Please note

The information in this book is provided to you for information and education
purposes only. The author, creator and publisher of this guide are not doctors. The
information contained within this publication should not be construed as medical
advice.

The advice and strategies in this publication may not be suitable for your situation.
Always consult with a qualified health professional when dealing with any medical
condition or program involving your health and wellbeing. Information about health
cannot be generalized to the population at large. Keep in mind you should consult
with a qualified physician when embarking on any program. Neither the publisher
nor author shall be liable for any loss or damages resulting from the use of this
guide.

All links are for information purposes only and are not warranted for content,
accuracy or any other implied or explicit purpose.

No part of this publication may be reproduced, stored in a retrieval system, or

transmitted in any form or by any means, electronic, mechanical, photocopying,
recording, scanning, or otherwise, except as permitted under Sections 107 or 108
of the 1976 United States Copyright Act, without the prior written permission of the
author or publisher.

Written by: Eric Brown

Publisher: BodyworkBiz

© 2007 BodyworkBiz
309-480 Oriole Parkway
Toronto, ON M5P 2H8
CANADA
www.bodyworkbiz.com

© 2007 http://www.bodyworkbiz.com 2
Table of Contents
Introduction .................................................................................... 5
Overview of changes through pregnancy..................................... 6
General guidelines for massage therapy...................................... 6
Stages of pregnancy......................................................................... 11
1st trimester .......................................................................... 11
physiological changes ..................................................... 11
common 1st trimester problems and their management ....... 11
fatigue ................................................................. 11
morning sickness................................................... 12
breast changes ..................................................... 13
constipation.......................................................... 13
headaches............................................................ 14
2nd trimester ......................................................................... 16
physiological changes ..................................................... 16
common 2nd trimester problems and their management ...... 16
stretch marks ....................................................... 16
other skin changes ................................................ 17
backache ............................................................. 18
blood pressure ...................................................... 19
carpal tunnel syndrome .......................................... 20
3rd trimester .......................................................................... 22
physiological changes ..................................................... 22
common 3rd trimester problems and their management ....... 23
discomfort at ribs, heartburn, indigestion,
shortness of breath................................................ 23
incontinence ......................................................... 24
edema of ankles and feet........................................ 24
preparation of breasts for feeding ..................................... 25
preparation of perineum .................................................. 28
high risk or problem pregnancy ........................................ 30
Exercise during pregnancy: General guidelines ..................................... 33

© 2007 http://www.bodyworkbiz.com 3
Hydrotherapy during pregnancy: General guidelines .............................. 38
Stress management through pregnancy .............................................. 39
Labor and delivery ........................................................................... 42
overview................................................................................ 42
stage 1.................................................................................. 45
stage 2.................................................................................. 48
stage 3.................................................................................. 49
Postpartum ..................................................................................... 51
Summary ....................................................................................... 52
About the Author ............................................................................. 53

© 2007 http://www.bodyworkbiz.com 4
Introduction
Many people know me as a marketing expert, but what many people don’t
know is that I’ve taught over a thousand massage thereapists in
comprehensive 2,200-hour college massage programs in Canada and
thousands more in workshops across North America.

Some time ago a large American publisher asked me to participate in the

writing of a research-based massage textbook. This report is an unpublished
chapter on Pregnancy Massage that I thought I’d share.

The process of pregnancy and childbirth creates some unique opportunities

for the massage therapist. This comprehensive report looks at the role
massage can play in assisting a woman through this time. It must be
remembered that pregnancy is not a pathological condition, so the focus of
treatment is primarily on maintaining wellness and preparing the woman's
body for the rigors of childbirth.

This report outlines the normal process of pregnancy and discusses how the
massage therapist can assist the client with musculoskeletal complaints and
other common problems. It also examines the use of exercise, hydrotherapy,
and relaxation. Because massage therapists may have the opportunity to
assist a client through childbirth, the role of the massage therapist through
this process is also explored.

Enjoy,
Eric Brown, MT
http://www.bodyworkbiz.com

© 2007 http://www.bodyworkbiz.com 5
Pregnancy and the massage therapist

Overview of changes through pregnancy

A woman's body undergoes significant changes during the 40 weeks of

pregnancy. These physical changes are the result of hormonal changes as
well as the growth of the fetus and the resulting metabolic demands. The
external manifestations only give a hint of the profound internal
transformation which is taking place. Consider just a few of these (Kisner and
Colby, 1990):

• the uterus increases 5-6 times in size and about 20 times in

weight by the end of the pregnancy
• maternal blood volume gradually increases 35 to 50 percent
• cardiac output increases 30 to 60 percent
• there is a 15 to 20 percent increase in oxygen consumption and the
respiratory rate increases to meet this need

The psychological and emotional impact of pregnancy and motherhood may

be equally dramatic. The woman will need to adjust to her changing role in
the family, especially in regards to her relationship with her mate. She may
also have to cope with a changing self-image, the uncertainty of a new
experience, and the financial and emotional difficulties associated with
quitting a job or taking maternity leave.

General guidelines for massage therapy

Massage is used to help the pregnant woman feel more comfortable

throughout the pregnancy. This is accomplished primarily by managing
common musculoskeletal complaints and other symptoms. Because you will

© 2007 http://www.bodyworkbiz.com 6
often have ongoing contact with the prospective mother, you can develop a
long term treatment plan and play an important role in preventing potential
problems from occurring. This can include helping to resolve "weak spots"
such as old injuries or surgeries, optimizing biomechanics to prevent
posture-related dysfunction, and preparing your client's body for labor by
assisting her in keeping her body in top physical condition. Since pregnancy
can also be a very emotional and stressful period in a woman's life,
emotional support and relaxation may be vital elements in your treatment
strategy.

Because you may have ongoing contact, it is important to be aware of the

normal changes that take place during pregnancy so that you can refer your
client to her medical practitioner when unusual signs and symptoms occur.
Your role will also be that of educator, answering her questions and offering
professional advice when necessary.

It is important to be sensitive to your client's feelings and needs. Because the

process of pregnancy can be stressful she may experience a wide range of
emotions. Do not assume that this is always a joyful experience for the
mother-to-be. Also bear in mind that her desire for touch or massage will
vary throughout pregnancy and labor. Make no assumptions and
communicate clearly and openly.

Pregnancy is a normal physiological process and not a pathology. Most

pregnant women are not physically fragile so there is no need for an overly
cautious approach to massage.

Positioning is not usually problematic until the fifth or sixth month of

pregnancy. Until then, your pregnant client can be positioned in any way that
a non-pregnant client would be. After that point in the pregnancy, the prone
position is usually uncomfortable because of the size of the abdomen and
therefore should not be used. Many therapists will also avoid the supine

© 2007 http://www.bodyworkbiz.com 7
position in the second half of the pregnancy because in this position the
weight of the fetus compresses the inferior vena cava (a major vein which
returns blood to the heart) and to a lesser extent the aorta. As she becomes
larger, the supine position may also put undue stress on the spine. However,
these are not usually serious concerns for the short periods of time that the
woman will be on her back for the massage. Elicit feedback from your client
frequently and use her comfort level as a guide. You will generally find that
many women will begin to feel uncomfortable after 10 or 15 minutes on their
back. Towards the end of term, they may not feel comfortable lying on their
backs at all.

Figure 1. Find positions for your client that are comfortable for her while
allowing you good access to the areas of the body you wish to massage.
Note the use of pillows to support the client in a sidelying, semiprone, and
sitting position.

© 2007 http://www.bodyworkbiz.com 8
You may have to be creative in finding a position which is both comfortable
for the woman and which allows you good access to the part of her body you
wish to work on. Try sidelying, semiprone, sitting in a chair, or sitting with
legs elevated. Illustration below shows some of these. Make generous use of
pillows for support. For example,if you are using a sidelying position use
pillows under her head, under her abdomen, and between her legs.
Oftentimes, the massage will have to be shortened or the client may require
frequent changes of position.

