Features Practice Technique
The Pregnant Pelvis

Studies conducted in Sweden reported that 48 and 56 per cent 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 per cent 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.¹

A 1994 survey of prenatal massage therapists collaborated these findings, citing relief from pregnancy aches and pains as a primary motivator for their clients seeking therapy.²

Back and pelvic pain in pregnancy is the result of the woman’s changing 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; and referred pain from uterine ligaments.³

Prenatal Posture And Structural Integrity
The shift in centre 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, allowing the uterus to rest forward against the abdominal walls. This misalignment increases the lumbar curvature stretching and weakening  all of the abdominal muscles.

A baby’s left or right side position preference can overburden the favoured side of the mother’s back. Some women develop temporary or permanent scoliosis from fetal positioning preferences.

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 shift forward anterior as she compensates by leaning her upper ribcage more posteriorly her pectoral girdle sinks into forward rotation.

The growing anterior weight also creates a cascade of postural reactions throughout the pregnant woman’s body. Her posterior musculature becomes fatigued, tight, and fibrotic, and posterior trigger points flourish.

The external rotation of the hip joints  along with the loss of iliopsoas function in walking results in the characteristic pregnancy gait.

She will also hyperextend her knees in reaction to change in centre of balance and weight, causing calf cramping and collapse of the medial arches of her feet.⁴

Further, a baby’s left or right side position preference can overburden the favoured side of the mother’s back. Some women develop temporary or permanent scoliosis from fetal positioning preferences.

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 also strained and compressed.

The greatest impact is felt in the intervertebral and facet joints, particularly in the lumbar spine; lumbosacral joint; sacroiliac joints; pubis symphysis; and hip joints.

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 Achiness in the centre of the sacral and lumbar areas often indicates strain and compression of the lumbosacral joint.

The pelvic junction of the pubic bones, the symphysis pubis, is vulnerable to horizontal sheering strains that are excruciating when one side of the pelvis is elevated or depressed.

Sharp, stabbing pain in the centre 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

HORMONAL INFLUENCES ON BACK AND PELVIC PAIN
As early as the 10th 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.

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 supportive ligaments, which are formed of thickened external connective tissue of the uterus, 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 when strained refer low back, buttock and sciatic-like pain referral pattern, especially in the sixth month, and often disappearing in months seven or eight;

Round ligament strain creates a diagonal pain from the superior uterus to the groin; usually one-sided, depending on fetal position; sometimes as extensively felt in the vulvar and upper thigh fascia;

Sacrouterine ligament strain is experienced as achiness just lateral to or beneath the sacrum, occurring especially in the 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.⁷

Prenatal Massage Therapy For Lumbar & Pelvic Pain
Thankfully, 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 implicated in the changing weight and posture to 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.

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 & Pelvic Massage Therapy
Pain level: It is essential, to never exceed a pregnant client’s experience of pleasure on the borderline of pain. Maintaining a pleasure/pain level assures that neither the mother nor the fetus is stimulated to sympathetic arousal. Pain activates adrenal production of the hormones that elevate blood pressure, heart and respiratory rate and 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: Another aspect of pregnancy massage therapy for adaptation is insuring that application of any technique will neither increase intrauterine pressure, decrease blood flow to the uterus, or create localized, deep pressure into the abdomen.

Short-term increased intrauterine pressure is probably not a significant safety concern in most normal, uncomplicated, low risk pregnancies. However, it is of particular relevance when there are abnormalities in placental attachment or function, or higher risk of such conditions; 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 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 labour, or placental dysfunctions.¹²

It is necessary to 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.

Positioning for Safety And Comfort:
The most appropriate positioning guidelines are discussed at length in another article in this edition, Positioning Concerns for Prenatal Massage Therapy. In light of the implications of pre-natal physiology prone positioning should be eliminated after the first 13 weeks, regardless of personal preference and prone positioning supports, earlier if multiples or large for gestational situations.

Supine positioning also involves safety considerations when working with pregnancy related sources of lumbar and pelvic pain.

In the second trimester (weeks 14-22) a small pillow support under the right torso will shift the weight of the uterus to the left side and off the inferior vena cava, decreasing risk of supine hypotensive syndrome.¹³

After 22 weeks, elevate the entire torso to a semi-reclined angle of at least 45 degrees and provide firm
supports under the knees and lower legs. When women are advised by their healthcare provider to never
lie on their backs, always observe these restrictions. Well-supported in a side lying position is the safest, most posturally neutral and 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.

Blood clots:
In pregnancy blood clotting capacity escalates four to five times higher than non-pregnant levels.

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

The formation of clots is greatest in the veins where blood is most stagnant – the iliac, femoral, and saphenous veins¹⁵ – due in part to the restriction of iliac and femoral venous return by uterine weight on these vessels and to hormonal influences on the vascular smooth muscle and 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. 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.

Ligament laxity precautions: 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.

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.

High Risk Pregnancies: In 80 per cent of pregnancies the baby grows healthily inutero for 38-40 weeks well supported by the functions of the mother’s body and the placenta.

In the other 20 per cent, situations arise which threaten the viability of the pregnancy, putting the mother and baby at higher risk for miscarriage or premature delivery. Cautious therapists will refer women in high risk situations to a specialized prenatal massage therapist if not comprehensively
educated in this work.

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.

However, ongoing communication and evaluation in conjunction with the woman’s primary care provider and further considerations for treatment and positioning are required in the treatment of high risk situations.

Conclusions:
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.¹⁶

Footnotes:

1. Unpublished survey of graduates of C. Osborne-Sheets former pregnancy training program,1994.
2. Ostgaard, H.C., Andersson, G.B.J., et al. Prevalence of back pain in pregnancy, Spine 17, 1: 53-55, January, 1992.
3.  Artal, R., Friedman, M.J., McNitt-Gray, J.L. Orthopedic problems in pregnancy, The Physician and Sportsmedicine, 18: p. 93-105, 1990.
4. Noble, Elizabeth, P.T. Essential Exercises for the Childbearing Year. Fourth edition, p. 20, 225. Harwich, MA, New life Images, 1995.
5. Ibid., p. 54.
6. Ibid., p. 53.
7. Ostgaard, p. 54.
8. Osborne-Sheets, Carole. Deep Tissue Sculpting: A Technical and Artistic Manual for Therapeutic Bodywork Practitioners. Second Edition, p. 96-99 Body Therapy Associates, 2002.
9. Noble, p. 81-146.
10. Gorsuch, R. and Key, M. Abnormalities of pregnancy as a function of anxiety and life stress, Psychosomatic Medicine 36: p. 353, 1974.
11. Catz, Charlotte. Prevention of embryonic, fetal, and perinatal disease. HEW, p. 123, 1976.
12. Gilbert, Elizabeth Stepp and Harmon, Judith Smith. Manual of High Risk Pregnancy and Delivery, p.265, 416. St. Louis Missouri, Mosby – Yearbook, Inc., 1993.
13. Ibid., p. 40.
14. Ibid., p. 7.
15. Alexander, Doug. Deep vein thrombosis and massage therapy, Massage Therapy Journal 32, 3: p. 56, 1993.
16. Pre- and Perinatal Massage Therapy workshops taught by the author are offered throughout North America. For more information contact:Body Therapy Associates at www.bodytherapyassociates.com

Carole Osborne-Sheets is a well respected pre and perinatal massage therapy specialist and the  author and developer of the book and program “Pre and Perinatal Massage Therapy.” Linda Hickey, also a pre and perinatal massage therapist in Calgary, Alberta is a colleague of Carole’s and instructor with her program.