NOTE: The following article is intended to present the massage therapist/bodyworker safe, effective guidelines for addressing the most common pregnancy complaint, lumbar and pelvic pain. Sections of this article are excerpted from, Pre- and Perinatal Massage Therapy, which forms the theoretical foundation of the 4-day course developed by Carole Osborne. This article was originally published in Massage Magazine, Summer 1998 issue.
Pelvic and Lumbar Pain During Pregnancy
In a 1994 survey of prenatal massage therapists, they cited relief from pregnancy aches and pains as a primary motivator for their clients seeking therapy. 1 Studies conducted in Sweden reported 48-56% of all pregnant women experience backache during pregnancy. They described this pain as generalized fatigue, tightness, and achiness with concentrated areas of pain. Half of these women suffered discomfort in the sacroiliac area. Another 25% complained about the lower back while the upper back was most problematic for another quarter of these subjects. Many women found months 5-9 most uncomfortable, and many reported their first incidence of chronic pelvic and back pain during a pregnancy. 2
Back and pelvic pain secondary to pregnancy is the result of: improper posture created by the anterior weight load of enlarging breasts, uterus, and fetus; muscle strain and imbalance; myofascial trigger points; fetal positioning; hormonal effects on ligaments; referred pain from uterine ligaments. 3
Prenatal Posture and Structural Integrity
The shift in center of gravity created by more anterior weight in the breasts and abdomen challenges a pregnant woman’s structural integrity. As pregnancy progresses her pelvis will inevitably rotate anteriorly, spilling the uterus forward against the abdominal walls. This misalignment increases the lumbar curvature and stretches and weakens all of the abdominal muscles. Pressure against the interior abdominal walls subsequently both separates the rectus abdominus at the linea alba (diastus recti) and incites hyperirritable, tender points (myofascial trigger points) in the abdominal muscles that characteristically refer pain posteriorly. In compensation for lumbar and pelvic misalignment, her head and neck jut forward anterior of the optimal vertical line; she leans her upper ribcage more posteriorly; and her pectoral girdle sags into forward rotation.
Struggling against the increasing weight, all of her posterior musculature becomes fatigued, tight, and fibrotic, and posterior trigger points flourish. Increased abdominal and overall weight also encourages external rotation of her hip joints and loss of iliopsoas function in walking, resulting in pregnancy’s characteristic waddling gait. To prevent falling forward with the increased anterior weight, her knees hyperextend, and her calves frequently cramp. She tends to collapse her increased weight into the medial arches of her weary feet. 4 A fetus with a left or right preference in uterine position often overburdens the favored side of the back making it tired and sore with the unbalanced weight load. Some women develop temporary or permanent scoliosis from fetal positioning preferences.
These postural adjustments to pregnancy result in strain and pain in the following muscles and muscle groups: levator scapulae, sternocleidomastoid, trapezius, and supraspinatus; pectoralis major and minor; abdominal group; erector spinae, multifidi, rotatores, quadratus lumborum, iliopsoas; pelvic floor muscles; hip rotators, adductors, quadriceps group; gastrocnemius, soleus, and peroneals.
Stressed by the anterior load and an average weight gain of 25 to 35 pounds, the weight-bearing joints and associated myofascial structures of pregnant women are strained and compressed. Greatest impact is felt in the intervertebral and facet joints, particularly in the lumbar spine; lumbosacral joint; sacroiliac joints; pubis symphysis; and hip joints. All of these strains are multiplied if a woman exceeds this recommended weight gain.
Most importantly, the relationship of the ilea and sacrum at the sacroiliac joint shifts when the enlarged abdomen protrudes anteriorly. As the pelvis anteriorly rotates, the ligaments of these deep pelvic joints are compressed, strained, and can become hyper or hypomobile in response. Sacroiliac pain is typified by a chronic achiness in the upper, medial quadrant of the buttocks, across the iliac crest, or at the posterior iliac spine of the pelvis, and radiating for several inches. Prolonged periods of standing or sitting, high heels, and poor seated back support, can all create additional strain to these joints. Occasionally one sacroiliac joint’s hypomobility will result in excessive mobility in the other. A sharp, stabbing posterior pelvic pain is then often experienced when rolling from a supine position, particularly on hard surfaces. 5 The lumbosacral junction is similarly affected by increased anterior weight load. Achiness in the center of the sacral and lumbar areas often indicates strain and compression of the lumbosacral joint.
Hormonal Influences on Back and Pelvic Pain
As early as the tenth week, the pregnancy hormone, relaxin, begins softening connective tissues in preparation for labor. Intended to increase the parameters of the pelvic outlet, relaxin is, however, systemic in its effect. The resulting laxity in all ligaments, tendons, and fascia throughout the body contributes to joint instability and more strain on weightbearing structures, especially in the lumbar spine and pelvis.
Probably relaxin’s most detrimental prenatal effect is on the symphysis pubis. Softened by relaxin, this pelvic junction of the pubic bones is vulnerable to horizontal sheering strains that are excruciating when one side of the pelvis is elevated or depressed. Sharp, stabbing pain in the center of the anterior pelvis occurs particularly when rolling over in bed or on a therapy table, climbing stairs, or any movement creating unilateral strain to the pelvis or requiring one leg to move differently than the other. 6
Uterine Ligament Strains
Over the 40 weeks (nine lunar months) of pregnancy the uterus blossoms from a plum sized pelvic organ to watermelon proportions. The fundus, or superior aspect, reaches xiphoid process level by term. It is suspended by the supportive structure of its ligaments. Formed of thickened external connective tissue of the uterus, these ligaments include: two broad ligaments extending laterally to attachments in the internal pelvic cavity walls at the ilea (these also support the fallopian tubes and ovaries); two round ligaments arising from the anterior, superior surface of the uterus and attaching in the connective tissue of the mons; the sacrouterine ligament continuing from the posterior uterus to attach on the posterior pelvic cavity wall at the anterior sacral surface.
As uterine growth inexorably stretches these ligaments, they typically refer pain beyond their attachment sites as follows:
- Broad ligaments: low back, buttock and sciatic-like pain referral pattern, especially in the sixth month, and often disappearing in months seven or eight
- Round ligaments: diagonal pain from the superior uterus to the groin; usually one sided, depending on fetal position; sometimes as extensively felt as the vulvar and upper thigh fascia
- Sacrouterine ligament: achiness just lateral to or beneath the sacrum, especially in last three months.
Pain in one or both buttocks that radiates down the posterior leg is occasionally not referred from the broad ligament. Severe postural imbalance in the lumbar spine and pelvis or chronic piriformis tension may entrap and compress the sciatic nerve. Sciatic nerve pain is usually burning and may be accompanied by tingling, numbness, and weakness in the legs of only 1% of pregnant women. 7
Prenatal Massage Therapy for Lumbar and Pelvic Pain
Many touch therapies are effective for the pregnant pelvis. Promoting any one method or any procedural sequence as the maternity massage therapy would deprive women of the many benefits of the wide range of somatic practices available to the professional massage practitioner.
Therapists should focus on the muscles and joints listed above utilizing techniques that reduce muscle spasms and fibrosis, relieve myofascial shortening and pain, extinguish trigger points, reduce uterine ligament strain, and reeducate efficient structural integrity and body use. Beneficial methods include:
- assisted resisted stretches, including proprioceptive neuromuscular facilitation and muscle energy techniques
- craniosacral therapy
- cross fiber friction
- deep tissue massage, myofascial release, and structural balancing
- passive movements, including joint mobilizations, rhythmic movements or trepidations, strain counterstrain or positional release, stretching, traction, and Trager reflexive massage, including bindegewebsmassage, foot zone therapy, trigger point or neuromuscular massage, and Oriental methods somato-emotional integration Swedish massage
Educational activities also are effective interventions for reducing pain and decreasing stress on the weight bearing joints and other myofascial structures. 8 Correct and safe abdominal strengthening activities and body-use guidelines for walking, sitting, sleeping, carrying, and other daily activities will further reduce strain in the neck, back, and pelvis. 9 Introducing more efficient movement patterns enhances and reinforces the effectiveness of hands-on therapy, including those listed above for pain and spasm reduction.