Avoid any positioning or technique that involves strong compression to the

abdomen. Deep abdominal massage performed over the fetus should be
avoided through all stages of pregnancy. (See Constipation and Discomfort
at Ribs sections for more specific guidelines.)

The hormones estrogen and relaxin cause ligaments (and other connective
tissue structures) to relax. This allows for greater movement at the sacroiliac
joints and the symphysis pubis which aids the passage of the baby through
the birth canal. However, all joints are affected by this generalized laxity and
as a result some modifications will be necessary in treating your client. No
aggressive joint mobilization techniques should be performed. As well,
positioning and handling of the joints must ensure that they are not stressed
excessively. Also be aware that sacroiliac joint dysfunction and irritation of
the symphysis pubis are seen frequently in pregnant women.

The use of medications, both prescription and non-prescription, is generally

contraindicated during pregnancy. Drugs are easily passed to the fetus
through the placental circulation and can often have a negative impact on
fetal health. Even in the postpartum period, some medications can be passed
on to the infant through breast milk (Rylance and Plant, 1991). Aspirin, for
example, which is commonly used for numerous musculoskeletal problems, is
passed to the infant through breast milk and if present in sufficient quantities
can cause salicylism or metabolic acidosis. When appropriate, alternative

© 2007 http://www.bodyworkbiz.com 9
treatments such as massage, hydrotherapy, or therapeutic exercise should
be explored. Bear in mind, however, that as a massage therapist it is beyond
our scope to advise clients regarding their medication. Any decisions to
forego drug treatment must be made by the woman in consultation with her
attending physician.

© 2007 http://www.bodyworkbiz.com 10
Stages of pregnancy

1st trimester

physiological changes

The fetus develops from a single cell to become very human looking in these
first three months. At the end of the third month the fetus is about three
inches long and weighs about half an ounce. The woman will start to feel that
her clothes are getting a little tight around the waist and bustline. The
abdomen may appear slightly enlarged.

Because of significant hormonal changes that take place, the woman may
experience a variety of symptoms in the first trimester. The presence and
degree of these symptoms varies greatly from individual to individual. Some
women will go through their pregnancies virtually symptom free, whereas for
others the symptoms can be quite debilitating. The most common symptom
of the first trimester is fatigue. Also experienced are nausea, heartburn,
indigestion, bloating, and constipation, as well as heat, tenderness, and
heaviness of the breasts.

common 1st trimester problems and their management

fatigue

Given the extent of bodily changes which occur in pregnancy, it is not

surprising that fatigue is the most common complaint throughout pregnancy.
This is particularly true in the first trimester as the mother's body
manufactures the baby's support system. However, fatigue is extremely
common in the last trimester as well. It is essential that the woman takes
time for rest and relaxation on a daily basis. Many women find that moderate

© 2007 http://www.bodyworkbiz.com 11
exercise helps maintain their energy level. Extra sleep is almost always
necessary. During these periods, relaxation should be a key component of
the massage.

morning sickness

Morning sickness is the nausea and vomiting that many women experience
during pregnancy. Although it is called morning sickness, it can occur at any
time during the day or night. It has a variety of physical and psychological
causes. Physical causes include high levels of certain hormones in the blood,
the rapid stretching of the uterine muscles, and the relaxation of the muscles
of the digestive tract. These physical occurrences are common to every
pregnancy but not all women suffer from nausea. In fact, only about one
third to one half of all pregnant women experience any morning sickness.
Because of this, it is thought that stress may play an important role.

There are numerous research findings that support this idea. For one thing,
morning sickness is virtually unknown in most primitive cultures. For
another, women who suffer hyperemesis (excessive vomiting) will recover
quickly if placed in a relatively tranquil environment away from their families
and the problems of day-to-day living. Also interesting is the fact that some
women are more likely to experience morning sickness with unwanted,
unplanned, or first pregnancies than in subsequent pregnancies, or planned
pregnancies (Eisenberg et al, 1991).

Because stress appears to play a significant role in morning sickness, women

should take time for relaxation and reduce daily stresses as much as
possible. Massage has been found to reduce the incidence of nausea (Ueda,
1993) and vomiting in other situations, for example, persons undergoing
chemotherapy (Scott and others, 1983). The mechanism behind this seems
to be relaxation (Clarke 87), so that regular massage with a focus on
relaxation would likely have the same effect in cases of morning sickness.

© 2007 http://www.bodyworkbiz.com 12
Additional suggestions to reduce morning sickness include: eating frequent
small meals; avoiding an empty stomach; taking food to bed so that a snack
can be had before getting up in the morning; and avoiding foods or odors
that cause queasiness.

breast changes

The breasts will undergo a number of significant changes during pregnancy.

These changes are usually more pronounced during the first pregnancy. The
breasts will grow in size in preparation for providing the baby with food. They
may feel hot, swollen, and tender to the touch, but this usually does not last
beyond the third or fourth month. The areola (the pigmented area around
the nipple) will spread and darken and small bumps may appear as the
sebaceous (sweat) glands enlarge. As well, veins may become more
prominent throughout the breasts. These are normal changes and the
breasts will return to their normal state after nursing is discontinued.
Because of the extreme tenderness of the breasts, breast masage is best
avoided during the first trimentster. Even the lightest touch can be very
uncomfortable. However, a cold hydrotherapy application to the breasts such
as a cold compress or a cold towel wrap would be indicated. This will assist in
minimizing the tenderness and swelling.

constipation

Constipation is a common complaint of pregnancy. Gentle massage to the

abdomen, using techniques such as effleurage and stroking, may help relieve
constipation and poses no danger to the fetus. Stimulation of the skin over
the abdomen is thought to stimulate movement of the intestines (peristalsis)
through the activation of a cutaneous reflex. Rocking or passive range of
motion to the torso and hips may also be beneficial.

© 2007 http://www.bodyworkbiz.com 13
However, aggressive or deep abdominal massage which is often used to
relieve constipation in non-pregnant clients should not be employed as this
may pose a significant risk to the health of the fetus. Vigorous abdominal
massage has been associated with a high incidence of still births (Becroft and
Gunn, 1985). In some cases, abortionists have used deep abdominal
compression to terminate a pregnancy (Maiai, 1985).

Also beneficial is regular exercise, increased fluid intake, the consumption of

whole foods including whole grains and whole grain products, legumes, fresh
or dried fruits, and vegetables. If constipation is prolonged, a medical doctor
should be consulted. Likewise, bouts of diarrhea should be investigated
promptly.

headaches

Headaches tend to become more frequent in pregnancy. They are most

commonly the result of hormonal changes, fatigue, hunger, and stress. Non-
drug treatment is by the far the best management approach to headaches.
Aspirin and ibuprofen (Advil, Nuprin, Medipren) may interfere with fetal
growth and cause other problems including prolonged pregnancy and labor,
and increased risk of hemorrhage. Although acetaminophen (Tylenol, Datril,
Anacin III) does not appear to pose any problems, it should not be taken
indiscriminately (Eisenberg). All non-prescription drugs should only be used
under the guidance of a physician.

Massage has proven to be extremely useful in the management of headaches

(Puustjarvi et al., 1990) and should be considered a preferred treatment
choice. Even migraine headaches can be markedly reduced with relaxation
therapy in pregnant women (Hickling, 1990).

Other headache prevention measures may include taking regular time for
relaxation, getting adequate sleep, stretching muscles that are tense or that

© 2007 http://www.bodyworkbiz.com 14
contain trigger points, eating regular and frequent meals, and maintaining
good posture. If a headache is unusually severe and lasts longer than several
hours, or if the headache is accompanied by fever, visual disturbances, and
puffiness in the hands or face, the woman should consult her doctor
immediately and should not be massaged.

© 2007 http://www.bodyworkbiz.com 15
 2nd trimester

physiological changes

By the end of the sixth month, the fetus likely has grown to over a foot in
length and weighs close to two pounds. Its body systems are sufficiently
developed so that if the fetus is born it could possibly survive with intensive
care. The movements of the fetus will be forceful enough to be felt by the
mother.

