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November/December 2015 Issue

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Massage for Moms-to-Be

By Elaine Stillerman

There is something so special, so thrilling, about massaging a pregnant woman. It is an honor and a privilege. It also comes with tremendous responsibilities. Competent and appropriate training in this specialty is essential for the safety of mother and baby. And creating a nurturing, nonjudgmental working environment is paramount to achieving your desired treatment outcomes.

Since stress has negative effects on pregnancy, labor, and postpartum recovery, one of the main goals of a prenatal massage practitioner is to control and lower maternal stress and anxiety. Common pregnancy-related physical discomforts—such as backaches, nausea, swelling—and any emotional concerns may add to maternal stress levels. Long-term exposure to heightened stress levels can lead to potentially serious health problems, such as suppressed maternal immune function, high blood pressure, and heart disease.
The blood catecholamines norepinephrine and epinephrine play a significant part during the stress response. The placental vascular bed is hypersensitive to the constrictive effects of epinephrine, which can lead to failure of labor to progress and decreased placental circulation, thereby inhibiting fetal nutrition. In addition, these stress compounds dampen the effects of other hormones, such as oxytocin, which is essential for a normal progression of labor and mother-child bonding.
It is important to understand the complex influence of a mother’s emotions on her growing baby. Prenatal predisposition to stress can profoundly affect in utero development and may predispose babies to higher risk of disease. If your clients are educated about ways to control the stressors in their lives, they and their babies will fare much better.
Severe stress during pregnancy has been linked with both physical and neurological disabilities. Obviously, creating an environment that reduces maternal stress and anxiety, such as through frequent massage, fosters relaxation and is essential for a healthy pregnancy and birth outcome.
Massage and bodywork, when appropriately administered during pregnancy, can have a powerful influence in mitigating the effects of stress. Massage sedates and restores the nervous system. Proprioceptors of the deeper soft tissues relay messages to the central nervous system about muscle tension and blood pressure. The heat produced by massage signals both the sympathetic and parasympathetic systems to balance, correct, and restore these self-regulating mechanisms.

Effects of Stress on Pregnancy
• Dampened effectiveness of oxytocin.
• Delayed infant neuromotor development.
• Elevated maternal heart rate and blood pressure.
• Higher incidences of miscarriage.
• Increased stress hormones.
• Increased labor pain.
• Increased likelihood of (maternal) unhealthy lifestyle habits.
• Low fetal birth weight and premature labor.
• Maternal depression.
• Obstetrical complications.
• Prolonged labor or failure to progress.
• Uterine vasoconstriction.

Effects of Stress on Fetal Development
• Behavioral problems, such as ADD.
• Cleft lip and cleft palate.
• Cognitive delays, such as autism and autistic spectrum disorders.
• Diabetes later in life.
• High blood pressure and cardiovascular disease later in life.
• Hypersensitivity.
• Low birth weight.
• Neuromotor delays.
• Obesity later in life.
• Premature labor.
• Slowed brain development.

Relaxation is further enhanced by the pain-reducing, or analgesic, effect it provides. Blood vessels dilate, waste products get reabsorbed and excreted, tissues become oxygenated, and pain is diminished. Beta-endorphins and serotonin (a neurotransmitter) are secreted during massage and work together to inhibit the central nervous system and produce that “feel-good” response.
Prenatal massage also addresses many of the musculoskeletal discomforts expectant women experience—abdominal pressure, backaches, hemorrhoids, sinus congestion, and swelling can all be relieved or reduced by appropriate prenatal massage. In addition, the emotional and psychological effects of prenatal massage cannot be overlooked or underestimated. The nurturing and respectful touch given by a qualified practitioner helps the expectant mother achieve a sense of peace during an unsettling time. A woman who feels validated and affirmed through someone’s loving touch is also more likely to display better parenting skills, be more attentive to her baby, and touch her child in a loving, supportive manner.
The next time you massage a pregnant woman, remember the loving work you are doing has a positive impact on both her and her growing baby, not only while the baby is in utero, but throughout the baby’s life. Everything the mother feels is transmitted to her baby through biochemical agents. The experiences she has while pregnant, and the type of birth she has, leave lasting patterns in her baby.

Prenatal Massage Contraindications and Precautions
Before beginning any treatment, it is important to know when massage should be avoided or modified, and when the client should see her health-care provider. The obvious contraindications, such as fever, high blood pressure, and nausea still apply to pregnant women. But pregnancy-specific precautions include:
• Asking permission before massaging her abdomen.
• Avoiding all aromatherapy during the first trimester and making certain the aromas you use are safe during pregnancy.
• Avoiding all deep strokes on the legs. The safest and most effective modality to use is manual lymphatic drainage (MLD). Swedish massage is not appropriate on the legs.
• Avoiding electric blankets, heating pads, hot stones, and hydroculators.
• Avoiding hyperextension of her joints.
• Making sure your client is comfortably positioned at all times and supported with bolsters, pillows, or wedges.
• Making sure your client isn’t hungry or hasn’t had a big meal.
• Never positioning your client flat on her back, which may cause a hypotensive response.
• Waiting an entire week after any invasive genetic tests.

