teach postural correction to alleviate associated musculoskeletal complaints
Enhanced Lactation and increased Prolactin: Nurturing touch stimulates prolactin production, enhancing a mothers “nesting” instincts and abilities to nurture her infant
Improved Emotional Wellbeing: Studies indicate that massage can decrease stress hormones, reduce depression and anxiety, and increase serotonin production, increasing one’s sense of well-being. All these benefits will also improve outcomes for the baby in-utero
Increased immunity and decreased Intra Uterine stress: Touch enhances the immune system function by reducing stress. Reduced maternal stress means a decrease in the possible detrimental effects of intrauterine stress on the baby.
Improved Relaxation Skills and Self-Connection: Massage enhances a woman’s body-awareness by bringing her attention to areas of muscular tension that can relax with bodywork and focused breath. Massage provides an opportunity for a woman to practice this relaxation and breathe awareness in preparation for the birth process.
Increased energy: Massage can reduce or relieve some of the common complaints of pregnancy including fatigue, stress, and insomnia – concerns that sap a woman’s energy.
Increased ability to nurture others: Massage provides an experience of nurturing, healing touch, which increases a woman’s ability to touch her infant similarly.
Clearly, as therapists we can provide an important service during a woman’s pregnancy. Still, there are fears and issues that sometimes prevent pregnant women from taking advantage of the benefits of massage therapy.
ISSUES WITH MASSAGE DURING PREGNANCY
Body Image: A healthy woman will typically gain 13kgs on average during a normal pregnancy. Some of which is naturally deposited in the thighs and buttocks. Without this extra weight the baby would not thrive. For some women this creates a diminished confidence and avoidance behaviors surrounding touch.
Fear of Miscarriage: Another major concern of expectant mothers and their partners is the fear that touch – by themselves or others – could lead to a miscarriage. This becomes especially important after the woman feels the baby move inside her belly for the first time.
Some couples begin to view the pregnant body as being fragile and unstable and believe that if the woman is massaged the “wrong” way or in the “wrong” place, the mother or fetus could be harmed. Being massaged by a knowledgeable therapist can help ease these concerns and build confidence in the nurturing touch and benefits that massage can provide to her and her baby.
Violation of personal boundaries: Physical changes are happening at a radical rate within the woman’s body one very level and it is not uncommon for them to become unfamiliar with themselves. Being respectful towards this and maintaining professionalism builds trust and raport over time and will allow the mother to further relax as treatments progress.
Education for the massage therapist: Many therapists lack knowledge and understanding in regards to pregnancy massage and are unwilling to perform pregnancy massage. While causing problems is unlikely, this concern is valid and there certainly are contraindications for massage during pregnancy and times when certain types of treatment are inappropriate. By understanding pregnancy massage and acquiring the skills and knowledge surrounding such treatments will help ease therapists and ultimately the pregnant woman’s concerns.
Education for the mothers: Finally, the mothers own lack of knowledge about the safety and benefits of massage during pregnancy which can become an obstacle. It is helpful for you to have a span of knowledge about the perinatal cycle to work confidently and reassuringly, especially when working with women who have concerns or reservations about treatment.
A lot of pregnant women will turn to sources such as the internet and friends to research pregnancy massage and will find many statements dressed up as fact that may discourage them from seeking treatment. A lot of old myths have been disproven but are still taught within our industry despite no solid reasoning or evidence base for such concerns.
As professional therapists working in Australia’s largest clinic it is our duty to educate ourselves and clients about the benefits of pregnancy massage and address any concerns they may have with receiving treatment. It is important that we inform them of any contraindications or precautions relative without putting the fear of god into them. If a contraindication is not relevant to the treatment plan required there is no need to divulge such information unless the client enquires to avoid causing undue stress to mother and unborn child.
If you have any concerns regarding handling this conversation please contact your clinic manager who will put you in contact with relevant staff for a professional development workshop or someone who can clarify your concerns.
PRECAUTIONS AND CONTRAINDICATIONS FOR MASSAGE DURING PREGNANCY
Type 1 Massage
Stimulating: Generally more intensive and may be stimulating to the circulatory and/or musculoskeletal system, with a tendency to increase the release of cellular waste products.