The breasts and the abdomen will enlarge significantly in this trimester. The
weight gain and change in posture will likely cause the prospective mother to
feel some aches and pains, such as back pain, or tightness and achiness in
the lower abdomen. The nausea and extreme tenderness of the breasts
experienced earlier usually subside. The woman may notice a number of skin
changes including stretch marks, more visible veins, and pigment changes in
some places. Minor swelling may occur in the feet and hands and she may
experience occasional faintness or dizziness.

During this trimester, the pregnant woman may start to experience

contractions of her uterus. These contractions which are usually irregular and
which often stop with a change of position or activity are called Braxton-
Hicks contractions. They prepare the uterus for labor and will occur more
frequently towards the end of the pregnancy.

common 2nd trimester problems and their management

stretch marks

Most Caucasian women -- about 90% -- will develop stretch marks. They
occur less frequently in black and Asian women (Parmley and O'Brien, 1990).
These marks, also known as striae gravidarum, are pink or reddish streaks

© 2007 http://www.bodyworkbiz.com 16
which are slightly indented and oftentimes itchy. They are most common on
the abdomen, breasts, and hips.

As the name implies they are caused by stretching of the skin which occurs
with rapid growth or weight gain. With the stretching of the abdomen, the
woman may experience itching and dryness of the abdominal skin. Stretch
marks are more common in heavier women and less common when
birthweight is low (Davey, 1972). Hormonal changes may also contribute to
their development. Within months after delivery they fade to become a white
color.
Abdominal massage with oil has been found to be associated with fewer
stretch marks (Davey 1972; Wierrani et al, 1992), although the reason for
this is not clear. It is possible that massage of the abdomen stretches the
skin and subcutaneous adherences in a slow and gradual manner, thus
minimizing the possibility of stretch marks. Skin rolling, used in the first and
second trimesters before the skin becomes too taut, would be a particularly
appropriate technique.

other skin changes

Changes in skin pigmentation are the most common type of skin change and
are experienced by over 90% of pregnant women (Parmley and O'Brien,
1990). The areas most commonly affected are the thighs, perianal and labial
skin, the abdominal midline, the areolas, and the face. The darkened areas of
skin usually return to normal or near normal in the postpartum period.

Skin tags, small growths of skin, often start to appear in the second
trimester. They occur on the sides of the neck, under the arms, and below
the breasts. They are harmless, and like the pigmented skin areas, usually
disappear postpartum. About two thirds of white women and one third of
black women experience vascular changes which give rise to red, blotchy,

© 2007 http://www.bodyworkbiz.com 17
and sometimes itchy marks on the palms. Vascular sensitivity to cold can be
a problem for some pregnant women.

These vascular changes usually vanish within two weeks after birth. All the
skin changes mentioned here are normal aspects of pregnancy. If you notice
changes or growths not described above be sure to send your client for
appropriate assessment.

backache

Many postural changes occur in pregnancy, largely in response to the weight

gain that occurs in the breasts and abdomen. This causes an anterior shift of
the center of gravity and generally results in increased lordosis of the cervical
and lumbar spine, protraction of the shoulders, and other compensatory
changes through the lower body.

Add to these postural stresses a generalized laxity of the joints caused by the
hormone relaxin and it is easy to see why about 50% of pregnant women
experience some form of back pain at some point in the pregnancy (Mower,
1993). The pain may result simply from fatigue and stress to the lumbar
musculature, or it may reflect lumbar or sacroiliac joint dysfunction.

Massage can help by minimizing muscular imbalances, relaxing tight

muscles, improving blood flow through muscles, and by evoking general
feelings of relaxation. A massage therapist with appropriate training may
assess and treat joint dysfunction with joint mobilization techniques.
Otherwise, if joint dysfunction is suspected, a referral to a chiropractor,
physiotherapist, or osteopath would be advisable. The massage therapist can
help minimize episodes of back pain by educating the client regarding her
posture and developing a home exercise program to help correct muscle
imbalances (see Exercise and Pregnancy below).

© 2007 http://www.bodyworkbiz.com 18
As well, the client can be given some basic advice regarding activities of daily
living. For example, you can suggest the use of good biomechanics when
lifting, sleeping on a firm mattress, placing a pillow between the knees when
lying on the side, wearing low heels, avoiding long periods of standing or
sitting, placing one foot on a small step if standing for any length of time,
and placing a lumbar roll or small pillow in the small of the back when sitting.

blood pressure

Blood pressure changes throughout pregnancy. It normally decreases in the

first trimester, reaches its lowest point in the second trimester, and gradually
rises in the third trimester [reference]. The downward fluctuations are likely
the result of lowered peripheral vascular resistance caused by a number of
hormones. The decreased peripheral resistance may result in reduced blood
flow to the brain and cause temporary lightheadedness or dizziness,
especially when standing from a lying position. These changes are generally
not a concern for the massage therapist, although you may wish to assist the
woman in getting up from the table or advise her to get up slowly and sit
briefly before standing.

High blood pressure (hypertension) occurs in about 10% of all pregnancies

(Porth). The cause is usually unknown, although it is postulated that stress
and anxiety may play a significant role, especially during a first pregnancy.
For this reason, researchers studied regular relaxation in hypertensive
pregnant women and found that relaxation decreased blood pressure
significantly and decreased the rate of hospital admittance (Little et al,
1984). Because massage evokes a relaxation response similar to that
obtained with relaxation exercises, it will likely have a similar effect. Although
in most cases high blood pressure is not a concern, it can in some cases be
dangerous for both the mother and the fetus. For this reason, blood pressure
should be monitored by the massage therapist on an ongoing basis. The
therapist should also watch for any signs of pre-eclampsia. Pre-eclampsia,

© 2007 http://www.bodyworkbiz.com 19
also known as pregnancy induced hypertension, can be a fatal condition for
both the fetus and the mother. It usually develops after the 20th week of
pregnancy and is recognized by a sudden or marked increase in blood
pressure, sudden weight gain not associated with food intake, and severe
edema of the hands, face, and ankles. Symptoms in the later stages include
blurred vision, headaches, scanty urine output, confusion, and severe
abdominal pain. Pre-eclampsia occurs primarily in first pregnancies, and in
pregnancies in women with chronic high blood pressure, diabetes, or kidney
disease. The massage therapist should monitor blood pressure carefully for
women with these conditions. If there is any reason to suspect that your
client may have pre-eclampsia do not massage her, but make sure that she
gets immediate medical attention.

carpal tunnel syndrome

The vascular changes which cause swelling in pregnant women often give
rise to carpal tunnel syndrome. Fluid accumulation in the wrists and hands is
aggravated by the effects of gravity. As the fluid builds in the narrow carpal
tunnel of the wrist, the median nerve becomes compressed and the woman
may experience pain or numbness in the wrist and hand. The condition can
usually be effectively managed with massage. Focus on effleurage and
petrissage to the arms to encourage better venous and lymph return. Try
using petrissage techniques and joint mobilization techniques to stretch the
fibrous connective tissue around the wrist. If the pain wakes your client at
night have her raise the arm and shake it vigorously. If the pain becomes
sufficiently uncomfortable, her medical practitioner may prescribe the use of
wrist splints. Drug therapy for the condition is not usually indicated in
pregnancy. Even without treatment, the symptoms of carpal tunnel
syndrome usually resolve after delivery.

© 2007 http://www.bodyworkbiz.com 20
Other compression syndromes often occur with pregnancy, usually as the
result of altered biomechanics. These include thoracic outlet syndrome and
piriformis syndrome.

© 2007 http://www.bodyworkbiz.com 21
 3rd trimester

physiological changes

The fetus continues to grow and begins to deposit fat in its body. The lungs
mature through this trimester. At term the baby is about 20 inches long and
weighs about 8 pounds on average. Because the growing fetus is confined in
a very small space, fetal movements may diminish as it increases in size and
the mother's abdominal contents will be compressed leading to many of the
symptoms described below. Typically, the mother's physical discomfort
increases and her abdomen begins to feel hard and tight.

