Perinatal Massage

The challenges and rewards of treating the pregnant patient
Nicole Nifo, RMT
June 24, 2013
By Nicole Nifo, RMT
As Carole Osborne-Sheets states in her book Pre- and Perinatal Massage Therapy, “Appropriate touch with childbearing women has the potential to positively change not only individual women and their families, but also to knit an ever-widening fabric of nurturing touch to help unite and transform our current violent, touch-aversive societies.”

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The RMT’s pressure, for belly massage during pregnancy, is very light and is not meant to palpate the baby as her midwife or obstetrician does.

 

I often speak of the importance of massage for babies, but shouldn’t we also promote this nurturing touch for the pregnant mother? She can nurture her growing baby and body from Day 1 of conception and learn appropriate self-care, have massages, and build a relationship with a health-care provider with whom she can communicate openly about her pregnancy.

Recently, one of my postpartum patients spoke of a list of must-dos or must-haves during pregnancy, and she stated that prenatal massage was in the top 3 on her list. She also said that “massage therapy is something that every women needs to do to take care of herself and to feel good about her changing body.”

As massage therapists, we bear witness to many life-changing events in our patients’ lives. Pregnancy is a time of transition – a woman’s body is growing and changing to prepare her for birth and becoming a mother. It is a time of strength and vulnerability. RMTs working with pregnant women have the opportunity to explore their pregnancy with an intimacy that she often does not share with another person, other than her partner. Not only will you help her relax and treat her body pains, but you will form a close bond. It is important that you create a caring, non-judgmental clinical environment for women to openly and honestly express the many emotions they experience during pregnancy.

I recently read a study from the Miami School of Medicine in the Touch Research Institute, where researchers found that after receiving pregnancy massage, “only the massage therapy group . . . reported reduced anxiety, improved mood, better sleep and less back pain by the last day of the study. In addition, urinary stress hormone levels (norepinephrine) decreased for the massage therapy group and the women had fewer complications during labor and their infants had fewer postnatal complications (e.g., less prematurity).”(Field et al., 1999)

MY REASON TO FOCUS ON PERINATAL CARE
One of my favourite moments as a massage therapy student was when I attended a hospital outreach program for high-risk pregnant women. It truly changed my perspective on therapeutic massage therapy. I worked with a woman who was a few hours postpartum and suffered from a traumatic birth experience. She was inconsolable and constantly sobbing. I approached her with a soft voice and gentle touch. Most of the treatment was sidelying using effleurage and c-scooping to her neck and back. Within 10 minutes, her mood dramatically changed and she actually had a smile on her face. Her husband thanked me as if I had saved her life. Who knows, maybe that moment altered her state for an hour or two, so that the new parents could bond with their new baby (which is extremely important in the first 24 hours after birth). I didn’t realize how powerful touch was until that experience, and I barely applied any of the techniques I had practised as a MT student. A little goes a long way, and we don’t just massage people – we touch their lives. It was an incredible experience and as a student therapist, it gave me a boost of confidence that I would carry into my massage therapy career.

FERTILITY AND MASSAGE
The childbearing years for women can be exciting and stressful at the same time. For some, getting pregnant is easy. For others, the cost and stress of fertility procedures can make getting pregnant emotionally, financially and physically draining. As her massage therapist, you can help decrease stress hormones, help nurture her body as it undergoes medical treatments, and help her to reconnect with her body. I usually ask my patients how they got pregnant so that I can get a clearer picture of what they have been going through physically and emotionally for the last year or so.

POSITIONING FOR A SAFE AND COMFORTABLE TREATMENT
It is not up to the pregnant patient to know what positions are safe for massage. As her RMT, you can educate her on safe positions and make sure she is comfortable on your table. Often, new patients ask about the massage tables with a hole for her belly or pregnancy pillows that allow her to lie prone in her second and third trimester. It is not OK for your patient in her second or third trimester to be prone for any reason. The prone position on a table with a hole puts too much strain on the sacrouterine ligaments and the prone pillows increase intrauterine pressure. These positions actually make some patients feel more stressed out.