Prenatal Massage Contraindications
Your client should not receive any massage and must see her health-care provider when:
• Placenta abrupta (tearing away of the placenta from the uterus) occurs.
• Placenta previa (occlusion of the placenta over the cervix) occurs.
• She has a throbbing migraine headache.
• She hasn’t felt fetal movement for 8–10 hours.
• She is experiencing preterm labor (labor before 37 weeks gestation).
• She is experiencing severe abdominal or back pain.
• There is a condition with which you are not familiar or don’t feel comfortable treating.
• There is a spike in her blood pressure or a hypertensive condition.
• There is an ectopic (outside of uterus) pregnancy.
• There is any bleeding or staining.
• There is pitting edema.

Contraindicated Acupuncture and Reflexology Points
When I mention these points, it is important to understand exactly what I mean by contraindicated. None of these points should be stimulated. There should be no continuous or deep pressure to these specific locations.  
However, this does not mean that these locations have to be avoided completely. You can lightly glide over them (without stopping on them) during your massage. Since the leg work is always 10–30 grams of pressure (using MLD principles), there is no danger of stimulating the points on the feet or legs at all. As far as the other contraindicated points found elsewhere on the body, treat them as if you were on an express train, simply passing through these local stations. To clarify, these points are not avoided, but deep, protracted pressure is not used on any of them. All these points are bilateral.

Physical, Emotional, and Psychological Changes of Pregnancy
Pregnancy and becoming a mother is a defining and life-changing experience for many women. It can be an emotional roller coaster ride, especially for first-time moms who may not be aware of all the dynamic changes pregnancy causes to the body and psyche.
Many of these changes are brought on by hormonal shifts, particularly the elevated levels of estrogen and progesterone, which are increased to nearly 10 times their normal levels. Emotional liability, or the ups and downs of pregnancy, and conflicting feelings are part of the experience. But it can be disconcerting for women who expect to feel one way, but actually feel another.
For some women, their growing bodies bring tremendous satisfaction and pride, while others dislike their shape and have a poor self-image. The aches and pains from the common discomforts of pregnancy add to their malaise. Fears and concerns about the pregnancy and impending childbirth, parenthood, and relationships with their partners, families, and friends are also factors in this richly emotional, sensitive time. The support a woman has—or doesn’t have—has a tremendous impact on her pregnancy and labor.
Past traumas can also leave indelible scars on the pregnancies of some women. Survivors of physical or sexual abuse (1 in 3 women before age 18) may have a harder emotional time with their pregnancies and labors than women who did not suffer these traumas. With such a large percentage of the population in this category, it is vital to give all your clients respect, control over the massage environment, and support if they seek help.1
Domestic violence escalates during pregnancy. The numbers are astounding: 1 in 4 women in this country are victims of spousal abuse and domestic violence during pregnancy. Homicide by a spouse or domestic partner is the leading cause of death during pregnancy in the United States, eclipsing accidents and hypertensive disorders.2
We often think of pregnancy as a happy time. Yet for 1 in 5 women, pregnancy is a time of depression. And 1 in 4 pregnancies in this country were not planned, with 25 percent of these unplanned pregnancies occurring because contraception failed.3 The impact of an unplanned pregnancy can certainly be a cause of concern for some unprepared women and their families.
At all times, your overall goal in treating pregnant women is stress reduction. This takes precedence over the physical complaints they have, because stress can often make these aches and pains worse and can have serious health consequences for mom and her baby. Maternal stress has a direct impact on the baby’s health. A study on the effects of maternal stress on the baby indicated that fetal heart rates of stressed mothers stayed higher longer, suggesting a heightened reaction to stress.4 These responses to stress have been linked to delayed or stunted fetal development, low birth weight, preterm labor, and higher incidences of cardiovascular disease and diabetes later in life for the babies. The study went on to say that the women who regularly employed relaxation techniques—such as massage, meditation, and yoga—had lower blood pressure and fostered a healthy in utero environment, thereby producing calmer babies.
Stress can affect blood flow to the uterus by as much as 65 percent, denying the growing baby essential nutrients and oxygen, which in turn may lead to low birth weight, preterm labor, and a long, difficult labor for mom. It is important that, in addition to relieving her aches and pains, the massage provides a safe haven of comfort, nurturing, respect, and stress reduction that impacts both the mother and her baby.

Appropriate modality: soothing, calming, nurturing Swedish massage. You must set up an environment of safety, respect, and support. You must provide a nonjudgmental environment that addresses her physical and emotional needs.

