Effects of Labor: Immediately after the placenta is delivered, postpartum recovery begins. For the new mother, this is an intense and dramatic period of physical and emotional adjustment. In traditional societies, it was common to support the pregnant, labouring and postpartum woman with massage. However, applications were most important during the postpartum recovery period, to ensure that all remnants of the placenta were expelled and to encourage uterine involution (the return of the uterus to its pre-pregnant shape and size).
For several days after the birth of her baby, the new mother has an increase in urine output, hot flashes and heavy sweating, as her body rids itself of excess interstitial fluids and waste products. She will also lose anywhere from 10-15 pounds within hours of the birth, including 7-8 pounds of baby, 1-2 pounds of amniotic fluid and blood, and 1-2 pounds of placenta and other fluid.
The Uterus: After the placenta is delivered, the uterus continues to contract. Called “after-pains,” these contractions are more common in women who have given birth before than in first-time mothers, and serve to restore the uterus to its pre-pregnant size and shape.
Nursing mothers often complain about severe cramping because prolactin, the hormone of milk production, activates uterine contractions. These contractions serve an important purpose; to expel any remaining clots and uterine tissue and control hemorrhages at the placental site.
The day after the birth, the uterus is just above the umbilicus. Almost a week later, the top of the uterus is midway between the umbilicus and the symphysis pubis. After 10 days, the uterus has shrunk down behind the symphysis pubis.
Abdominal massage immediately after the placenta is expelled can be painful, but it is very helpful in encouraging uterine involution and the flow of lochia, the natural postpartum discharge. The massage, which can be performed by the new mother on herself, is done on the abdomen in a clockwise direction using small, circular kneading strokes.
The uterus should harden and contract with this treatment and the massage should be applied every four hours until the discharge is pale, for about 2-3 weeks. A woman who has had a Caesarean (C-section) should take care to avoid direct pressure on her scar until it heals.
Fatigue: Many women feel exhilarated immediately after giving birth. However, the ensuing days, weeks and even months can be fraught with exhaustion. Sleepless nights, musculoskeletal pain, hormonal adjustments, the discomforts and by-products of labour, nursing difficulties and, of course, tending to the baby can all take a toll on the new mother and sap her strength.
Rest is the most important factor in postpartum recovery. A light, general massage will help the new mother fight some of the fatigue by encouraging circulation, lymphatic drainage and relief from musculoskeletal aches and pains.
Hormonal adjustments: Within a few hours after birth, estrogen and progesterone, the hormones that supported the new mother’s pregnancy, drop – while oxytocin and prolactin increase, particularly if she is nursing. This sudden shift in hormones can account, in part for her postpartum emotional state, which can include depression. It is also the reason she experiences postpartum shaking, which can last up to several weeks.
Postpartum thyroiditis, inflammation of the thyroid gland, should also be considered by the woman’s physician when postpartum blues continue for a prolonged period of time and the woman is tired and unable to lose weight. Generally, the thyroid gland slows down during pregnancy but increases functioning after birth, releasing an excess of hormones. Then it returns to normal.
However, in postpartum thyroiditis, which affects one in 15 new mothers and is often undiagnosed, the damaged thyroid may remain underactive until medically treated. A blood test determines thyroid gland functioning. This condition sometimes reverses without intervention, or thyroid replacement pills are prescribed.
It may take 4-6 months before the changes to collagenous connective tissue and ligaments are reversed due to the presence of relaxin. This impacts the postpartum woman’s joint stability, posture and co-ordination.
Headaches: A new mother may experience severe or migraine headaches from small amounts of cerebral spinal fluid leaking at the site of epidural injection. These headaches can be debilitating, and can last from several hours to many days, or longer. The new mother is often treated for these headaches
with medication. Massage is generally not feasible until the headaches have subsided. The massage therapist should then concentrate on the upper back, neck, facial and cranial muscles. Craniosacral therapy is a wonderful and effective technique to apply in this instance.