Figure 2. The fetus

which probably weighs
about eight pounds by
the end of the ninth
month fills the
abdominal cavity to
capacity. This
compresses the
abdominal organs
causing a variety of
odd symptoms.

© 2007 http://www.bodyworkbiz.com 22
The mother's breasts begin to produce colostrum which may occasionally
leak. Colostrum is a thin yellowish fluid that is high in protein and calories. It
contains numerous antibodies and lymphocytes which confer the immunity of
the mother to the baby.

common 3rd trimester problems and their management

discomfort at ribs, heartburn, indigestion, shortness of breath

These seemingly unrelated symptoms are all caused by the growing fetus
and expanding uterus. Women often report ribcage discomfort. It may be a
general feeling of tightness, or it may feel as though the baby actually has a
foot between the ribs. Massage of the intercostal spaces and at the costal
borders may help relieve some of the discomfort by stretching and relaxing
the intercostal and abdominal muscles. If the baby's position is causing the
discomfort, advise the mother to move or change her position. Doing so may
alter the position of the fetus somewhat. For example, it may be useful to
have the woman go on her hands and knees and tilt the pelvis anteriorly
(sway back) and posteriorly (arched back) several times. Although heartburn
and indigestion may be partially caused by hormonal changes, they are
exacerbated by the pressure of the fetus on the stomach and intestines.
Likewise shortness of breath results from an upward pressure of the fetus on
the diaphragm. These symptoms will be aggravated if the woman lies in a
supine position for any length of time. In all these cases, massage to the
intercostal and abdominal muscles as outlined above may be helpful. In
addition, it may be helpful for the woman to eat smaller, more frequent
meals. She should wear loose fitting clothes around the waist, and when
bending, should bend at the knees instead of the waist. Raising the head of
the bed when sleeping at night may also be useful.

© 2007 http://www.bodyworkbiz.com 23
 incontinence

Incontinence (leaking urine), like the symptoms described above, is often the
result of pressure of the growing fetus on the bladder. It is most likely to
occur if the pelvic muscles (perineum) are weak. Most often, the incontinence
occurs when the woman coughs or sneezes. This is referred to as stress
incontinence. An important tool in managing this problem is Kegel's exercise
which should be started as early in the pregnancy as possible (see Exercise
during pregnancy section). Kegel's exercise may not only help control stress
incontinence during pregnancy, but will also prepare the perineum for
delivery and minimize the incidence of incontinence in the postpartum period.

edema of ankles and feet

Edema of the ankles and feet occurs in about 75% of pregnant women
(Eisenberg, 1991). If the swelling is mild and is not accompanied by signs
and symptoms suggesting pre-eclampsia, it is normal. If the swelling is
uncomfortable or bothersome, it can be managed with a self care routine
that includes elevating the legs or lying down occasionally, wearing
comfortable shoes, and avoiding elastic top socks or stockings. Some
hydrotherapy applications may also be effective. Try either a cold or
contrasting bath for the lower leg, moderating the temperatures if necessary.
The doctor may suggest support hose which are put on before getting up in
the morning.

Diuretic drugs are generally contraindicated through pregnancy, primarily

because of possible side effects to the fetus. Massage, on the other hand, is
safe and extremely effective at decreasing local edema. In this case elevate
the woman's legs as much as possible and use effleurage and petrissage
manipulations in a centripetal direction. Manual lymph drainage techniques
and passive range of motion to the hips, knees, and ankles will also be

© 2007 http://www.bodyworkbiz.com 24
useful. The same techniques can also be used to reduce edema of the hands
and arms.

Massage has also been shown to be useful in the treatment of more

generalized types of edema during pregnancy that are the result of kidney
disease (Kaaja and Tiula, 1989).

preparation of breasts for feeding

Some women report nipple pain and breast engorgement while nursing. This
is a frequently cited reason for discontinuing breastfeeding in the early
postpartum period since pain limits suckling time and inhibits the let-down
reflex, resulting in poor milk flow. Many experts say that this can largely be
avoided by proper positioning of the baby at the breast when nursing, and by
frequent feedings. However, these problems may also be alleviated by the
use of breast massage and nipple conditioning in the latter half of the 3rd
trimester (Storr, 1988). These techniques are simple and the mother can be
taught to use them on a daily basis.

Note that it would not be appropriate for a massage therapist to massage the
nipple or areola. The conditioning techniques described below are for the
woman to perform as part of her self care regime. If necessary, refer the
client to her medical doctor or a lactation consultant for instruction or advice.

Conditioning the nipple results in toughened and thickened skin that may
minimize pain and nipple damage once breastfeeding begins (Atkinson,
1979; Storr,1988). This can be achieved by exposing the nipples to gentle
friction and airing, for example allowing the nipples to rub against outer
clothing for a few hours daily by removing the bra occasionally if support is
not needed. The expectant mother may also rub the nipples for about 15
seconds with a terry cloth towel daily.

© 2007 http://www.bodyworkbiz.com 25
Some conditioning techniques will break down adhesions at the base of the
nipple thus making the nipple more protractile so that it can be more easily
grasped by the baby. One technique which is often used by expectant
mothers involves a gentle rolling of the nipple between the thumb and first
finger while applying gentle traction to the nipple. This is done for two
minutes and is performed twice daily.

Another self-massage technique which can be used to break down adhesions

at the base of the nipple and allow the nipple to protract normally is
illustrated here (Applebaum, 1970).

Figure 3. In about one third of

mothers, the nipple does not
protract normally, presumably
because of adhesions at the base
of the nipple. This self-massage
technique is effective in releasing
these adhesions. Have the woman
place her fingers or thumbs at the
areolar margin. Slowly and gently
drag the tissues outwards. Repeat
in a vertical plane. This can be
performed for several minutes
daily.

Breast massage is another

conditioning procedure. The client can begin this as a self-massage technique
(figure 4) six to eight weeks before the expected due date. When she
massages her breasts colostrum may or may not leak from the nipples. The
woman's body will continue to produce this substance so there is no reason
for concern when small amounts are expressed.

© 2007 http://www.bodyworkbiz.com 26
Breast massage, like massage for the nipple, is thought to decrease
adhesions around the nipple and improve protraction. The observation has
been made that regular prenatal breast massage will reduce breast
engorgement and improve milk flow (Iffrig, 1968).

In addition, it helps the woman feel more comfortable in handling her

breasts. This nipple and breast conditioning work should be started at least 6
weeks prior to delivery. Shorter periods of conditioning may not allow
sufficient time to achieve effective results (Brown and Hurlock, 1975).

Figure 4. Self-massage for

the breasts. Starting at the
base of the breast, place a
hand on each side of the
breast. With moderate and
even pressure around the
breast, slide the hands
toward the nipple. The
circle formed by the hands
will become smaller.
Continue until you reach
the areola. Repeat this
procedure 4-6 times.

There are some contraindications to nipple and breast conditioning.

Stimulation of the nipple causes the release of the hormone oxytocin which
produces strong uterine contractions. Although this effect is limited until the
woman reaches term, small amounts sufficient to cause some activity in the

© 2007 http://www.bodyworkbiz.com 27
uterus are still released with nipple stimulation during pregnancy. In fact,
there is an increasing interest in replacing injected oxcytocic drugs with
nipple stimulation during the last trimester to produce uterine activity for the
contraction stress test (a test of fetal health) (Curtis and Resnick 86; Curtis
and others 86; Chayen and others 85; Chayen and Kim 88; Gantes 85;
Huddleson 84; Lenke 84; MacMillan 84; Mashini 87).