Type 2 Massage
Gentle: Physically gentle, non-forceful or nonintrusive, and does not stimulate the physical body in the same way as the above mentioned.
Abdominal massage is contraindicated in a few situations. Because the majority of miscarriages occur during the first trimester, avoid DEEP abdominal massage at this time. The primary reason for this recommendation is to prevent any questioning or association of massage with miscarriage in your own mind and the mind of the client, should this pregnancy result in miscarriage.
Note: Be aware that type 2 massage such as slow superficial effleurage on the abdomen will not cause harm and some experienced practitioners may choose to utilize these techniques with the clients request and consent.
Along with first trimester contraindications, type 1 abdominal massage is also contraindicated at any time during pregnancy that there are concerns or risks with the health of the uterus or placenta, as well as when the mother is having preterm labor risks, or if the baby is demonstrating signs of stress, as indicated by irregularities of the heartbeat. These are situations for which the client would be medically managed.
Understanding why abdominal work is avoided can help you make the appropriate choices and communicate effectively with your client about touching her abdomen.
In the second trimester, once the pregnant belly has grown larger, abdominal massage can be offered if five other criteria are met first.
The client is not experiencing abdominal or pelvic pain, cramping or bleeding.
The client is not considered at high risk for preterm labor.
You have asked permission first before touching the clients abdominal region.
You always ask your client for feedback regarding your use of pressure and her comfort level.
You use firm ( but not forceful) effleurage as opposed to very light touch on the pregnant
The use of a few specific acupressure points is contraindicated during pregnancy. These points are based on the “forbidden” points of acupuncture. Not all of the prohibited acupuncture points are prohibited for acupressure; however, many of the points are contraindicated for applying needles only, not for using finger pressure.
Be aware that contraindications for acupressure are sometimes misconstrued into contraindications for massage in general. These are different techniques that do not affect the body similarly; therefore, contraindicated acupressure points are only contraindicated for acupressure treatment.
This is lucky for women, for if it were true that the regions of contraindicated acupuncture or acupressure points could not be massaged, then the shoulders, hands, abdomen, inner calves, and ankles would all have to be avoided for massage as well.
To influence acupressure points, strong and continuous pressure, repeated over a period of hours or days, is necessary to have any hope of possibly stimulating a uterine contraction. Gentle massage can therefore be done without fear in the areas of points prohibited for acupressure.
Aromatherapy: A pregnant woman is likely to be more sensitive to aromas, especially in the first trimester when nausea or vomiting is common. Many essential oils are contraindicated for use during pregnancy and postpartum. Until you have studied a full course in aromatherapy, it is advisable to assume all essential oils be contraindicated in the first trimester, unless you have specific instruction for there use. The Melrose H20 oil and sorbolene which we use in the clinic are fine for pregnancy treatment.
MASSAGE OF ADDUCTORS AND INNER THIGH
Varicose veins in the legs often appear for the first time during pregnancy. Adhere to standard massage contraindications and avoid massaging over varicosities, and on legs with known phlebitis, and blood clots. Severe varicosities can indicate that clots are present in deeper veins. Obtain medical approval before beginning any massage work for clients who a currently being treated for a blood clot. Not all clots are obvious and symptomatic. Small ones often go unnoticed and eventually are broken down by the body.
You will most likely know when your client has a symptomatic clot, as she will be medically treated. Sever pain and swelling in the leg is likely to have come on suddenly, with an 80% - 90% chance that it occurred in her left leg or in the left illiofemoral vein. If a woman is being medically managed for a clot, than all massage to the legs will be contraindicated to avoid possibly dislodging the clot into the circulatory system.
You will not know if your client has a nonsymptomatic, but potentially dangerous clot, therefore however always practice safety. A general recommendation is to only apply gentle pressure to the legs, especially in the hip adductor region and avoid techniques such as tapotement, deep vibration, cross fiber friction, pettrisage, deep effleurage, and pressure in the hip adductor region of the leg between the knee and groin, and any work that involves tissue compression which can slow or block the blood flow momentarily.