Safety Guidelines in Prenatal Back and Pelvic Massage Therapy
Pain Level
It is essential to maintain pressure, speed, and intensity, regardless of method used, to never exceed a pregnant client’s experience of pleasure on the borderline of pain. This level of intensity allows for sufficient depth to accomplish most appropriate somatic practices’ therapeutic goals. Maintaining a pleasure/pain level also assures that neither the mother nor the fetus is stimulated to sympathetic arousal. Pain activates adrenal production of the hormones that elevate blood pressure, heartrate, and respiratory rate and which lower immune function and blood flow to the uterus. 10 Since these hormonal signals diffuse into fetal circulation through the placenta, the fetus is similarly negatively impacted. 11 Certain techniques require lighter pressure to be physiologically effective, and tissue health, injuries, and other safety considerations discussed later in this article often dictate more superficial touch.
Abdominal Pressure, Technique Modifications, and Positioning
While the techniques listed above are effective in relieving back and pelvic pain, insure that application of these techniques will neither increase intrauterine pressure, decrease blood flow to the uterus, or create localized, deep pressure into the abdomen.
Increased intrauterine pressure probably is not a significant safety concern in most normal, uncomplicated, low risk pregnancies. It is of particular relevance when there are abnormalities in placental attachment or function, or higher risk of such conditions; any uterine or cervical abnormalities; and any of many factors associated with concerns for fetal blood supply, such as high blood pressure, multiples, or intrauterine growth retardation. Women who have been diagnosed with these conditions often are uninformed about their impact in relationship to receiving massage therapy. Also, some of these problems go undetected until bleeding, cramping, or other overt signs of problems have occurred to warrant further diagnostics.
While the effect of deep abdominal massage techniques on pregnancy has never been specifically studied, increased intrauterine pressure and deep, pointed, or abrupt pressure into the abdomen may increase the risk of miscarriage, premature labor, or placental dysfunctions. 12 Thoroughly evaluate all massage therapy techniques contemplated for pregnant women to confirm that their performance will not directly or indirectly press into the abdomen. Many procedures, such as resisted assisted stretches and positional releases, are modifiable to avoid this safety concern. Further reduce the possibility of increasing intrauterine pressure by only massaging the pregnant abdomen at the skin and superficial fascia level. This precaution also applies to any techniques performed on the lateral abdomen, anterior of the quadratus lumborum. Light, full-handed pressure avoids any possibility of abdominal trauma that may provoke uterine contractions or injure the intestines.
Eliminate massage therapy in the prone position entirely after the first 13 weeks gestation, earlier if multiples or if the fetus is larger than normal gestational age. After the first three months, safe prone positioning for effective massage therapy is not possible, even with additional pillows, and/or tables and other equipment currently marketed for this purpose. Prone positioning with other equipment that doesn’t elevate intrauterine pressure often further strains the taxed uterine and lumbar ligaments, exacerbating the very causes of many women’s discomfort. The sacrouterine ligament is particularly vulnerable in prone position.
Supine positioning also involves safety considerations when working with pregnancy related sources of lumbar and pelvic pain. In this position, the weighty uterus compresses against the inferior vena cava. Extended compression will result in low maternal blood pressure and decreased circulation both to the mother and her fetus (supine hypotensive syndrome). 13 In second and third trimesters, mitigating measures for more extended supine positioning are prudent. Shift the uterus to the left side with pillow support under the right lumbar area (weeks 14-22), or, after 22 weeks, elevate the entire torso to a semireclined angle of at least 45 degrees. Use a densely cushioned therapy table, and provide sufficient supports for the lumbar area and the knees. When women are advised by their healthcare provider to never lie on their backs, always observe these restrictions.
When sufficiently supported with firm pillows, bolsters, and/or a Contoured bodyCushion, sidelying position is the safest, most posturally neutral, and most comfortable position for most women to receive prenatal massage therapy. Even in the sidelying position, however, pressure must be applied without rolling the woman onto her abdomen, and her top leg must be aligned horizontally with her hip. This is most important during deep work on the posterior structures when addressing back and pelvic pain.
Blood Clots
Avoiding deep, pointed, and/or ischemic compression to the pregnant abdomen also eliminates pressure into one of the most dangerous locations, the inguinal area. Blood clotting capacity escalates four to five times higher than non-pregnant levels during pregnancy. As fibrinolytic activity, the clot dissolving capacity of the blood, decreases dramatically, women are protected from potential hemorrhaging during childbirth; however, they also are more likely to develop blood clots (thrombi). 14
Clot formation is greatest in the veins where blood is most stagnant. The veins most likely to harbor clots during pregnancy are the iliac, femoral, and saphenous veins. 15 This is due to restriction of iliac and femoral venous return by the weight of the uterus on these vessels and to hormonal influences on vascular smooth muscle and on blood and fluid volumes. Given the likelihood of clots and their potential harm if freely circulating, do not press deeply into the abdomen, especially in the inguinal area. Additionally, use only soft, whole hand pressure throughout the medial surface of the legs where these veins traverse. Perform no tapotement nor deep, pointed, or stationary (ischemic) pressure, sufficiently sustained to restrict localized blood flow, regardless of the type of technique and its potential benefits.
Miscarriage and Prematurity
Miscarriage (spontaneous abortion) is a natural termination of pregnancy before the fetus has reached viability, most common in the first trimester. Preterm labor involves regular contractions that dilate the cervix after 20 weeks and before the end of 36 weeks gestation. Note that one of the most common symptoms of premature labor and miscarriage is low back/pelvic pain, referred from the contracting uterus; however, there are usually other identifying symptoms, such as bleeding or amniotic fluid leakage and abdominal cramping or regular uterine contractions. Remember that musculoskeletal back pain usually is relieved with a change in position or activity, while referred organic pain is not. Ask her physician to rule out miscarriage, preterm labor, or other possible causes of back pain, such as urinary tract infection, neurological dysfunctions, eclampsia, or prior, unresolved injuries. Take full prenatal and medical histories, and evaluate thoroughly at each massage therapy session.
Certain maternal conditions, high risk factors, and complications of pregnancy increase the risks of miscarriage and prematurity including:
- previous miscarriage or preterm labor
- altered nutrition leading to low maternal weight gain
- smoking and other teratogenic agents such as radiation, alcohol, etc.
- drug abuse, especially cocaine
- emotional stress
- heavy work load at home or on the job
- decreased blood flow to the uterus caused by:placenta abrupto, placenta previa, diabetes, renal disease, cardiovascular disease, systemic lupus and other autoimmune factors, preeclampsia/eclampsia (GEPH), overdistension of the uterus in multiple gestations and polyhydramnios
- abdominal trauma or surgery
- premature rupture of membranes
- diethylstilbestrol (DES) exposure in utero resulting in uterine abnormalities
- incompetent cervix and other uterine anomalies
- urinary tract or vaginal, uterine, or fetal infections
- fever
- maternal age over 36
- chromosomal abnormalities 16
No one wants to have any doubt as to whether any massage therapy intervention was harmful nor have their protocols questioned. Some sobering facts of American maternity care are very relevant to massage therapy practitioners: more than 75% of obstetricians and gynecologists are sued; more than one third of them are sued more than three times; and nurses and other perinatal healthcare providers are more and more frequently being included in these lawsuits. 17 Massage practitioners are wise to be aware of the litigious atmosphere in childbearing.