Blood: Blood-clotting activity is still ongoing during the postpartum period, with the iliac and femoral veins being most susceptible. The massage therapist should recognize that pulmonary embolism is a major cause of maternal mortality after birth. C-section births have twice the risk factor than vaginal births. This usually reverses by 10-12 weeks postpartum. Until then, massage to the back of the legs should be light – and deep pressure, tapotement and vibration should all be avoided. The increased blood volume level usually reverses 3-4 weeks after the birth.
Caesareans: Some C-sections are planned, while others are emergency decisions. Regardless of the reason, this is a major surgical operation from which the new mother must recover. The C-section patient is more tired than a woman who had a vaginal birth and is usually very emotional about the birth outcome. Working lightly can invigorate her, while deep tissue work may be too depleting for her early in her recovery.
The massage therapist must avoid working on the scar tissue until the wound is closed and the client feels comfortable about this localized massage. There can be a lot of emotional issues stored in this area of the body, and trust must be established before scar treatment can begin. It is advisable to ask permission before beginning your treatment.
Release the tissue gently, longitudinally on either side of the incision without lubrication. This myofascial release will break up adhesions. As long as the scar does not show signs of keloid formation (thick, ropy, dimensional tissue), you can proceed with light transverse friction using lubrication to loosen the scar.
A keloid scar is abnormal cell growth and should not be stimulated. Remember, it is important to position your client so the incision isn’t pulled and the abdomen is supported.
Show your client how to do this for herself – not only will it speed up healing and restore elasticity to the site, but it will be gratifying for her to take effective charge of her body.
The C-section patient will often experience intestinal gas pain and referred pain under the scapula from air trapped under the diaphragm. Slow and careful movement, while pain is present, is the best way to encourage healing, eliminate gas and stimulate peristalsis.
The Back: Long-term postpartum backaches are relatively common, and can occur for various reasons.
The site of the epidural injection may cause the new mother discomfort for a long time after the birth.
It is important to avoid massaging directly on the area and position her in such a way that pressure to the site is avoided. This might mean side lying or seated.
A misaligned pelvis creates musculoskeletal problems, which can lead to further complications if it is not addressed early. Concentrate your work on rebalancing the pelvic
muscles, such as iliopsoas, quadratus lumborum, piriformis. SI joints and medial pelvic compression.
If she has a diastasis recti (a separation of the two halves of the rectus abdominis muscles in the midline at the linea alba), her abdominals will be weakened and her lower back will hurt. It is extremely important that she contract her transverse abdominis with all activity and avoids crunches; sit-ups or twisting movements until the diastasis recti has healed.
Poor body mechanics or lifting the baby (and older children) may exacerbate her discomfort. Neck and shoulder pain from one-sided nursing, or from holding and gazing at the baby, is also common. The use of front-positioned baby-packs adds stress to back muscles.
The presence of relaxin for up to six months impacts on the stability of her joints and further increases back stiffness and soreness. Changes in bone density of the lumbar spine generally reverse after about six months or after breastfeeding stops. Until such time, she should avoid lifting heavy objects.
Your postpartum client may experience acute pain in her symphysis pubis from joint separation. Also called symphysiolysis or diastasis symphysis pubis, this joint shearing causes severe pain during movement and the inability to walk without support. She should take short steps when she walks and avoid standing for any extended period of time. Ice to the site is recommended; avoid hip traction during the massage.
During the second stage of labor, as the baby is descending, damage is done to the ligaments of the coccyx with or without coccyx displacement or fracture. This postpartum condition, coccyodynia, may aggravate lower back pain and be incapacitating. Rest is the best solution, along with gentle pelvic and hip massage. If not addressed, this condition can persist for a long time.
Your client may also be experiencing general back stiffness and soreness from birthing positions, the physical exertion of labor and all the physical and emotional adjustments of motherhood.
Legs: Labor positions may also be responsible for achy feet and tired legs. Follow lymphatic protocol to reduce swollen feet from intravenous medication. Although there is a great amount of diuresis following delivery, it takes anywhere from a few days to a few weeks before all fluid retention is eliminated. For greater comfort and increased drainage, elevate the client’s legs during sessions.