Many of the researchers exploring the use of nipple stimulation for this test
express concern over the possibility of inducing labor or producing
contractions strong enough to compromise the baby's health. These concerns
are not warranted in normal pregnancies as nipple stimulation has not been
associated with an increased incidence of premature labor or detriment to
the baby's health. However, as a precautionary measure, nipple conditioning
and breast massage should not be used in the case where the woman has a
history of either miscarriage or premature birth, or is at high risk for preterm
labor because of premature rupture of the membranes. It should also be
avoided in cases of multiple gestation, incompetent cervix, known uterine
malformations, or third trimester bleeding (Freeman, 1982). (See High risk
or problem pregnancy section.)

preparation of perineum

The episiotomy has been a common surgical procedure since the 1920's.
Today, it is used in 80% to 90% of first births and about 50% of subsequent
births (Eisenberg et al., 1991). The operation involves surgically enlarging
the vaginal opening just before birth. An incision, beginning from the vagina
and carried either posteriorly towards the rectum or in a posterolateral
direction, is made to prevent laceration of the perineum (the area between
the vagina and rectum) - a common occurrence during childbirth.

Proponents say that episiotomy not only prevents damage to the perineal
muscles, but is also easier to repair than a ragged tear. In addition, it can

© 2007 http://www.bodyworkbiz.com 28
shorten the pushing stage (2nd stage) of labor which can be advantageous
at times when there is prolonged labor, maternal exhaustion, or fetal
distress. However, the benefits of routine episiotomy have been largely
presumed and not well researched (Bromberg, 1986).

Opponents of episiotomy say that the procedure is unnatural and largely

unnecessary. Like other surgical procedures, it carries certain risks. These
risks include blood loss, infection, complications of laceration, postpartum
pain, dyspareunia (pain with intercourse), and poor restoration of the
perineum (Varner,1986).

Numerous factors can affect the need for an episiotomy. Many of these
factors, such as fetal size, gestational age, pelvic structure, and labor
patterns, cannot be controlled. However, many other factors exist which can
be optimized. These include the woman's nutritional status, her pelvic floor
muscle tone, her ability to relax and to control pushing, the delivery position,
as well as the technique and skill of the birth attendant (Schrag, 1979).

Stretching of the vagina and perineum by a previous vaginal delivery is

probably the most widely recognized factor in increasing the ability of the
perineum to accommodate the fetus without tearing (Schrag, 1979). For this
reason daily perineal massage in late pregnancy is often suggested since it
stretches the perineal muscles and softens any scar tissue present from
previous trauma or surgery. Performing this massage is beyond our scope of
practice as massage therapists. However, it is a simple technique which can
be easily taught to the woman and her partner (see box 1).

With stretching or softening of the perineal tissues, the resistance to delivery

is decreased. This is supported by clinical observations and research. Studies
have found that perineal massage practiced daily for the last six weeks of
pregnancy decreases both the number of lacerations and the number of
episiotomies required (Avery, 1986; 1987). Lacerations and episiotomies

© 2007 http://www.bodyworkbiz.com 29
occurred in 48% of the women who practiced perineal massage, as opposed
to 77% of women who did not.

According to the participants in one study, perineal elasticity seemed to

increase most dramatically in the first 2 to 3 weeks of massage; this was
maintained but not significantly increased as the massage continued through
the remaining weeks. So it may be possible to start the perineal massage
closer than six weeks before the due date with similar results.

In addition to perineal massage, midwives and childbirth educators

recommend several other techniques to reduce the need for episiotomy.
These include use of the Kegel exercise, frequent squatting to condition the
perineum (Zacharin, 1977), hot compresses to the perineum during second
stage labor, and warm oil massage of the perineum during delivery.
However, even at birthing centers where these techniques are employed
regularly, between 15% and 25% of women have episiotomies, and 25% to
30% of the others tear badly enough to need repair (Eisenberg et al.,1991).

high risk or problem pregnancy

There are a number of conditions associated with pregnancy that place the
mother and fetus at a higher risk for harm during the pregnancy or birth.
These high risk or problem pregnancies can often be managed successfully
with careful monitoring and appropriate action by the woman's physician.
However, these conditions should be considered contraindications for full
body massage. Seek advice from the woman's physician before performing
any massage.

Here is a list of some conditions which could possibly be encountered:

• Preterm rupture of membranes: a rupture of the amniotic sac weeks

or months before the delivery date

© 2007 http://www.bodyworkbiz.com 30
 • Premature onset of labor: labor that begins after the 20th week and
before the 37th week
• Incompetent cervix: a cervix that dilates prematurely because of the
pressure of the fetus
• Placenta previa: a placenta which grows in the lower part of the uterus
and covers or touches the opening of the uterus
• Pregnancy related hypertension or pre-eclampsia: high blood pressure
related to pregnancy with no known cause. It is also called toxemia. -
Multiple gestation: multiple fetuses. Sometimes if there are three or
more fetuses the mother's body will not be able to support them all
and as a result the health of the fetuses or mother suffers
• Chronic medical conditions: including diabetes, epilepsy, hypertension,
multiple sclerosis, heart disease, and anemia

Besides these particular conditions, there are a variety of signs and

symptoms that indicate that there may be a problem with the pregnancy.
The massage therapist should be aware of these so that the woman can be
advised to seek medical counsel. It would not be advisable to massage any
woman with these symptoms until their cause has been investigated. They
include the following:

Bleeding: although vaginal bleeding during pregnancy occurs frequently and

does not necessarily indicate anything serious has happened, it may precede
miscarriage and should therefore be reported to the woman's physician.

• Abdominal pain: especially if the pain is sharp, intense, accompanied

by cramping, or continues for more than one day
• Severe nausea or vomiting
• Recurrent vomiting in the second or third trimester
• Sudden or unusual swelling or puffiness: especially if it appears in the
face

© 2007 http://www.bodyworkbiz.com 31
 • Severe headache that lasts for more than two or three hours. Visual
disturbances
• Fainting or dizziness
• Fever
• Sudden changes in weight: especially if the changes are not related to
food consumption
• Reduction in or altered fetal activity: more specifically radical
slowdowns or cessation of activity for more than 24 hours
• Sudden increases in blood pressure
• Intense depression
• Sharp or burning sacral pain: which is referred to as pre-sacral pain
may indicate a miscarriage

© 2007 http://www.bodyworkbiz.com 32
Exercise during pregnancy: General guidelines

It is common knowledge that moderate exercise through pregnancy is not

only safe (Work, 1989), but can be extremely beneficial for both the mother
and fetus. However, there are exceptions, and women, especially those with
high risk pregnancies, should get explicit guidelines from their medical
practitioner.

Having a baby is hard work. Keeping fit during pregnancy will reduce the
incidence of musculoskeletal complaints and keep energy levels high. The
work of childbirth will be easier and strains and cramping will be minimized.
Being fit will also assist the mother in recovering faster after birth. The
pregnant woman should be encouraged to continue exercising, or if she has
been inactive and is unfit, to begin a gentle and progressive exercise
program which addresses all three components of fitness: cardiovascular or
aerobic fitness, strength, and flexibility. Monitor your clients' progress and
take care that the type and degree of activity is appropriate to their fitness
level.

Aerobic exercise will improve endurance and will enhance the health of the
circulatory system thus helping prevent edema, varicose veins, hemorrhoids,
and assisting the woman in coping with a lengthy labor. It also reduces
fatigue, improves sleep, prevents excessive weight gain, and enhances the
woman's ability to cope with the physical and emotional stresses of
pregnancy. As well, pregnancy outcomes are more favorable for women who
exercise (Hall and Kaufmann, 1987).

Pregnant women must be cautioned about getting too hot when doing
aerobic exercise. Exercise that raises the core body temperature more than 2
degrees Fahrenheit can be dangerous to the fetus. The woman should be
advised not to exercise in very hot or humid weather, or in a hot stuffy room.
Being drenched in sweat or having a pulse that is still over 100 beats per

© 2007 http://www.bodyworkbiz.com 33
minute five minutes after completing a workout is a sign that the intensity of
the exercise is excessive.

If the woman was not active before the pregnancy, loading of the
cardiovascular system must be gradual. As a general guideline, vigorous
activities, especially those that involve sudden, twisting, or jerky movements,
should be avoided in favor of more moderate activities such as walking,
swimming, cycling, low impact aerobics, and special prenatal exercise
classes. Be aware that there is an added risk of injury in pregnancy because
of joint laxity and a changing center of balance.