Some added precautions that could avoid erroneous, but costly, legal questions:
Do not touch the abdomen of a first trimester woman or of one whose risk of miscarriage or preterm labor is high. (See list above and sections later in this article on complications and high risk factors.) Always ask permission to gently touch her abdomen. Strictly adhere to midwives’ and physicians’ restrictions regarding abdominal massage. If not comprehensively trained in prenatal massage therapy, a further precaution worth considering is to not work with first trimester women or those at higher risk of pregnancy losses or prematurity.
Ligament laxity precautions
Symphysis pubis separation demands several special considerations in choosing and performing massage therapy. First: rolling over is painful with this condition, so minimize position changes. Second: firm, reliable bolsters and other supports are essential in all positions to prevent extended tugging on the joint. Finally, eliminate any techniques creating traction on the pelvic and hip joints or that compress the pelvis unilaterally.
All of a pregnant woman’s ligaments are easily overstretched due to the softening effect of relaxin. Overstretched ligaments result in joint instability and more pain. Minimally invested with elastic fibers, ligaments do not tighten after excessive lengthening. Modify assisted resisted stretches, positional release, Swedish gymnastic movements, range of motion, and other passive and active movements to avoid overstretching of joint structures.
Other complications and high risk pregnancies
In addition to miscarriage, premature labor, and placental dysfunctions, other physiologic complications to a normal gestation occur. These include: gestational diabetes and several types and severities of hypertensive disorders. When any complications arise, massage therapy is contraindicated until resolved or only with consultation with her healthcare provider. Cautious therapists will refer these women to more qualified prenatal massage therapists if not comprehensively educated in this work. If they do work with a complicated pregnancy, they will require written release from the woman’s healthcare provider and practice ultraconservatively.
In high risk pregnancies, either the mother or the fetus has a significantly increased chance of disability or death. Most of these conditions will not be negatively impacted by massage therapy; in fact, it may be invaluable in reducing the negative effects of increased anxiety and the bedrest frequently prescribed. With the further risk involved, however, thorough training and a written release from the woman’s healthcare provider are advisable.
Conclusion
The guidelines in this article are an introduction to effective, safe massage therapy for the pregnant pelvis. Pregnant women experience numerous other structural, physiological, and emotional changes and discomforts that respond well to specific, therapeutic techniques. Further study of the many other relevant intricacies of pregnant physiology and psychology and thorough, hands-on training and are highly recommended. 18
Carole Osborne-Sheets is the author of and Pre- and Perinatal Massage Therapy, and a contributor to the upcoming textbook Teaching Massage Therapy, as well as numerous other publications. She is the 2008 recipient of the AMTA Jerome Perlinski National Teacher of the Year Award. The work outlined in this article is adapted from portions of the author’s textbook Deep Tissue Sculpting.
For these and other books, click here.
For information about her certification program, Pre- and Perinatal Massage Therapy, and other hands-on workshops, click here.
Footnotes
- Unpublished survey of graduates of my former pregnancy training program,1994.
- Ostgaard, H.C., Andersson, G.B.J., et al. Prevalence of back pain in pregnancy, Spine 17, 1: 53-55, January, 1992.
- Artal, R., Friedman, M.J., McNitt-Gray, J.L. Orthopedic problems in pregnancy, The Physician and Sportsmedicine, 18: p. 93-105, 1990.
- Noble, Elizabeth, P.T. Essential Exercises for the Childbearing Year. Fourth edition, p. 20, 225. Harwich, MA, New life Images, 1995.
- Ibid., p. 54.
- Ibid., p. 53.
- Ostgaard, p. 54.
- Osborne-Sheets, Carole. Deep Tissue Sculpting: A Technical and Artistic Manual for Therapeutic Bodywork Practitioners. Second Edition, p. 96-99 Body Therapy Associates, 2002.
- Noble, p. 81-146.
- Gorsuch, R. and Key, M. Abnormalities of pregnancy as a function of anxiety and life stress, Psychosomatic Medicine 36: p. 353, 1974.
- Catz, Charlotte. Prevention of embryonic, fetal, and perinatal disease. HEW, p. 123, 1976.
- Gilbert, Elizabeth Stepp and Harmon, Judith Smith. Manual of High Risk Pregnancy and Delivery, p.265, 416. St. Louis Missouri, Mosby – Yearbook, Inc., 1993.
- Ibid., p. 40.
- Ibid., p. 7.
- Alexander, Doug. Deep vein thrombosis and massage therapy, Massage Therapy Journal 32, 3: p. 56, 1993.
- Gilbert and Harmon, p. 265 and 416
- Ibid., p.160.
- Pre- and Perinatal Massage Therapy workshops taught by the author are offered nationwide. For more information contact us.
Michele Holland on Interacting with Maternity Healthcare Providers
VideosTips from authorized instructor of Pre- and Perinatal Massage Therapy, Michele Holland, to grow your practice through productive, respectful relationships with doctors, midwives and other maternity healthcare professionals
Breathing, Positions & Blood Clots: Doing No Harm with Prenatal and Postpartum Massage Therapy During the Coronavirus Pandemic
ArticlesFirst though, a note: This article will NOT be covering necessary changes to your environment, policies, information collection, hygiene, etc., that are so thoroughly discussed elsewhere. ABMP has informative, practical input for you on their website,1 as do most state associations and credentialing agencies. Also, stay current with the Occupational Safety and Health Administration (OSHA),2 the National Institutes of Health,3 the Centers for Disease Control and Prevention (CDC),4 and your local jurisdictions for up-to-date guidance relevant to massage therapy).
Some of these agencies offer evolving data on the pandemic’s specific impact during pregnancy, labor, and postpartum. I have combined information from these agencies and from Evidence Based Birth,5 American College of Obstetricians and Gynecologists,6 Midwives Alliance of North America,7 the CDC, and other comparable agencies in other countries, resulting in a well-rounded perspective on COVID-19 and childbearing.
From these sources during late July 2020, it appears that:
While some of this information is reassuring, pregnant women are disproportionately affected by respiratory illnesses in general, and thus they may be at higher risk for contracting COVID-19. Managing your practice hygiene then is critical.
Physiological and mechanical changes in pregnancy increase susceptibility to infections in general, particularly when the cardiorespiratory system is affected, and encourage rapid progression to respiratory failure.8 As data gradually emerge regarding the effects of COVID-19 infection on pregnant, birthing, and postpartum people, the implications for us when they become our clients evolves too, and it is likely to remain ambiguous and incomplete. If you are seeing childbearing massage therapy clients, staying currently informed is an ethical imperative.
Not So Fast to the Treatment Room
Coronavirus or not, pregnancy’s common companions of back, pelvic, and hip pain continue to bring clients seeking relief from our work. And the additional stress of the pandemic for those expecting a baby can be overwhelming. Regardless of need, any expectant clients with COVID-19 symptoms, presumed or suspected infection, or positive test results should not be receiving massage therapy while ill or contagious. If they had credible exposure, they should undergo 14 days of isolation to prevent spread if they are infected. Because of the varied severity of symptoms and recovery time, best practice is to seek medical or midwifery review of every pregnant client’s unique condition and request any massage therapy limitations or contraindications specific to that person. Even with that clearance, you may want to delay for at least three months after illness.
Unfortunately, with the high rate of asymptomatic infection and the testing limitations, your clients and/or you may or may not be infected at any point in your treatment interactions. Consequently, I believe it is most responsible to modify all maternity massage therapy protocols as though each expectant or new-mother client has, or has had, this infection. Adaptations for respiratory and placental efficiency and the prevalence of blood clots have always been critical factors with pregnant and postpartum massage therapy clients, even prior to the emergence of the coronavirus. COVID-19 appears to increase these concerns significantly. Let’s next consider these respiratory, positioning, and blood-clotting factors and the ramifications for safe practice.