When massaging the new mother’s legs, keep in mind that prolonged labor and pushing may cause varicosities and fibrinolytic activity to continue during postpartum recovery. Avoid dislodging clots my massaging her legs with an open hand and staying clear of deep friction and any percussive or vibratory strokes.
Nursing: Three to four days after birth, prolactin stimulates milk production. Prior to this, the baby was nourished at the breast by fat-enriched colostrums. While breastfeeding is undoubtedly best for the baby’s health, growth and development, as well as for speeding the mother’s recovery, it is often accompanied by its own set of discomforts.
Poor nursing positions can affect the baby’s ability to latch on properly and create serious maternal back, neck and shoulder tension and pain. This may start an emotional tailspin about nursing altogether. Sore or cracked nipples and breast engorgement only add to the frustration so many women experience.
Breast massage is usually not included in regular massage therapy sessions, yet simple techniques can ease a new mother’s discomforts. If your client is uncomfortable with breast massage, talk her through it so she can do this for herself.
Emotional Recovery: The emotional recovery of the postpartum woman is important. The dramatic drop of hormones immediately after giving birth can be one of the reasons women go through such emotional highs and lows. Disappointment with birth outcome, a medicated delivery or unscheduled C-section, physical or sexual abuse issues suddenly surfacing, sleep disturbances, the needs of partner or older child(ren), single parenting and assuming the new role of mother can all contribute to postpartum blues. A grieving woman, one who experienced a miscarriage, stillborn birth or neonatal death, has to heal physically as well as deal with her enormous loss.
It is estimated that almost 80 per cent of postpartum women experience transitory postpartum blues. Symptoms include crying for no reason, irritability, anxiety, anger, frustration, restlessness and impatience. The least severe of all postpartum emotional conditions, the blues comes on a few days after the baby’s birth and subsides within a week or so. A nurturing massage helps tremendously by relieving the woman’s physical discomforts and providing her with emotional understanding and support.
A more serious birth reaction is postpartum depression, which affects almost 10 per cent of new mothers. This condition can come on early after the birth, or a bit later on. The new mother may have many of these symptoms; sadness, depression, feelings of hopelessness, exaggerated highs and lows, hyper-anxiety about the baby or lack of interest, fears of hurting herself or the baby, and feelings of worthlessness and inadequacy.
Some women with postpartum depression may develop postpartum anxiety, or panic disorders or postpartum obsessive compulsive disorders, which require the intervention of a skilled psychotherapist and/or support group.
Postpartum psychosis is the rarest form of postpartum reaction but the most severe, affecting 1-2 per cent of the postpartum population.
Symptoms usually appear within the first three weeks after the birth and are very exaggerated. There may be a loss of reality, delusions or hallucinations, extreme mood swings and abnormal behaviour. This is a serious emergency situation that requires immediate medical/psychological intervention.
General Considerations: The new mother can receive her much-needed postpartum massage therapy as soon as she wants to.
The massage therapist should proceed with a few precautions and with specific goals for immediate and long-term postpartum care.
Ideally, mom should come to her appointment by herself so she can relax and enjoy her massage without distractions. Side-lying or seated positioning is usually advised for those women who had a C-section or are experiencing soreness at the epidural site. Support her with extra pillows where she needs them, such as breasts and abdomen.
I strongly urge any practitioners interested in massaging expectant and new mothers to take a certified pregnancy/postpartum massage course before working with these women.
I trust you will find, as I have, that this is some of the most exciting and fulfilling work you can do.
Elaine Stillerman, LMT, is the author of MotherMassage: A Handbook For Relieving the Discomforts of Pregnancy (Dell, 1992) and The Encyclopedia of Bodywork (Facts On-File, 1996. Licensed in New York since 1978, she has been massaging pregnant and postpartum women since 1980 and is the developer and instructor of the nationally approved course MotherMassage: Massage During Pregnancy. She is the proud mother of Luke.