Stretching and strengthening exercises will be very useful. These exercises

can be done to help counter the postural changes that normally occur
through pregnancy. Since the weight of the abdomen and breasts tends to
cause a swayback posture, stretching should focus on the hip flexors, low
back extensors, hip adductors and lateral rotators, and the pectoral muscles.
Strengthening exercises should be focused towards the abdominal muscles,
gluteals, scapular retractors, and thoracic extensors. Stretching should not
be forceful and any exercise performed while lying on the back should be
avoided after the fifth or sixth month of pregnancy.

Some caution must also be applied to strengthening exercises. The Valsalva

maneuver, a holding of the breath used in lifting heavy loads, decreases
oxygen delivery to the placenta and should thus be avoided. As with
aerobics, a moderate approach is best. Suggest less resistance (lighter
weights) and more repetitions. It is safer to isolate muscle groups than to
perform complex maneuvers. As well, weight machines are safer than free
weights, especially if no spotter is available (Work, 1989). For example, to
strengthen the quadriceps, it would be safer to do leg extensions on a
machine than squat lifts with free weights.

© 2007 http://www.bodyworkbiz.com 34
Because the sacroiliac (SI) joints and the symphysis pubis are lax, they are
especially vulnerable to irritation and dysfunction. Exercises that force the
hips into extremes of flexion and extension should be avoided. As well, avoid
exercises that involve weight bearing on one leg only as these stress the
joints considerably.

The abdominal muscles will not tolerate strenuous exercise as the pregnancy
progresses. Occasionally a condition called diastasis recti will develop (figure
5). The stress on the abdominal wall caused by the growing fetus, along with
a generalized laxity of the connective tissues of the body, will weaken the
linea alba which is the central fibrous tissue of the abdomen. As a result a
gap may develop between the two rectus abdominus muscles. This
separation may be small or may be up to three or four inches in width. To
prevent the condition from worsening discontinue strenuous abdominal
exercises and exercises that rotate the hips or trunk.

Figure 5. As the central

fibrous tissue of the
abdomen becomes
weakened, the rectus
abdominus muscles may
separate. This condition
is called diastasis recti.
You can palpate this gap
easily when the woman
contracts her abdominal
muscles to sit up.

© 2007 http://www.bodyworkbiz.com 35
It is important to strengthen the pelvic floor muscles. Although it may seem
odd to do strengthening exercises for these muscles, it is vital because a
strong pelvic floor gives support to the pelvic organs and prevents stress
incontinence. A strengthening exercise was first suggested by Kegel which he
called the pubococcygeal exercise. Today it is simply called the Kegel
exercise. It involves isometric contractions of the pelvic floor muscles. Many
women are unaware that they have control over these and about 30% are
unable to consciously contract them without training (Laycock, 1991).

To determine the degree of control your client has over her pelvic floor
muscles ask her if she can control or stop the flow of urine when she is
urinating. To assist the woman in becoming aware of them, have her place
her hand on the perineum and feel the movement as she contracts them.
Alternatively, when at home, she can insert one finger into the vagina and
attempt to squeeze the finger or prevent its withdrawal. This method, which
the woman can do in privacy at home, ensures that the muscles are actually
contracting and the woman is not just bearing down, or tightening the
gluteals and adductors. Once the woman learns to contract the muscles
correctly, the exercise can be started.

The exercise needs to be performed regularly and consistently to achieve

good results. Suggest to your client that the she perform it at specific times
of the day or accompanying certain activities (e.g. every time she brushes
her teeth) to help improve compliance. Because the perineal muscles consist
of both slow and fast twitch fibers, have the woman alternate sustained
contractions (10 seconds or longer) with short, quick contractions to activate
and strengthen the muscles effectively.

The contractions should be repeated for three to five minutes and performed
several times a day. The exercises should not be done while urinating as this
promotes incomplete emptying of the bladder. Since noticeable improvement

© 2007 http://www.bodyworkbiz.com 36
in strength takes weeks to months of training, it is best to start these
exercises as early in the pregnancy as possible (Leaky bladders, 1992).
Kegel's exercises should be continued after the delivery to facilitate the
recovery of the pelvic musculature.

Here are several ways that the Kegel exercise can be performed:

1. The basic Kegel. Simply contract the pelvic muscles as tightly as

possible and then relax them completely.
2. The elevator. This exercise can be done in any position. Imagine the
pelvic floor as an elevator which is going from the first to the tenth
floor of a building. Contract the pelvic muscles a little at a time,
tightening them a little more at each floor until the tenth floor is
reached at the count of ten. Gradually release the muscles as the
elevator descends back to the ground floor.
3. The wave. Although this method can be performed in any position,
try sitting on a firm chair with the feet on the floor and slightly apart.
Now tighten all the sphincter muscles - anal, vaginal and urethral -
from front to back, in succession. While it is difficult to separate these
muscles from one another, it's much easier to contract them in
succession. When all three are tightened, hold the position and then
release the muscles in a wave-like motion from front to back.

© 2007 http://www.bodyworkbiz.com 37
Hydrotherapy during pregnancy: General
guidelines

Hydrotherapy is generally safe and, like massage and exercise, is particularly

useful when drug treatment is contraindicated. For example, local
applications of cold or heat are useful for muscle soreness, and cold sponge
baths are indicated for mild fever. Any full body heat treatment would be
contraindicated. Do not use saunas, steam rooms, whirlpools, and hot tubs.
As with exercise, raising the body's temperature in these ways can have a
detrimental effect on the fetus.

Using these heat treatments for periods of less than ten minutes is probably
not sufficient to cause significant changes in body core temperature.
However, the evidence available is not conclusive, so it would be wise to
avoid these modalities altogether. If the woman is accustomed to soaking in
a hot bath, recommend that the water temperature be lowered to a warm
level. Local heat applications pose no special risks.

Vascular sensitivity to cold may develop in some women. With a cold

application, their skin may turn bluish and blotchy. Although this condition is
painless and poses no risk to the mother, it may be wise to refrain from cold
applications if the client has this reaction.

There are no particular contraindications to hydrotherapy in the postpartum

period. Sitz baths are often recommended for perineal pain after childbirth.
Although warm or hot sitz baths have often been suggested in the past, a
cold sitz bath will be more effective for decreasing pain and inflammation
(Droegmueller). A cold compress or ice packs to the perineum will also help
decrease the soreness and swelling.

© 2007 http://www.bodyworkbiz.com 38
Stress management through pregnancy

Stress is not necessarily a bad thing. However, excessive stress during

pregnancy can exacerbate many common complaints of pregnancy such as
headache, backache, fatigue, insomnia, loss of appetite, and morning
sickness. Stress and anxiety have also been related to a number of
complications of pregnancy and labor including premature birth, decreased
uterine efficiency, prolonged labor, poor infant health, and poor mother
infant bonding (Beck, et al, 1980; Crandon, 1979; Farber et al, 1981;
Gaffney, 1986; Lederman et al, 1978, 1979, 1981; Norbeck and Tilden,
1983; Norbeck and Anderson, 1989).

Figure 6. This graph illustrates the relative distribution of complications

between high and normal anxiety groups(adapted from Crandon, 1979).

As well, animal studies show that stress or the presence of stress hormones
decreases blood flow and oxygen transport to the fetus, and causes the fetal

© 2007 http://www.bodyworkbiz.com 39
heart rate to decelerate. The graph shown here compares the distribution of
complications of delivery between women with normal and high levels of
anxiety.

It is clear that excessive maternal stress or anxiety is potentially harmful and

should be minimized as much as possible.

As massage therapists, we need to identify those clients with high stress

levels and help them with its management. For these women, massage with
a focus on relaxation combined with other forms of relaxation training is
essential to their well-being.

In addition, we can provide appropriate emotional support for our clients if

they want to utilize us in that capacity. Lack of social support has been
strongly related to increased maternal anxiety. This can be particularly
problematic when key sources of personal support, such as a partner or
mother, are not available.