Respiration, Placental Function, and Positioning
A common, though not universal, symptom of COVID-19 is shortness of breath. As a result, be sure to assess and think through positioning’s effect on maternal and fetal oxygenation for each individual. Common nursing practice9 and obstetrical research10 point to side-lying positioning during pregnancy, left or right, resulting in better maternal and fetal oxygenation and outcomes when compared to other positions. There is a slight advantage to the left side-lying position over the right that, in normally progressing pregnancies, is usually irrelevant.
With coronavirus, however, a recent small study showed some negative effects and compromise in placental functioning when expectant people are infected.11 As of yet, there is no data regarding how long after infection this reduction in placental function may last.
Recommended Side-Lying Positioning Guidelines
With these considerations in mind, I now recommend the following regarding side-lying positioning:
Recommended Supine Positioning Guidelines
If you work with a pregnant client in the supine position, then prevention of supine hypotensive syndrome is of increased importance, especially since your client may be asymptomatic and/or untested. Supine hypotensive syndrome is decreased blood pressure caused by the enlarged uterus compressing the inferior vena cava sufficiently to reduce venous return. Symptoms include uneasiness, dizziness, weakness, nausea, shortness of breath, or other discomforts when clients are lying flat on their back, although some report no symptoms (Image 2).
I recommend a strict adherence to the following positioning guidelines for all your pregnant clients.
If you are well-trained to work with pregnant clients, then providing stable, aligned positioning in side-lying, supine, or semi-reclining is second nature to you. Of course, those therapists already skilled in side-lying positioning will also have that side-lying advantage with all clients, providing an alternative that keeps therapist and client from breathing face-to-face as necessitated when the client is supine.
Blood Clot Considerations
Changes in clot-dissolving capacity occur in all pregnancies and are a normal and protective adaptation to avoid birth and postpartum hemorrhage. Safe perinatal massage therapy always requires taking precautions relevant to possible blood clots. Research points to approximately double the coagulation activity during pregnancy when compared to nonpregnant women, and a tendency toward formation of deep vein thrombosis (DVT) where clots form in the inguinal, femoral, and saphenous veins.12 DVT is even more common postpartum, particularly for those who had cesarean births, other surgeries, or who hemorrhaged. Those expectant and postpartum individuals who are on bed rest are especially prone to clot production; that risk also exists for people who smoke, are over 35 years old, have varicose veins, have recently used birth control pills, are obese, have lupus, have been pregnant multiple times before, or are carrying multiples.
If you are not fully educated about the physiology of normal and high-risk pregnancy- and postpartum-related hypercoagulation and guidelines to reduce chances of thrombi moving from the legs into general circulation during pregnancy and early postpartum, now’s the time to learn, and wait to work with these clients until you do. The accompanying illustration offers a very quick review of the most relevant massage therapy adaptations to reduce complications related to hypercoagulation during pregnancy, especially those relevant for the legs (Image 5). Do not consider looking at this image as adequate education on this critical topic.
The restrictions summarized in this illustration are aimed to reduce possible pulmonary embolisms (clots that have traveled from elsewhere that obstruct vessels in the lungs). It is critical you follow thesefor ALL prenatal and postpartum massage therapy clients, regardless of COVID-19. Of course, you alsoshould observe your clients for any of the characteristic symptoms of leg thrombi—increased edema in the foot and/or leg (often unilaterally), localized swelling, heat, redness, and painful, achy legs that can be tender with palpable, ropy veins. These symptoms are particularly worrisome if they increase when your client walks. But to be clear, legs that are painful or achy are a hallmark of pregnancy, so these symptoms alone do not guarantee a blood clot. A clear determination of the presence of clots is also difficult because thrombi are often asymptomatic.13 Given the increased likelihood that blood will coagulate in pregnancy and postpartum, the difficulty in determining the presence of clots, and the potential harm of freely circulating clots, it seems prudent to treat all pregnant and postpartum clients as though they have leg clots. For many decades, pre-coronavirus pandemic, we recommended observing the summarized guidelines in Image 5 throughout pregnancy and with postpartum clients for at least 8–10 weeks after birth. The emerging data about blood clots and COVID-19 is sobering, particularly when added to existing clot dangers during pregnancy and postpartum. Coagulopathy in COVID-19 is a disruption in blood-clotting mechanisms that can appear as organ damage, strokes, heart attacks, pulmonary embolisms, rashes, and COVID-toe, with bumps, swelling or redness as evidence of excessive bleeding and clotting in small vessels (microthrombosis).
Hypercoagulation during and after this illness further reinforces the contraindication that expectant and postpartum clients with COVID-19 symptoms, suspected infection, or positive test results should not be receiving massage therapy while ill or contagious. Furthermore, because of the varied severity of symptoms and recovery time, and the unknowns related to childbearing, I recommend you seek medical or midwifery review of everyone’s unique condition to request any massage therapy limitations or contraindications for that client.
For those cleared for massage therapy, be sure to assess thoroughly for COVID-19 specific manifestations, whether they have had the illness, what was its severity, and any subsequent recovery concerns.
Recommended Blood-Clotting Guidelines
For clients who have had COVID-19 and are seeking massage, these are my best recommendations.
If you do not understand fully the underlying physiological mechanisms and these guidelines, I urge you to delay working with pregnant and postpartum clients until you further educate yourself.
Can Massage Therapy Safely Help?
Absolutely! Despite all these increased precautions and limitations, expectant and postpartum clients may find great relief from skilled massage therapy, beginning with reducing the negative effects of this stress-saturated pandemic.
The following articles fully articulate these concerns as they affect massage therapy in general, and it is critical you understand this information. Read all of them prior to working with pregnant and postpartum clients while COVID-19 is still spreading as part of your “first, do no harm” imperative.
www.mywsmta.org/resources/Documents/COVID%2019/WSMTA’s%20Interim%20Guidance%20on%20Practice%20Guidelines.pdf
Editor’s note: Portions of this article are excerpted from the third edition of Pre- and Perinatal Massage Therapy by Carole Osborne, Michele Holland, and David M. Lobenstine. Projected publication is December 2020/January 2021 by Handspring Publishing.
Notes
www.ncbi.nlm.nih.gov/pmc/articles/PMC5778511.
Bearing Witness to Life and Death, Reflection #1
ArticlesWhat a year of transformation, transition, grief and joy! Three deaths close to my heart…. my first grandchild’s birth… a new home…. an unsettling election process. Oh, I have been tested and refined by 2016!
During and in its aftermath, questions abound: Can I adapt and go with the flow of even THIS? How can I stay grounded, open-hearted and find joy in the moment when fear, loss and anger swirl in me and around me? How do I use my therapist skills to assist the journey towards one’s first or last breath? Who is nurtured more, me or them, by these weekly days with the new family? By this wiped brow or that spine rocked? What deepens my restoration and furthers my new home as sanctuary? How do I stay focused and effective in my inner and outer work? What right actions and words encourage Unity and dialogue rather than hostility? What can my process add to my inner evolution and to that of my students, clients and colleagues?
It’s that last question that leads me to this and several future blog posts. I frequently write to understand and clear my heart and mind. Also, whenever I offer tidbits of 2016’s challenges and insights, inevitably I hear, “your sharing that is so helpful to me.” And so, with helpful intentions for you and me….
My Children’s Father
The ten years’ distance after divorce almost disappeared during my children’s father’s illness and death. For 15 months, Andy traversed his trail through lung cancer to his death in May. His current wife, step-daughter and our son, daughter and their partners that were rightfully the ones by his side. From my amiable but appropriate distance, I sent encouragement as well as solicited and unsolicited advice. I joined everyone’s delight when 10 months of treatment appeared to make him a poster child for chemotherapy’s best promises of extending his life. I took as priority my role as supporter of our children through this.