I “bit the bullet” and splurged on an ergonomic pillowing system. It is well worth the money and I get asked by patients where they can buy the pillows for sleeping at home all the time. Patients who have experienced the latter tell me that now, lying on their side, they realize how they were so tense on those tables, or lying prone, how they couldn’t fully relax. The supine position can be done by placing pillows behind her back, to create an incline, and under her knees, while supporting her right hip with a wedge pillow to avoid supine hypotensive syndrome. Sidelying is most recommended to your patients by their midwife or obstetrician because it is safe, facilitates sharing, avoids sinus congestion, decreases edema, maximizes maternal cardiac function and fetal oxygenation and avoids intrauterine pressure.

Also, take full prenatal and medical histories and evaluate your clients’ progress thoroughly at each massage therapy session.

EDUCATION ON POSTURE AND HER CHANGING BODY
Your pregnant patient’s body is constantly changing and growing. With every visit, she may present a new symptom picture or not have any discomforts at all. It is important to educate her on proper sleeping positions and exercises to treat or prevent discomfort, and to monitor any chronic injuries that occurred before she was pregnant. Empower her to be mindful of her body and the way she moves about. Most women are not at home relaxing while they are pregnant – they are usually working full time, and may have one or more small children at home. It can be very stressful for the modern-day pregnant woman, juggling work, family and life.

THE RMT AS A TRUSTED RESOURCE
Appointment booking times are a lot longer for massage therapy treatments than for any of a woman’s other health-care treatments. You are most likely the only practitioner she sees often, and with her appointments lasting from 30 to 90 minutes, the relationship you create allows your patient to feel safe receiving massage during such an important time in her life.

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Sidelying during a massage is safe and most recommended for the pregnant patient.

 
The Internet is a powerful tool, full of ideas and comments about pregnancy and childbirth. But what most people don’t realize is that a lot of Internet content is made up of opinions. The pregnant woman of 2013 is bombarded with advice from the Internet, family, friends and even strangers. Although no one means any harm, most women like to share their birth story and experiences with a mom-to-be (which can be scary for your patient to hear), but it is important that your patient has you as a trusted source of information, to ask questions of and use as a sounding board for ideas.

I recommend that you get to know other health practitioners in the area who have a focus on pregnancy and perinatal care – examples are physiotherapists, chiropractors, osteopaths and breast-feeding specialists – as well as community support such as a post-partum depression line or local mom groups.

BELLY MASSAGE
One of my favourite aspects of working with a pregnant patient is soothing and calming her unborn baby through abdominal massage. You must always obtain special consent before this type of treatment and explain the benefits of abdominal massage to your patient, namely, that it encourages relaxation; promotes circulation to her uterus; helps her bond more with her baby; and serves as, essentially, her baby’s first massage. Your pressure is light, and is always lighter than an ultrasound technician, and is not meant to palpate the baby as her midwife or obstetrician does. Techniques can include clockwise circles, sun/moon technique, criss-crossing and multi-directional effleurage strokes.

In the last few weeks of pregnancy, the baby is running out of space to move and stretch – because of this, unless your patient has an anterior placenta, you can literally feel the baby follow and push against your hand as you move back and forth across your patient’s belly.

TAKE SOME PRECAUTIONS WITH MASSAGE
Here are some elements to keep in mind when massaging a pregnant patient:
  • Relaxin hormone -- produced by the ovaries and placenta, relaxes the ligaments in the pelvis and softens and widens the cervix.
  • Separation of pubic symphysis – try not to move patient too much.
  • Avoid reflexive techniques to the lower leg and feet – it’s best to consult a reflexology chart for specific points.
  • Adjust treatments for hyper/hypotension, diabetes or any other high-risk concerns.
  • Nausea is usually experienced in the first trimester but can occur throughout pregnancy – clients suffering from nausea will not appreciate rocking or rhythmical movements.

TREATMENT FOCUS AND PRECAUTIONS
First Trimester (Weeks 1-13)
It is a misconception that massage therapy during the first trimester is unsafe. Prone position may be OK, as long as your patient is comfortable and not high-risk.