If your client does not have a primary support person or if she would like
more than one to accompany her through labor and delivery, she may ask
you to perform this role. This is an important role because support is vital
during labor and delivery. Pregnant women will experience the most stress at
this time, especially in an unfamiliar hospital environment. Anxiety can cause
prolonged labor because adrenaline, a stress hormone, slows down the
activity of the uterus. (Beck et al., 1980; Lederman et al., 1978).

Reassuring touch can decrease anxiety significantly (Sommers) and the

presence of a support person can have a positive influence on the outcome
(Norbeck and Tilden, 1983; Norbeck and Anderson, 1989). The presence of a
supportive lay person has been found to result in shorter duration of labor
and significantly fewer perinatal problems. Mothers are more awake and

© 2007 http://www.bodyworkbiz.com 40
smile and talk to their babies more (Sosa et al, 1980; Klaus et al, 1986). In
addition, they do not require as much anesthetic (Bradley).

Even low-risk women who have attended prenatal classes and are
accompanied by their husbands or partners have improved labor outcomes
with the presence of a professional support person. Professional one-on-one
support resulted in greater perceived control, along with less pain
medication, and fewer episiotomies (Hodnett and Osborn, 1989).

© 2007 http://www.bodyworkbiz.com 41
Labor and delivery

overview

Braxton Hicks contractions will usually become more frequent as the end of
the term nears. Oftentimes the occurrence of these contractions is confused
with actual labor and is referred to as false labor.

Prior to actual delivery, the expectant mother will experience what is called
lightening, or engagement, as the baby begins to descend into the pelvis.
The shape of the abdomen changes as the baby drops into the birth canal.
The woman will find breathing to be much easier, but may experience a
variety of new symptoms including increased edema of the lower limbs and
aches and pains in the groin or legs. This process usually occurs from a few
days to up to four weeks before the onset of labor. Labor generally occurs in
the 40th week of pregnancy. If the pregnancy goes beyond the 42nd week,
the woman's physician will likely induce labor to prevent complications and
minimize risk to both the mother and fetus.

The delivery process is divided into

three stages (see box). THE STAGES OF LABOR
Stage 1: Labor

The first stage is the labor stage in Phase 1: Early or latent labor

which regular contractions of the Phase 2: Active labor

uterus take place and the cervix Phase 3: Transitional labor

dilates fully. This first stage consists Stage 2: Pushing and delivery

of three phases. The contractions Stage 3: Delivery of placenta

become more intense and the

cervix dilates wider with each successive phase.

The second stage involves the actual birth of the baby.

© 2007 http://www.bodyworkbiz.com 42
In the third stage, the placenta (afterbirth) is delivered. The whole process
averages 14 hours for first time mothers and about 8 hours for subsequent
births. Actual duration, however, can be anywhere from 20 minutes to 40
hours.

Many massage therapists will have the opportunity to assist a woman

through labor; for some it is a regular part of their practice. The use of
massage in labor has a long established history. Towards the end of the 19th
century a noted anthropologist wrote that "There is hardly a people, ancient
or modern, that do not in some way resort to massage and expression in
labor, even if it be a natural and easy one." (Goldsmith, 1984) The massage
therapist today can play the role of assistant to the birth professional,
whether that be a medical practitioner or midwife.

The massage therapist also plays a secondary role to the woman's personal
support person. The pregnant woman will almost always bring in a support
person. This is usually the father, but not always. The support person knows
the woman better than the massage therapist or the birth professional. He
knows how best to respond to her needs, so it is imperative that he
maintains close contact with her throughout the process. Take care that he
does not feel displaced.

As a massage therapist you are regarded as a professional by the support

person. This may cause him to feel intimidated and give up his role to you.
Help him stay engaged in the process by showing him techniques that will
keep him physically close to his partner and supplement your work. For
example, you may show him how to massage the woman's temples and jaw
while you manage the back pain she is experiencing. During labor, there is
more than enough work for several people and you will likely find that you
and your client's partner will be working in shifts.

© 2007 http://www.bodyworkbiz.com 43
For some couples, birth is a very intimate process. Have respect for the
couple's privacy. Know that it may be more important at times to disengage
yourself from the process and let the couple work together on their own.

The work of a massage therapist in the labor process consists largely of back
massage or pressure to the back to relieve discomfort, supporting the
abdomen during contractions, massage to various parts of the body for
relaxation, distraction or pain relief, and oftentimes, simple hand holding for
reassurance.

One of the most important roles the massage therapist has in any labor is
that of helping the mother to relax. As has been stated earlier, stress and
anxiety during labor can cause a variety of complications during labor. For
this reason, the focus of massage and touch should be on relaxation.
However, some massage therapists have noted that if the woman lies down
for a long relaxing massage, the labor process can be slowed. This may or
may not be beneficial depending on the physical and mental state of the
client. For this reason, use a rhythmic, yet mildly brisk massage. Massage for
short periods of time and have the client walk around or change positions
once in awhile. As well, massage the client in a sitting or standing position
occasionally.

When positioning the woman, avoid the supine position. Not only can this
position compress major blood vessels, but it tends to slow labor. On the
other hand, upright positions like standing or sitting can shorten labor by
speeding dilation and fetal descent.

In general, women find that touch and massage helps them better cope with
their labor and creates a more satisfying experience. Most women will say
that massage helps decrease the pain they experience. Other effects of touch
and massage that have been reported by women include enhanced comfort,

© 2007 http://www.bodyworkbiz.com 44
self-control, relaxation, endurance, and alleviation of uncomfortable physical
sensations (Birch, 1986).

Note, however, that women giving birth will have very different responses to
massage. The approach you take to massage at this time will vary greatly
from client to client. What works for one woman may not work for another.
As well, be prepared for the woman to be erratic in her requests. Sometimes
she may want massage and at some points she may not want to be touched
at all. Be sure to establish open communication early in the process and be
prepared to adapt or discontinue your massage in response to your client's
immediate needs.

Educate yourself regarding medical routines used in labor units if you plan on
assisting your client in a hospital setting. IV's, lumbar epidurals, and fetal
monitors are frequently used and will impact on the work you will be able to
do. For example, if a continuous drip epidural is used the woman will remain
in a sidelying position and the spine will be taped from T1 to the sacrum.
Although pain sensation is blocked, she may still have tactile sensation so
that massage to her legs or feet may be beneficial.

stage 1

Stage 1 labor consists of three phases. The first phase, called early labor, is
the longest and easiest of the three. In this phase the cervix dilates to 3 cm
in diameter. There may or may not be a consistent pattern of contractions at
this time. The second phase, or active phase, lasts from 2 to 3 hours on
average. During this time the cervix dilates to 7 cm. Contractions become
stronger and more consistent than in the first phase, lasting for up to a
minute and occurring every three or four minutes. The third phase is referred
to as transitional labor and is characterized by full dilation of the cervix to 10
cm. Its contractions last for about a minute to a minute and a half and occur

© 2007 http://www.bodyworkbiz.com 45
every two or three minutes. This phase is short and may last from 15
minutes to one hour.

During the first stage of labor, the massage therapist can help keep the
woman relaxed. This will prevent fatigue and ensure that she has as much
energy as possible for the delivery. Breathing exercises or relaxation
exercises are often helpful. Encourage the woman to walk and move around.

General massage may be useful early on, but as labor progresses it will be
more beneficial to focus on areas of tension. It is very important to help the
woman relax her abdominals. When contractions start becoming intense, use
gentle massage on the abdomen between contractions. Sometimes simply
touching the tense area is enough to make the woman aware of the tension
so that she can release it.

It may be useful to massage the tense proximal areas of the body: the
thighs, gluteals, abdomen, or the low back. The hip adductors in particular
tend to get very tense and it would be useful to use deep effleurage or
petrissage to help these muscles relax. Passive range of motion to the hips
and knees can be equally effective.

Sometimes it is more helpful to massage the distal areas. For example,

massaging the hands or the feet may provide a useful distraction. Leg
cramps occur frequently and massage can be used to help release the cramp
and manage the associated discomfort. The most common muscles to cramp
are the hamstrings, adductors, and calves.