Avoid supine positioning after about 22 weeks ‘gestation or any time a woman’s pregnant belly is visibly obvious and she is uncomfortable lying supine for more than a few moments. When the client is supine, the weight of the baby and other uterine contents can press directly onto the large blood vessels (the aorta and inferior vena cava) along the mothers back. If it does, blood flow will decrease, affecting both the mother and baby. The baby’s heart rate will decelerate, its oxygen saturation levels will drop, and the mother may feel dizzy, nauseated, or generally uncomfortable or uneasy. If this should happen, the optimal treatment is to have her turn immediately onto her left hand side to relieve the pressure on the blood vessels and resume full blood flow. Encourage her to breathe deeply to increase oxygenation.
HEALTH FACTORS THAT INCREASE RISK DURING PREGNANCY
Some pregnancies begin with or develop risk factors indicating minor or major concerns for the mother and/or the baby. These risks may lead to serious complications. Pre-existing risk factors include maternal age, obesity, history of repeat miscarriage, or asthma, while risks that can develop during pregnancy itself include preterm labor and gestational hypertension. If the client has a condition that increases her risk for complications, massage restrictions are not always necessary unless problems actually develop during the current pregnancy.
Some of the issues and bodywork precautions include:
Maternal Asthma: Ask whether the client’s asthma is affected by certain scents, and avoid the use of lubricants or candles/incense that may produce scents that could trigger an attack.
Obesity: It is worthwhile to consider using the side lying or semi reclining position during the first trimester if it is more comfortable for your client. The supine and prone positions can increase breathing difficulties for extremely obese people. Semi-reclining position may be more comfortable than side lying for some women as pregnancy progresses.
Chronic Hypertension: For a client with severe hypertension, a medical release is recommended to determine the level of risk your clients PCP considers her to be, and to determine if Type 1 full body techniques are appropriate. Abdominal massage is contraindicated with severe hypertension.
Thromboembolic Disorders: If the client is complaining of leg pain that is unexplained by new activity or strain, or if you notice redness, swellings, and heat in an area of the leg, instruct her to call her PCP immediately for further assessment.
History of repeat miscarriage: If a client has had 2 or more consecutive miscarriages, avoid abdominal massage until 1 to 2 months past the date of the previous miscarriages, unless the client asks for belly massage and feels that this touch will help to ally anxieties. The contraindication is simply to avoid association between your touch and another miscarriage, should that unfortunately occur. With this in mind, if the client has a history of multiple miscarriages, has a high level of anxiety related to it , has had preterm contractions in this pregnancy, or is, for additional reasons, at higher risk for repeat miscarriage, avoid any stimulating touch such as vigorous type 1 bodywork that could alarm a client who already has concerns about receiving massage. A medical release is recommended for clients with three or more consecutive miscarriages to help ascertain risks or precautions.
Previous premature birth: Wait to offer abdominal massage 1-2 months past the time of the previous premature labor. Avoid Type 1 massage until the mother has been told her risk for preterm labor in this pregnancy has decreased.
Fetal Genetic Disorders, Intrauterine Growth Restriction, Oligohydramnios: The massage itself will not affect the condition of the baby, but in some instances a woman’s uterus will be more irritable and contractile, increasing the risk for pre-term labor or premature rupture of the membranes or amniotic sac and making abdominal massage, and sometimes Type 1 massage a contraindication.
5th or subsequent pregnancy: A woman in her 5th or subsequent pregnancy will tend to have more low back pain and need extra abdominal support. She should be encouraged to do abdominal strengthening form the start of her pregnancy (or sooner) and should be assessed for diastasis recti as a cause of low back pain.
Gestational Diabetes: A woman with Gestational Diabetes may have an extra-large abdomen and be especially prone to low back pain, leg pain, and pelvic congestion. Proper abdominal support under the belly on the massage table is, as always, essential.
Urinary Tract Infection: If your client has a UTI, ensure that she has been treated for this condition and is not having acute symptoms of pain, fever or chills, or preterm contractions during massage. It would b unlikely for you to see a client in this condition, unless the symptoms have only just begun to increase prior to the massage session. Avoid massage to the abdomen until the UTI is fully resolved.