When a nagging pain, diagnosed as a hip flexor strain suffered while captaining a sailboat, began curtailing Andy’s gusto for his remaining life, all involved navigated the complexities of his receiving bodywork from me. This was finally assistance that I was eminently qualified to give, despite only basic knowledge in massage for those with cancer. (Thank you, again, Tracy Walton, for your excellent course oh- those- many- years ago!)
Ethics and Healing Touch
Working with Andy required my best in boundary management, scope of practice, relationship dynamics, and focus. I mostly was able to be satisfied with breath and movement improvement rather than to feel heroically responsible for saving my children from the loss of their dad. Fairly consistently, I restrained my urges to advise him about supplements or to nag him about what I would do. Instead I focused on maximizing the myofascial and autonomic benefits of our work. Together we created a remarkable balance between physical familiarity and professional connection. Sometimes I wandered mentally into the what- ifs, fears or memories of our shared history. That’s when I cleared my inner eye, returned to his breath and mine as the moment’s reality and asked his tissue and his Being, “How is this now?” He usually enjoyed some 12-32 hours of pain reduction.
A revised diagnosis of bone metastasis soon explained why the dwindling relief. To say that information devastated everyone is an understatement; however, those precious three sessions were uplifting on many levels. He talked of the relief in feeling treatment hands that were seeking to comfort and to know rather than to prod or eradicate. Brief as they were, he called those post-session hours of less pain “vacations” that tremendously enhanced his remaining time.
For me, serving him in this professional way further refined my practitioner abilities. It also was a soothing salve on old wounds. Those three hours echo in me as shining testimony to the power of touch to bridge inner and outer distance and differences in the name of a Higher Love. It’s what we do with each client, but it’s ironically often too complicated and almost impossible to achieve with someone so close.
Choices and Lessons
When Andy chose to end his life a few short months later, that emotional gulf widened again exponentially, remaining still to be fully crossed. In the immediate aftermath, my inner mother bear roared endlessly. She remains vigilant that her wounded cubs be protected from further harm. She’s sometimes still enraged that she can’t prevent what’s already happened yet determined that his is the only life that Andy has the authority to take. I continue to put my attention on realizing that intention as much as possible.
Every spiritual, philosophical and relationship fundamental I counted on was put into question as I wrestled with suicide’s many facets. For months I was often exhausted, ultra vulnerable, and sometimes slammed around between conflicting feelings. Occasionally I got ambushed into physical sensations and emotional turmoil that I thought I had resolved years ago. Most things took more time and effort. I was on a physical and emotional roller coaster seemingly not of my choosing.
(Throughout all of this, the needs of my dear friend and housemate who also was walking his own unique journey with metastasized cancer were a similar blessing and trial, but that’s a whole other blog post to come.)
I have coped reasonably well with multiple transitions this year. How? Decades of developing my inner and outer strength, I think, and by recognizing that others endure far more with dignity and effectiveness – by retaining my daily tai chi practice – resuming psychotherapy – regular bodywork and acupuncture – increased walking, dancing, meditation and sleep. Whenever safe to, I yielded to the gradually lessening yet always cleansing waves of crying/screaming/shaking/coughing release. I regularly sought the comfort of my sweetheart’s gentle calmness, my decades-long friends’ listening ears and wisdom and my children’s familiarity. I prioritized their heightened needs; my son’s baby was a few months away from his birth. (third blog post in this series to come), and my daughter was newly engaged. Both of these exquisite delights were also poignant reminders that they miss their father terribly, and always will.
I emerged from Andy’s end of life a humbled and determined single parent. I am more experienced with ethical nuances and maddening impossibilities both professionally and personally. I am a more empathetic, refined therapist. Lessons in letting go, death and self-responsibility have enriched me. I know better the vast distances and infinite closeness between us all.
With Gratitude
Writing helps to create resolution for me; you remember that? Maybe not, as this is such a long post; however, since you are still reading this, finally, I want to share a related, profoundly healing piece that mostly I wrote in the month after Andy’s death. I’d like for you to know more of this unique man who fathered my children, accompanied me during some of the most productive and enriching years of my life, and continues to offer lessons in loving far after his last sunset here on earth.
(Remember to check back into this blog in a few weeks for Bearing Witness to Life and Death, Reflection #2)
Born and raised in Monroe, Michigan, Andy hunted, ice skated and read his way through childhood to graduate from Jefferson High School. After serving four years in the Navy, primarily off the coast of Vietnam on the USS Enterprise, he made San Diego his new home, finding community with his spiritual brothers and sisters of the Arica Institute.
For work, he pursued electronics, scuba diving, computer engineering, massage therapy, and, finally, sailing, becoming an exuberant captain, instructor and director of education at Seaforth Boat Rentals. His role as a mentor and teacher is one of his legacies; he was diligent, caring, empathetic and flexible in helping them to “find their path” in any given task. On or in the ocean, he relaxed, thrived, and adventured, rejoicing in teaching others with patience and skill. He couldn’t resist seeing what was around the next bend, over the summit of a mountain, at the end of a desert trail, or in a book’s last chapters. He delighted in repurposing and engineering various materials into useful or entertaining creations: a tube to serve as a sword or kitty toy; a portable shower for desert camping; a toddler’s slide or tunnel chamber from a shipping box.
Andy was above all else a family man. As a young man, he met Ann Leahy and was introduced to the love and joy family can bring. For the five Leahy children, he stepped into the role of “that father we always wanted” to many of them. He allowed himself to grow in this father role, readying him for his time with his own children, Josh and Elizabeth (the Elder). Together with their mother, Carole Osborne, he found a love through his children that was real and fulfilling. His reputation with his children’s friends was found in role-playing games or leading hide-in-the-dark tag, his imagination, playfulness, resourcefulness, devotion, tailoring and baking (oh, that bread, those pies, those pecan rolls!).
His presence obviously reached fruition in Josh and Elizabeth’s happy, successful lives, but he still had another child ahead.
Andy found a new love in Francine Martinez, expanding his family as he knew it. A second daughter emerged from that marriage as he and Francine’s daughter, Elizabeth (the Younger), bonded as father-daughter, finding in each other a kindred spirit. With the expanded family, he now became the consummate host, introducing barbecued/smoked meals and spirit exploration, competitive card games and hours of Sunday football filled with laughter and lively banter.
To Andy we say, “Sail on.”
Tip #1 Body Mechanics for Massage Therapists/Bodyworkers
VideosIf you spend time working from a rolling stool, it’s all about sitting tall (in the saddle?!). Safeguard your massage therapy career by learning to apply various Tai Chi principles to using body weight and aligning joints. It’s worked for me since 1974!
People Skills Secure Your Future
VideosTip #2 for Longevity as a Massage Therapist
Join me as I celebrate my 42nd year of therapeutic massage and bodywork by sharing with YOU what works!
Specializations Lead to Success
VideosTip #1 for Longevity as a Massage Therapist
Join me as a celebrate my 42nd year of therapeutic massage and bodywork by sharing with YOU what works!
The Pregnant Pelvis – An Introduction to Safe, Effective Prenatal Massage Therapy
ArticlesNOTE: The following article is intended to present the massage therapist/bodyworker safe, effective guidelines for addressing the most common pregnancy complaint, lumbar and pelvic pain. Sections of this article are excerpted from, Pre- and Perinatal Massage Therapy, which forms the theoretical foundation of the 4-day course developed by Carole Osborne. This article was originally published in Massage Magazine, Summer 1998 issue.