Some educators stress the importance of keeping the jaw relaxed through
labor. There is no physiological connection between the jaw and the uterus
as some writers suggest, but relaxing the facial muscles and muscles of
mastication may assist the woman in breathing more easily.

© 2007 http://www.bodyworkbiz.com 46
Sometimes the baby's position may not be ideal during descent. The back of
the baby's head may be pushing against the mother's sacrum. This causes
excruciating low back pain and is referred to as back labor, although severe
back pain may be present even when the baby is in a good position. There
are several things that can be done to provide relief. One of the most useful
will be to apply counter pressure. Using the heel of your hand, or perhaps
the back of your knuckles, push into the lower back or sacrum on or around
the area of pain until you find a location that gives the woman some relief.
This can be done with any positioning and will be particularly useful if you
sustain the counter pressure for the duration of the contraction. This
technique is illustrated in a variety of positions below.

Local deep petrissage may also provide some relief. In addition,

hydrotherapy can be applied to the back. Use the modality that the woman
feels is giving her the most relief, whether an ice pack or a heat pack. Some
women may even enjoy taking a warm shower. Lastly, have the woman

© 2007 http://www.bodyworkbiz.com 47
change her position. Have her try squatting, going on all fours, or sidelying in
a fetal position.

Obstetric literature often suggests that many woman do not like to be

touched in the transitional phase of labor, the reason being that this is the
most intense and painful time of labor. Research, however, suggests that
instead of aversion to touch there is often a strong desire to be touched in
this phase (Birch, 1986). Since transition is the most difficult phase of labor
the woman's anxiety may be at its highest and thus massage or even simple
touching may be most beneficial at this time to help relax or comfort the
woman. Bear in mind that the pregnant woman's needs and preferences
must always form the basis for your decision to intervene or not intervene
with massage and touch in this or any other stage.

stage 2

Stage 2 is the delivery stage. It can last from 10 minutes to three hours,
although it typically lasts from about half an hour to one hour. The
contractions become more regular and a little farther apart than in the
transitional phase of stage 1. The mother must assist the contractions at this
stage by actively pushing. As the baby passes through the vagina the mother
will recognize the burning sensation that she felt while doing the perineal
massage.

During the contractions you can either use firm counter pressure or massage
at a rhythm that supports the breathing technique that the woman is using.
As the actual delivery approaches, you will need to give way to the birth
professionals. Support the birthing team and the woman in any way they feel
is appropriate. You can apply cool compresses to the forehead or neck, use
counter pressure, massage the back to ease pain, or just be nearby for
support.

© 2007 http://www.bodyworkbiz.com 48
 stage 3

This final stage involves delivery of the placenta, also called the afterbirth.
The stage lasts anywhere from 5 minutes to one half hour or more, since it
takes some time for the placenta to detach itself from the uterine wall. Mild
contractions continue after the birth to push the placenta out of the body.
Episiotomy or laceration repair is usually done after delivery of the placenta.

At this stage, most of the strenuous work is over for the mother and it is
likely that her attention will be diverted from her discomfort and toward the
baby. Massage for the mother is not necessary unless it is needed to assist
uterine contraction and delivery of the placenta. Any direct massage,
kneading, or squeezing of the uterus to expel the placenta is contraindicated
as it may provoke abnormal contractions and interfere with normal progress.

However, after delivery of the placenta massage of the fundus, the top
portion of the uterus, can be used to encourage involution (shrinking) of the
uterus and reduce hemorrhage. Although the massage should be vigorous
enough to stimulate contraction, caution must be used to prevent descent or
inversion of the uterus. Placing a hand above the symphysis pubis to elevate
the uterus during massage (figure 8) would be a good safeguard (Long,
1986). Even light stimulation of the skin of the abdomen may be sufficient to
cause reflex contraction of the uterus (Curtis and others '86).

Massage for assisting involution can be continued for up to two weeks after
the birth.

© 2007 http://www.bodyworkbiz.com 49
Figure 8. When massaging the abdomen after delivery, use one hand to
apply gentle pressure above the symphysis pubis to prevent inversion of the
uterus.

© 2007 http://www.bodyworkbiz.com 50
Postpartum

The birth of the baby does not mark the end of the mother's need for
massage. On the contrary, massage can play an important role in helping the
woman cope with the new stresses of motherhood and in rehabilitating birth
injuries and surgery.

The birth process is exhausting. Many women feel completely drained and
sore all over the next day. Some women describe the feeling of being hit by a
truck or of finishing a marathon. A massage to release tension and help the
woman relax is invaluable. In addition, the woman will probably have little
sleep as she must attend to the baby constantly. The anxiety associated with
having to take care of a newborn and the lifestyle changes that are imposed
may be even further cause for stress. At this time, shortly after the birth, it is
important that the mother take time for relaxation on a regular basis.
Massage can be particularly fulfilling because the mother has attention
focused on her alone at a time when her welfare seems to be placed in a
secondary position to that of the baby.

You will often find that your client complains of achiness around the
shoulders, mid-back and neck after giving birth. Initially this may be caused
by her positioning for the birth or simply the tension which has developed
from the process. Later, she may feel the discomfort because of carrying the
child and holding the child for feeding.

Massage can play a key role in helping the mother recover post-surgically.
Cesarean sections are extremely common. In the United States about one
out of every four births is a cesarean delivery and this rate has been
relatively consistent for a number of years (Taffel et al., 1992). If the woman
has had a cesarean birth, massage can help restore peristalsis, prevent
keloid formation, and reduce adhesions in the affected tissues (Javril 88).

© 2007 http://www.bodyworkbiz.com 51
The woman's physician must be consulted if you decide to do post-surgical
massage.

If there are no complications, abdominal massage for cesareans can be

started within a few days following delivery to reduce any swelling and
promote movement in the intestines. Gentle effleurage and manual lymph
drainage techniques can be used provided they do not stress the surgical
incisions. Once the incision is fully closed, which usually occurs within 10
days, you can begin working into the scar and the deeper tissues to prevent
adhering. At first you may use the gentlest petrissage techniques and as the
healing continues you can incorporate more aggressive techniques like skin
rolling. Again, care must be exercised not to place excessive stress on the
healing tissues.

Summary

Pregnancy can be a time of excitement, but it can also be a stressful time for
a mother-to-be. Massage is a great way to help women through this time of
change. It is also invaluable for helping a woman manage the various
uncomfortable symptoms she may experience – everything from back pain to
swelling - as her body goes through some very dramatic changes.

While pregnancy is not a pathology, there are many special considerations

that need to be taken into account when doing prenatal massage. This book
has covered many of the most common ones and has provided you with
guidelines for treatment. We've also looked at a number of issues regarding
massage through labor and in the post partum period.

© 2007 http://www.bodyworkbiz.com 52
About the Author
Eric Brown, Massage Therapist, is one of the world's leading authorities on
massage. He has taught thousands of massage therapists across North
America. He speaks regularly at various massage conferences and his
writings appear in trade publications across the world.

Here are some of the organizations he has founded to help massage

professionals:

BodyworkBiz http://www.bodyworkbiz.com
Marketing and business resources for massage professionals. Everything you
need to have a successful practice from ecourses and presentation kits, to
business cards and client education newsletters. Sign up for the FREE
marketing tips newsletter, chock full of valuable practice building tips:
http://www.bodyworkbiz.com/newsletter.php

Massage Therapy Radio http://www.massagetherapyradio.com

Join one of our upcoming broadcasts as we interview leaders in the field of
massage therapy.

World Massage Conference http://www.worldmassageconference.com

This groundbreaking online conference was the first virtual conference in the
industry and the largest event in the history of massage with close to 12,000
registrants from around the globe and a line up of about 70 international
massage experts. Check outthe current year’s offering which promises to be
even bigger and more exciting.

Thermal Palms http://www.thermalpalms.com

The soft alterantive to hot stone massage. Visit the site to watch the videos
and find out why therapists are tossing their stones into the river and
embracing this unique heat modality.

© 2007 http://www.bodyworkbiz.com 53