High Risk Complications of Pregnancy Placental Abruption (Marginal or Partial): After recovery from a partial abruption, once the mother is able to resume some of her daily activities (although they will likely be quite modified), massage can be done with gentle Type 2 work. Recommended that a medical release be sought prior to treatment from PCP to alleviate concerns of the mother.
Placenta Previa: Gentle massage can be performed, and will benefit a woman, but avoid abdominal massage. All Type 1 full body stimulating massage is also contraindicated if the client has had any bleeding. A medical release is highly recommended to be certain the PCP approves of massage, to alleviate concerns of the mother, massage therapist, and identify any other potential risks.
Preterm Labor: Full Body Type 1 massage is contraindicated for a client relegated to bed rest or restricted activity due to preterm labor, but localized Type 1 or generalized Type 2 massage can still be applied. Obtain a medical release prior to beginning bodywork. Offer her a drink of water and encourage her to drink more than normal after receiving massage to minimize the effects of a massage-stimulated release of cellular waste into the circulatory system, which could potentially further irritate an already irritable uterus.
Gestational Hypertension, Preeclampsia, and HELLP Syndrome: If your client has GH or preeclampsia with no activity restrictions, then no bodywork restrictions may be necessary. If the client has progressed into preeclampsia with modified activity, Type 1 techniques should be limited and a medical release is highly recommended. Many women are restricted to the left-side lying position, which can provide an increased blood and oxygen perfusion to the fetus and uterus. This must continue during a massage, with sessions performed with the client solely in the left lateral position. Women with Hemolysis, Elevated, Liver enzymes and Low Platelets (HELLP) will be in the hospital for medical management of the condition. Type 2 bodywork may be supportive, but all Type 1 bodywork will be contraindicated. Cautions: Be aware of insidious symptoms of HELLP, which can develop relatively quickly. If your client in the late second or third trimester has not yet been seen by her PCP for a recent development of headache, nausea, right upper abdominal pain, or general malaise, have her call her PCP before deciding to continue with a massage.
Massage of the Ankles
Many massage therapists are taught “Don’t massage a pregnant woman’s ankles.” However the idea that it is dangerous to massage a healthy pregnant client’s feet or ankles is simply not true. The term “massage “is not specifically defined in that generic statement, but one would assume it refers to effleurage or other types of stroking or “Swedish “massage manipulations. There is no evidence that gentle stroking to the ankles is dangerous, and initiating effective uterine contractions during pregnancy is not that simple.
If inducing labor was as simple as massaging a woman’s ankles, the use of medical interventions to induce labor would be stopped.
Massage and Miscarriage
One of the biggest fears massage therapists have about working with a pregnant woman is unintentionally doing something that could cause her to miscarry or experience preterm labor. Miscarriage occurs in hundreds of thousands of pregnancies each year due to causes utterly unrelated to massage.
Using Massage as a quick route to Labor
When a woman’s due date has come and gone, she may develop anxiety about whether labor will ever start. Usually after 41 weeks’ gestation, doctors and midwives begin to consider options for inducing labor in an effort to avoid the baby getting to large or the placenta deteriorating. Some women who believe that receiving an “induction” massage might stimulate their labor ask their massage therapist for such help.
Massage does not trigger labor to begin. What massage can do is to help the mother relax. Relaxation helps diminish adrenalin and catecholamine production, allowing hormones, endorphins, and prostaglandins that prepare the body for labor, to function more optimally.
Massage can be very beneficial at this late stage of pregnancy, and if a woman’s labor does begin after receiving a massage, she may believe it was the touch that stimulated it. However, it is much more likely that it was due to her ability to relax under the touch and be offered reminders of her body’s inherent wisdom regarding birth, which allowed the natural development of contractions to occur. In this way, massage was a complementary support, rather than the cause of labor beginning. For many women, labor still does not begin until other elements are in place – physically, psychologically, or spiritually – even after receiving a thorough and focused massage with the intent of supporting labor.