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Positioning Concerns

The most obvious question practitioners initially consider when contemplating massaging pregnant women is how to accommodate that glorious belly! There are several relevant issues involved in this practical dilemma, including safety, comfort, and effectiveness of therapy.

September 22, 2009
By Carole Osborne-Sheets & Linda Hickey


The most obvious question practitioners initially consider when contemplating massaging pregnant women is how to accommodate that glorious belly! There are several relevant issues involved in this practical dilemma, including safety, comfort, and effectiveness of therapy.

Prone Positioning Restrictions:

While stomach sleeping may be a safe, comfortable resting position for the early pregnant woman, the pressure necessary for massage in this position creates an unreliably safe situation.


Prone positioning on a flat therapy table exerts strain on the lumbar, pelvic, and uterine structures. Posterior musculature is shortened; the lumbar vertebra and lumbosacral junction are compressed and anteriorly displaced; the sacroliliac joints are rotated; and strain on the already taxed sacrouterine ligaments is increased. Obviously, the prone position aggravates the very causes of many women’s back discomfort, particularly in later pregnancy.

Some practitioners may attempt to mitigate these problems with pillows or specialized equipment that is
marketed for pregnant clients.

Neither pillow props, body cushions, pregnancy pillows, most on site massage chairs, nor tables with cut-out ovals, with or without a sling or net designed to support the belly, solves the problematic aspects of prone positioning.


In fact, these alternatives can either add further strain to the taxed uterine ligaments, or create increased intrauterine pressure, particularly when sufficient pressure is applied to therapeutically address the posterior structures.

Increased intrauterine pressure is probably not a significant safety concern in the first trimester, or in most normal, uncomplicated, low-risk pregnancies. However, the increased pressure is of particular relevance when there are abnormalities in placental attachment or function, or a higher risk of such conditions.

More caution is also prudent if there is concern about fetal blood supply or uterine competence.

Women who have been diagnosed with these conditions are often uninformed about their impact with regard to receiving massage therapy. Some of these problems go undetected until bleeding, cramping, or other overt signs of problems have occurred to warrant further diagnosis. If “doing no harm” is of highest priority, then the risk of excessive intrauterine pressure must be avoided with all pregnant clients and positioning adaptation made.

Prone positioning involves the additional discomfort of pressure on breasts that are often very sensitive, even in the first trimester when abdomen is not significantly larger.

Because of increased mucous production and the inability to use alleviating medications, many women become unacceptably congested in prone position as well. Some women are uneasy with “lying on their baby.”

Finally, verbal and emotional sharing is hampered for many by the confines of face cradles and other devices which position the head when lying face down.

For the comfort and safety of the pregnant woman, eliminate entirely the prone position after the first 13 weeks of pregnancy, regardless of your or the client’s perception or preferences in this regard.

Supine lying guidelines:
Supine positioning also involves safety considerations. There is the potential for the weighty uterus to rest against the inferior vena cava. Extended compression of the vena cava will result in lowered maternal blood pressure and decreased circulation both to the mother and her baby, a condition referred to as supine hypotensive syndrome.
Some women report uneasiness, dizziness, shortness of breath, or other discomforts when lying flat on their backs, although others seem entirely content.

With or without notable negative effects, however, decreased fetal circulation occurs, particularly if the placenta is embedded posteriorly.

Some women are advised by their healthcare provider to never lie flat on their backs, primarily when there is increased concern about fetal circulation or oxygenation. Always observe these instructions, regardless of your or your client’s perception or preferences in this regard.

It appears safe for most women receiving massage therapy to lie on their backs briefly, two to five minute maximum after 13 weeks throughout pregnancy. In second and third trimesters, however, providing additional support for more extended supine positioning is necessary.
Options in early pregnancy, 13 to 22 weeks, include use of pillow support under the right side of the torso to shift uterine weight toward the left. After 22 weeks, this is not enough and the woman’s torso will need to be elevated to a semi-reclined position angle of 45-75 degrees.

Side-lying positioning:
When supported sufficiently with firm pillows, bolsters, and/or a Contoured bodyCushion, side-lying position is the safest, most posturally neutral, and most comfortable position for most women to receive prenatal massage therapy.

Even in the side-lying 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.

For more information on positioning and other maternity massage issues, consult Pre- and Perinatal Massage Therapy by Carole Osborne-Sheets, or attend a certification workshop by Carole Osborne-Sheets, (800)586-8322 or (858)748-8827. Visit for more information, workshop schedules or to order books.

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