Pelvic and Lumbar Pain During Pregnancy
In a 1994 survey of prenatal massage therapists, they cited relief from pregnancy aches and pains as a primary motivator for their clients seeking therapy. 1 Studies conducted in Sweden reported 48-56% of all pregnant women experience backache during pregnancy. They described this pain as generalized fatigue, tightness, and achiness with concentrated areas of pain. Half of these women suffered discomfort in the sacroiliac area. Another 25% complained about the lower back while the upper back was most problematic for another quarter of these subjects. Many women found months 5-9 most uncomfortable, and many reported their first incidence of chronic pelvic and back pain during a pregnancy. 2
Back and pelvic pain secondary to pregnancy is the result of: improper posture created by the anterior weight load of enlarging breasts, uterus, and fetus; muscle strain and imbalance; myofascial trigger points; fetal positioning; hormonal effects on ligaments; referred pain from uterine ligaments. 3
Prenatal Posture and Structural Integrity
The shift in center of gravity created by more anterior weight in the breasts and abdomen challenges a pregnant woman’s structural integrity. As pregnancy progresses her pelvis will inevitably rotate anteriorly, spilling the uterus forward against the abdominal walls. This misalignment increases the lumbar curvature and stretches and weakens all of the abdominal muscles. Pressure against the interior abdominal walls subsequently both separates the rectus abdominus at the linea alba (diastus recti) and incites hyperirritable, tender points (myofascial trigger points) in the abdominal muscles that characteristically refer pain posteriorly. In compensation for lumbar and pelvic misalignment, her head and neck jut forward anterior of the optimal vertical line; she leans her upper ribcage more posteriorly; and her pectoral girdle sags into forward rotation.
Struggling against the increasing weight, all of her posterior musculature becomes fatigued, tight, and fibrotic, and posterior trigger points flourish. Increased abdominal and overall weight also encourages external rotation of her hip joints and loss of iliopsoas function in walking, resulting in pregnancy’s characteristic waddling gait. To prevent falling forward with the increased anterior weight, her knees hyperextend, and her calves frequently cramp. She tends to collapse her increased weight into the medial arches of her weary feet. 4 A fetus with a left or right preference in uterine position often overburdens the favored side of the back making it tired and sore with the unbalanced weight load. Some women develop temporary or permanent scoliosis from fetal positioning preferences.
These postural adjustments to pregnancy result in strain and pain in the following muscles and muscle groups: levator scapulae, sternocleidomastoid, trapezius, and supraspinatus; pectoralis major and minor; abdominal group; erector spinae, multifidi, rotatores, quadratus lumborum, iliopsoas; pelvic floor muscles; hip rotators, adductors, quadriceps group; gastrocnemius, soleus, and peroneals.
Stressed by the anterior load and an average weight gain of 25 to 35 pounds, the weight-bearing joints and associated myofascial structures of pregnant women are strained and compressed. Greatest impact is felt in the intervertebral and facet joints, particularly in the lumbar spine; lumbosacral joint; sacroiliac joints; pubis symphysis; and hip joints. All of these strains are multiplied if a woman exceeds this recommended weight gain.
Most importantly, the relationship of the ilea and sacrum at the sacroiliac joint shifts when the enlarged abdomen protrudes anteriorly. As the pelvis anteriorly rotates, the ligaments of these deep pelvic joints are compressed, strained, and can become hyper or hypomobile in response. Sacroiliac pain is typified by a chronic achiness in the upper, medial quadrant of the buttocks, across the iliac crest, or at the posterior iliac spine of the pelvis, and radiating for several inches. Prolonged periods of standing or sitting, high heels, and poor seated back support, can all create additional strain to these joints. Occasionally one sacroiliac joint’s hypomobility will result in excessive mobility in the other. A sharp, stabbing posterior pelvic pain is then often experienced when rolling from a supine position, particularly on hard surfaces. 5 The lumbosacral junction is similarly affected by increased anterior weight load. Achiness in the center of the sacral and lumbar areas often indicates strain and compression of the lumbosacral joint.
Hormonal Influences on Back and Pelvic Pain
As early as the tenth week, the pregnancy hormone, relaxin, begins softening connective tissues in preparation for labor. Intended to increase the parameters of the pelvic outlet, relaxin is, however, systemic in its effect. The resulting laxity in all ligaments, tendons, and fascia throughout the body contributes to joint instability and more strain on weightbearing structures, especially in the lumbar spine and pelvis.
Probably relaxin’s most detrimental prenatal effect is on the symphysis pubis. Softened by relaxin, this pelvic junction of the pubic bones is vulnerable to horizontal sheering strains that are excruciating when one side of the pelvis is elevated or depressed. Sharp, stabbing pain in the center of the anterior pelvis occurs particularly when rolling over in bed or on a therapy table, climbing stairs, or any movement creating unilateral strain to the pelvis or requiring one leg to move differently than the other. 6
Uterine Ligament Strains
Over the 40 weeks (nine lunar months) of pregnancy the uterus blossoms from a plum sized pelvic organ to watermelon proportions. The fundus, or superior aspect, reaches xiphoid process level by term. It is suspended by the supportive structure of its ligaments. Formed of thickened external connective tissue of the uterus, these ligaments include: two broad ligaments extending laterally to attachments in the internal pelvic cavity walls at the ilea (these also support the fallopian tubes and ovaries); two round ligaments arising from the anterior, superior surface of the uterus and attaching in the connective tissue of the mons; the sacrouterine ligament continuing from the posterior uterus to attach on the posterior pelvic cavity wall at the anterior sacral surface.
As uterine growth inexorably stretches these ligaments, they typically refer pain beyond their attachment sites as follows:
Pain in one or both buttocks that radiates down the posterior leg is occasionally not referred from the broad ligament. Severe postural imbalance in the lumbar spine and pelvis or chronic piriformis tension may entrap and compress the sciatic nerve. Sciatic nerve pain is usually burning and may be accompanied by tingling, numbness, and weakness in the legs of only 1% of pregnant women. 7
Prenatal Massage Therapy for Lumbar and Pelvic Pain
Many touch therapies are effective for the pregnant pelvis. Promoting any one method or any procedural sequence as the maternity massage therapy would deprive women of the many benefits of the wide range of somatic practices available to the professional massage practitioner.
Therapists should focus on the muscles and joints listed above utilizing techniques that reduce muscle spasms and fibrosis, relieve myofascial shortening and pain, extinguish trigger points, reduce uterine ligament strain, and reeducate efficient structural integrity and body use. Beneficial methods include:
Educational activities also are effective interventions for reducing pain and decreasing stress on the weight bearing joints and other myofascial structures. 8 Correct and safe abdominal strengthening activities and body-use guidelines for walking, sitting, sleeping, carrying, and other daily activities will further reduce strain in the neck, back, and pelvis. 9 Introducing more efficient movement patterns enhances and reinforces the effectiveness of hands-on therapy, including those listed above for pain and spasm reduction.
Safety Guidelines in Prenatal Back and Pelvic Massage Therapy
Pain Level
It is essential to maintain pressure, speed, and intensity, regardless of method used, to never exceed a pregnant client’s experience of pleasure on the borderline of pain. This level of intensity allows for sufficient depth to accomplish most appropriate somatic practices’ therapeutic goals. Maintaining a pleasure/pain level also assures that neither the mother nor the fetus is stimulated to sympathetic arousal. Pain activates adrenal production of the hormones that elevate blood pressure, heartrate, and respiratory rate and which lower immune function and blood flow to the uterus. 10 Since these hormonal signals diffuse into fetal circulation through the placenta, the fetus is similarly negatively impacted. 11 Certain techniques require lighter pressure to be physiologically effective, and tissue health, injuries, and other safety considerations discussed later in this article often dictate more superficial touch.
Abdominal Pressure, Technique Modifications, and Positioning
While the techniques listed above are effective in relieving back and pelvic pain, insure that application of these techniques will neither increase intrauterine pressure, decrease blood flow to the uterus, or create localized, deep pressure into the abdomen.