What to focus on: Teach your  pregnant patient self-care and how important it is to carry on with it throughout her pregnancy. Focus your treatments on relaxation, especially if she had fertility issues, incorporate techniques to relieve headaches, reduce fatigue and alleviate morning sickness. Most women are overjoyed with being pregnant and the journey they will embark upon but feel bogged down by some of the elements that may accompany it. You may be able to assist with some of these.

Precautions: As mentioned above, there are many precautions that a therapist must take, for example, using reflexive pressure points that can stimulate the uterus (reflexology points) to the abdomen. If the patient has a high-risk pregnancy, I suggest only relaxation techniques and light-medium pressure.

Second Trimester (Weeks 14-26)
At this stage, your patient is experiencing “butterflies” in her tummy and by Week 26 she has already felt her baby kicking and moving. You will notice her posture changing and may need to address postural discomforts.

What to focus on: Your patient may start to feel some discomfort; aim to relieve leg cramps, back and hip tension. This is the ideal stage to start incorporating belly massage if your patient has consented.

Precautions: No prone positioning for any reason during massage. Avoid essential oils and pressure points that may induce labour.

Third Trimester (Weeks 27-40)
This is my favourite stage of pregnancy – there is growing anticipation and excitement as the birth gets closer. But, it is between Weeks 30 and 40 that the baby will gain the most weight, which can mean that your patient develops a waddle and may experience a chronic backache.

What to focus on: You may be seeing your patient weekly or biweekly at this stage. Treat hip tension, back strain, limb swelling, and carpel tunnel or Thoracic Outlet Syndrome. She may be experiencing gastrocnemius muscle spasm at night or waking up with headaches due to the lack of sleep.

Precautions: Keep a wedge under her right hip in the supine position. Monitor blood pressure and increased body swelling.

LABOUR SUPPORT
Being a massage therapist and also doubling as a labour support provider is becoming a popular trend for therapists who treat a lot of pregnant women. It is a unique relationship: because therapist and patient already have a connection, it will allow your patient to be herself during birth and trust in your guidance as her labour support.

POSTPARTUM
Although massage is safe within the first few hours or weeks after birth, you will most likely have to adjust positioning and pressure over sensitive areas.

Unless she has a doctor’s referral that states otherwise,  C-section mothers will always be positioned sidelying for at least four weeks or until her incision is less sensitive.

Working with women during such a transitional time in their lives, is so rewarding and also beneficial to your practice because new moms are very influential, and the power behind their word-of-mouth referrals can yield growth for your practice.

“To nurture the birth of a mother and of her baby with skilled touch is one of the most intellectually challenging, emotionally and physically demanding, humbling, inspiring and life-enhancing experiences that a somatic practitioner can engage in.” 

SOURCES USED FOR THIS ARTICLE
  1. Field T, Hernandez-Reif M, Hart S, Theakston H, Schanberg S, Kuhn C. Pregnant women benefit from massage therapy. J Psychosom Obstet Gynaecol. 1999 Mar;20(1):31-8.
  2. Osborne-Sheets, C. Pre- and Perinatal Massage Therapy: A Comprehensive Guide to Prenatal, Labor, and Postpartum Practice. Copyright 1998, Body Therapy Associates. San Diego, CA 92128.
  3. Bastard J, Tiran D. Aromatherapy and massage for antenatal anxiety: its effect on the fetus. 2006 Feb;12(1):48-54. E-pub 2005 Oct. 6, accessed March 8, 2013.


Nicole Nifo has been practising as a Registered Massage Therapist since 2005. She has extensive massage therapy training in obstetric and pediatric patients. For six years, Nicole has been managing a family-focused practice through her clinic, Fully Alive Wellness Centre in Oakville, Ontario. She has also written many MT-related articles for women and children and continues to strive to find new ways of communicating the importance of nurturing touch for children. Nicole can be reached at www.fullyalivecentre.com or on twitter @FullyAliveWC.

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