Increased intrauterine pressure probably is not a significant safety concern in most normal, uncomplicated, low risk pregnancies. It is of particular relevance when there are abnormalities in placental attachment or function, or higher risk of such conditions; any uterine or cervical abnormalities; and any of many factors associated with concerns for fetal blood supply, such as high blood pressure, multiples, or intrauterine growth retardation. Women who have been diagnosed with these conditions often are uninformed about their impact in relationship to receiving massage therapy. Also, some of these problems go undetected until bleeding, cramping, or other overt signs of problems have occurred to warrant further diagnostics.
While the effect of deep abdominal massage techniques on pregnancy has never been specifically studied, increased intrauterine pressure and deep, pointed, or abrupt pressure into the abdomen may increase the risk of miscarriage, premature labor, or placental dysfunctions. 12 Thoroughly evaluate all massage therapy techniques contemplated for pregnant women to confirm that their performance will not directly or indirectly press into the abdomen. Many procedures, such as resisted assisted stretches and positional releases, are modifiable to avoid this safety concern. Further reduce the possibility of increasing intrauterine pressure by only massaging the pregnant abdomen at the skin and superficial fascia level. This precaution also applies to any techniques performed on the lateral abdomen, anterior of the quadratus lumborum. Light, full-handed pressure avoids any possibility of abdominal trauma that may provoke uterine contractions or injure the intestines.
Eliminate massage therapy in the prone position entirely after the first 13 weeks gestation, earlier if multiples or if the fetus is larger than normal gestational age. After the first three months, safe prone positioning for effective massage therapy is not possible, even with additional pillows, and/or tables and other equipment currently marketed for this purpose. Prone positioning with other equipment that doesn’t elevate intrauterine pressure often further strains the taxed uterine and lumbar ligaments, exacerbating the very causes of many women’s discomfort. The sacrouterine ligament is particularly vulnerable in prone position.
Supine positioning also involves safety considerations when working with pregnancy related sources of lumbar and pelvic pain. In this position, the weighty uterus compresses against the inferior vena cava. Extended compression will result in low maternal blood pressure and decreased circulation both to the mother and her fetus (supine hypotensive syndrome). 13 In second and third trimesters, mitigating measures for more extended supine positioning are prudent. Shift the uterus to the left side with pillow support under the right lumbar area (weeks 14-22), or, after 22 weeks, elevate the entire torso to a semireclined angle of at least 45 degrees. Use a densely cushioned therapy table, and provide sufficient supports for the lumbar area and the knees. When women are advised by their healthcare provider to never lie on their backs, always observe these restrictions.
When sufficiently supported with firm pillows, bolsters, and/or a Contoured bodyCushion, sidelying position is the safest, most posturally neutral, and most comfortable position for most women to receive prenatal massage therapy. Even in the sidelying position, however, pressure must be applied without rolling the woman onto her abdomen, and her top leg must be aligned horizontally with her hip. This is most important during deep work on the posterior structures when addressing back and pelvic pain.
Blood Clots
Avoiding deep, pointed, and/or ischemic compression to the pregnant abdomen also eliminates pressure into one of the most dangerous locations, the inguinal area. Blood clotting capacity escalates four to five times higher than non-pregnant levels during pregnancy. As fibrinolytic activity, the clot dissolving capacity of the blood, decreases dramatically, women are protected from potential hemorrhaging during childbirth; however, they also are more likely to develop blood clots (thrombi). 14
Clot formation is greatest in the veins where blood is most stagnant. The veins most likely to harbor clots during pregnancy are the iliac, femoral, and saphenous veins. 15 This is due to restriction of iliac and femoral venous return by the weight of the uterus on these vessels and to hormonal influences on vascular smooth muscle and on blood and fluid volumes. Given the likelihood of clots and their potential harm if freely circulating, do not press deeply into the abdomen, especially in the inguinal area. Additionally, use only soft, whole hand pressure throughout the medial surface of the legs where these veins traverse. Perform no tapotement nor deep, pointed, or stationary (ischemic) pressure, sufficiently sustained to restrict localized blood flow, regardless of the type of technique and its potential benefits.
Miscarriage and Prematurity
Miscarriage (spontaneous abortion) is a natural termination of pregnancy before the fetus has reached viability, most common in the first trimester. Preterm labor involves regular contractions that dilate the cervix after 20 weeks and before the end of 36 weeks gestation. Note that one of the most common symptoms of premature labor and miscarriage is low back/pelvic pain, referred from the contracting uterus; however, there are usually other identifying symptoms, such as bleeding or amniotic fluid leakage and abdominal cramping or regular uterine contractions. Remember that musculoskeletal back pain usually is relieved with a change in position or activity, while referred organic pain is not. Ask her physician to rule out miscarriage, preterm labor, or other possible causes of back pain, such as urinary tract infection, neurological dysfunctions, eclampsia, or prior, unresolved injuries. Take full prenatal and medical histories, and evaluate thoroughly at each massage therapy session.
Certain maternal conditions, high risk factors, and complications of pregnancy increase the risks of miscarriage and prematurity including:
No one wants to have any doubt as to whether any massage therapy intervention was harmful nor have their protocols questioned. Some sobering facts of American maternity care are very relevant to massage therapy practitioners: more than 75% of obstetricians and gynecologists are sued; more than one third of them are sued more than three times; and nurses and other perinatal healthcare providers are more and more frequently being included in these lawsuits. 17 Massage practitioners are wise to be aware of the litigious atmosphere in childbearing.
Some added precautions that could avoid erroneous, but costly, legal questions:
Do not touch the abdomen of a first trimester woman or of one whose risk of miscarriage or preterm labor is high. (See list above and sections later in this article on complications and high risk factors.) Always ask permission to gently touch her abdomen. Strictly adhere to midwives’ and physicians’ restrictions regarding abdominal massage. If not comprehensively trained in prenatal massage therapy, a further precaution worth considering is to not work with first trimester women or those at higher risk of pregnancy losses or prematurity.
Ligament laxity precautions
Symphysis pubis separation demands several special considerations in choosing and performing massage therapy. First: rolling over is painful with this condition, so minimize position changes. Second: firm, reliable bolsters and other supports are essential in all positions to prevent extended tugging on the joint. Finally, eliminate any techniques creating traction on the pelvic and hip joints or that compress the pelvis unilaterally.
All of a pregnant woman’s ligaments are easily overstretched due to the softening effect of relaxin. Overstretched ligaments result in joint instability and more pain. Minimally invested with elastic fibers, ligaments do not tighten after excessive lengthening. Modify assisted resisted stretches, positional release, Swedish gymnastic movements, range of motion, and other passive and active movements to avoid overstretching of joint structures.
Other complications and high risk pregnancies
In addition to miscarriage, premature labor, and placental dysfunctions, other physiologic complications to a normal gestation occur. These include: gestational diabetes and several types and severities of hypertensive disorders. When any complications arise, massage therapy is contraindicated until resolved or only with consultation with her healthcare provider. Cautious therapists will refer these women to more qualified prenatal massage therapists if not comprehensively educated in this work. If they do work with a complicated pregnancy, they will require written release from the woman’s healthcare provider and practice ultraconservatively.
In high risk pregnancies, either the mother or the fetus has a significantly increased chance of disability or death. Most of these conditions will not be negatively impacted by massage therapy; in fact, it may be invaluable in reducing the negative effects of increased anxiety and the bedrest frequently prescribed. With the further risk involved, however, thorough training and a written release from the woman’s healthcare provider are advisable.
Conclusion
The guidelines in this article are an introduction to effective, safe massage therapy for the pregnant pelvis. Pregnant women experience numerous other structural, physiological, and emotional changes and discomforts that respond well to specific, therapeutic techniques. Further study of the many other relevant intricacies of pregnant physiology and psychology and thorough, hands-on training and are highly recommended. 18
Carole Osborne-Sheets is the author of and Pre- and Perinatal Massage Therapy, and a contributor to the upcoming textbook Teaching Massage Therapy, as well as numerous other publications. She is the 2008 recipient of the AMTA Jerome Perlinski National Teacher of the Year Award. The work outlined in this article is adapted from portions of the author’s textbook Deep Tissue Sculpting.
For these and other books, click here.
For information about her certification program, Pre- and Perinatal Massage Therapy, and other hands-on workshops, click here.
Footnotes
Supporting Pregnancy with Massage Therapy
Articlesby Carole Osborne
Nurturing touch during pregnancy, labor, and the postpartum period is not a new concept. Cultural and anthropological studies reveal that massage and movement during the childbearing experience was and continues to be a prominent part of many cultures’ healthcare. (1) Studies indicate that most of the more peaceful cultures use touch prominently during pregnancy and early childhood. 2 Midwives, who for centuries have provided maternity care, have highly developed hands-on skills.
Current research on the benefits of touch is providing a contemporary basis for its reintroduction in many technological societies, including the United States. Scientists have found that rats restricted from cutaneous self stimulation had poorly developed placentas and 50% less mammary gland development. Their litters were often ill, stillborn, or died shortly after birth due to poor mothering skills. (3) Pregnant women massaged twice weekly for 5 weekly for 5 weeks experienced less anxiety, leg and back pain. They reported better sleep and improved moods, and their labors had fewer complications, including less premature births. (4) Studies show that when women received nurturing touch during later pregnancy they touch their babies more frequently and lovingly. (5) During labor the presence of a doula, a woman providing physical and emotional support, including extensive touching and massage, reduces the length of labor and number of complications, interventions, medications, and Cesareans. (6)
Why Pregnancy Massage Therapy?
Profound local and systemic changes in a woman’s physiology occur as a result of conception and the process of labor. Changes during pregnancy span the psychological, physiological, spiritual, and social realms, according to Carole Osborne, author of Pre- and Perinatal Massage Therapy and maternity massage therapy specialist since 1980. “Massage therapy can help a woman approach her due date with less anxiety, as well as less physical discomfort,” says Osborne.
A typical session performed by a therapist specializing in pre- and perinatal massage therapy, can address pregnancy’s various physical challenges: edema, postural changes, and pain in the lower back, pelvis, or hips. Swedish massage may facilitate gestation by supporting cardiac function, placental and mammary development, (7) and increasing cellular respiration. It also reduces edema and contributes to sympathetic nervous system sedation. (8) Deep tissue, trigger point, and both active and passive movements alleviate stress on weight-bearing joints and myofascial structures, especially the sacroiliac and lumbosacral joints, lumbar spine, hips, and pelvic musculature. (9) Structural balancing and postural reeducation reduce neck and back pain caused by improper posture and strain to the uterine ligaments. “Prenatal massage therapy also can facilitate ease of labor by preparing the muscles for release and support during childbirth,” according to Osborne.
“Beyond these physical effects, an effective prenatal massage therapy session provides emotional support,” says Osborne. In the safe care of a focused, nurturing therapist, many women unburden their worries, fears, and other anxieties about childbearing. She believes that bodywork helps the mother-to-be develop the sensory awareness necessary to birth more comfortably and actively. “Laboring women whose partners learned and provided basic massage strokes to their backs and legs had shorter, less complicated labors. (10) Imagine the benefits generated by the skilled hands of a trained touch specialist!”
The Postpartum Period
Beginning with the baby’s birth, a new mother must cope with more changes. She is typically only 10 to 12 pounds lighter, yet she is still maintaining her body with an anterior weight load posture. The massage practitioner can facilitate proprioceptive reprogramming to gently return the body to its pre-pregnancy state, to alleviate pain, and to bring about a renewed sense of body and self.
As a specialist in postpartum work, Osborne focuses on repositioning the pelvis and repatterning overall body use. Postpartum massage sessions can restore functional muscle use in the lumbar spine area, as well as strengthen and increase tonus in the abdominal musculature stretched and separated by pregnancy. Additionally, the overtaxed, hypotoned iliopsoas muscle functions can be improved. Upper back muscles which now support larger breasts and the carried infant’s weight need work to reduce strain, and to help maintain flexibility despite the physical stresses of infant feeding and care. For post-Cesarean mothers, specific therapeutic techniques also can reduce scar tissue formation (11) and facilitate the healing of the incision and related soft tissue areas, as well as support the somato-emotional integration of her childbearing experience.
Pre- & Perinatal Massage Therapy Education
To safely massage pregnant, laboring and postpartum women, Osborne feels that it is imperative that practitioners be knowledgeable about normal pre- and perinatal physiology, high risk factors, and complications of pregnancy. “Many of these conditions necessitate adaptations and consultation with physicians and/or midwives prior to sessions. Various techniques and methodologies must be modified or eliminated, depending on the individual and the trimester of pregnancy,” according to Osborne.
“Somatic practitioners will find reliable detailed, research based protocols and contraindications in Pre- and Perinatal Massage Therapy, and in my home study course based on that text,” says Osborne. For those seeking comprehensive hands-on training and certification as a maternity massage specialist, she recommends her 32 hour workshop.
“My Pre- & Perinatal Massage Therapy book and training programs developed from 27 years as a somatic practitioner and educator and 22 years of specialization in maternity and infant massage,” says Osborne. “Our students benefit from our continually expanding body of knowledge, research, clinical experience, and consultations with other perinatal health care providers.”
“Our instructors offer somatic therapists a safe and comprehensive approach to pregnancy, labor, and postpartum massage therapy. We also encourage an empathetic, non-judgmental attitude in supporting women’s ‘pregnant feelings’. These certification workshops include over 80 techniques specifically adapted for pre- and perinatal needs, and the practical marketing strategies, ethics, and skills to elicit collaboration with other perinatal specialists and to build a successful pre- and perinatal massage therapy practice.”
Application has been made to the Scottish Massage Therapy Association and the Guild of Complementary Practitioners for continuing professional development (CPD) points. Carole Osborne is approved by numerous American associations and agencies. She is approved by the National Certification Board for Therapeutic Massage and Bodywork as a continuing education provider (32 category A units: workshops include two ethics hours). Her workshops and staff are also approved by the Florida Board of Massage, California Board of Registered Nursing, and International Childbirth Educators Association; meet current American Massage Therapy Association continuing education standards; can be used for Associated Bodywork and Massage Professionals membership; and can be used for continuing education credit with Doulas of North America.
The Pre- & Perinatal Massage Therapy certification workshop is Carole’s expansion and refinement of the original Bodywork for the Childbearing Year® training which she co-created and taught from 1980-1996. Since 1980 she has trained over 4,000 massage and perinatal specialists throughout the United States, Canada, and Scotland. Her first textbook, Deep Tissue Sculpting, is an established professional text. To order a book or to learn more about the workshops Body Therapy Education at (858) 277-8827.
[minti_blockquote]Carole Osborne-Sheets is the author of and Pre- and Perinatal Massage Therapy, and a contributor to the upcoming textbook Teaching Massage Therapy, as well as numerous other publications. She is the 2008 recipient of the AMTA Jerome Perlinski National Teacher of the Year Award. The work outlined in this article is adapted from portions of the author’s textbook Deep Tissue Sculpting.
For these and other books, click here.
For information about her certification program, Pre- and Perinatal Massage Therapy, and other hands-on workshops, click here.
[/minti_blockquote]
Footnotes
R-E-S-P-E-C-T: What’s That Mean in a Prenatal Massage Class?
VideosCarole Osborne’s Pre and Perinatal Massage Classes
Videos