The Anatomy and Physiology of Pregnancy
In order to know which modalities are appropriate for your clients, it is essential to understand how their bodies adapt to pregnancy.
The following section provides an overview of the changes and adaptations that occur in the systems of the body during pregnancy and provides appropriate massage therapy techniques to support the dynamic changes of pregnancy.

Musculoskeletal System
While it’s fair to say that nearly every system of a woman’s body is affected directly or reflexively by pregnancy, the system massage practitioners work with most directly is the musculoskeletal system. The maladaptive posture of pregnancy creates muscle achiness, stiffness, and strain, which are primary concerns for most pregnant women.
As the pregnancy progresses, the uterus displaces from the pelvic cavity to the abdominal cavity. At about 38 weeks gestation, the fundus, or the top of the uterus, is slightly inferior to the xiphoid process, compressing the respiratory diaphragm and the visceral organs.
The mother’s structural integrity is compromised as a result in the shift of her center of gravity and the influence of relaxin on connective tissue. Her abdominal muscles stretch, weaken, and separate, creating the diastasis recti, which contributes further to the lack of abdominal and spinal support and increased low-back pain. The important muscle to restore abdominal support and lumbar stability, and minimize the diastasis recti, is the transverse abdominis. Exercises that recruit the transverse abdominis will minimize the separation during pregnancy and heal it in postpartum recovery. For more information on testing for the diastasis recti and the correct abdominal core exercises to do to correct it—those that recruit the transverse abdominis—read Julie Tupler’s Lose Your Mummy Tummy (Da Capo Press, 2004).
The mother’s lumbar spine is compressed from the weakened abdominal muscles and the anterior pelvic tilt she develops as a result of the shift in her center of gravity. The anterior pelvic tilt strains the hip flexors and weakens the iliopsoas, so her gait becomes awkward as pregnancy progresses. She develops active trigger points along the pelvis, sacral region, hip flexors, and lumbar spine. When she is standing upright, it is natural for her to lean back for balance, but that adds additional compression on her lumbar spine. While standing upright, her shoulders laterally rotate to support her posture. Trigger points develop along the vertebral border of the scapulae, rhomboids, and trapezius. However, when sitting or sleeping, her shoulders medially rotate, creating myofascial stress patterns in her pectoral muscles and roundness in her upper back.
To find balance with her anterior-placed pelvis, mom’s head protracts, compressing the lower cervicals (a direct relation to the lumbars), creating weakness and tingling in her hands.
The anterior pelvic tilt also pulls on the hamstrings, tightening them and causing hyperextension in her knees. Her rib cage expands 2–3 inches anteriorly and laterally to make room for the growing uterus. This puts strain on her thoracic spine. Her pelvis widens and her hips laterally rotate to accommodate the wider pelvis, adding strain on the lateral hip rotators. Her feet pronate and the plantar vaults of her feet may drop.
The hormone relaxin is secreted in higher levels from weeks 10 to 14 in preparation for uterine growth. Relaxin softens all connective tissue and allows the mother’s body to widen for pregnancy and childbirth, but leaves her hypermobile and unstable. Relaxin results in lax fascia, ligaments (as relaxin allows the uterine ligaments to stretch as the baby grows), and tendons throughout the mother’s body. As a result, there is increased stress on weight-bearing joints, particularly in the pelvis and sacroiliac joints. Relaxin also slows down femoral lymph absorption, causing swelling in the lower extremities.

Appropriate modalities: decompression and myofascial stretching on tightened muscles, trigger point release, muscle balancing techniques, strain/counterstrain, sacral lift, pelvic tilt, Swedish massage, energy work, and manual lymphatic drainage on the legs and feet at all times.

Cardiovascular System
By the end of the pregnancy, mom’s heart pumps 30–50 percent more blood, most of which is directed to the uterus and 20 percent to her breasts. This explains why pregnant women often feel hot. It is important they stay hydrated to avoid preterm labor.
The mother’s heart gets slightly larger as it pumps more blood, but her blood pressure remains the same, although it takes longer for blood pressure to stabilize. This is important to remember when turning your clients on the massage table, helping them to a seated position, or having them stand after a massage. All movements should be done slowly.
As a protective mechanism, the mother’s immune system is slightly suppressed (so her body doesn’t expel the fetus), and it takes longer to recover from viral infections.
Varicose veins (which increase the risk of deep vein thrombosis) or spider veins are often caused by the fetal demand on the mother’s circulatory system. By the end of the pregnancy, swelling is common because women have 40 percent more interstitial fluid being carried by weakened vessels. The swelling is most evident in the mother’s legs and feet. In most cases, healthy pregnant women exhibit what is called “gravity swelling.” In other words, when her legs are elevated, the swelling is reduced. However, as many as 1 in 4 women can have pitting edema, which may indicate a hypertensive syndrome, or worse. That is why a pretreatment evaluation for pitting edema is so important before each massage. If your finger’s imprint remains after a count of 10–30 seconds, do not massage, and have your client call her health-care provider.
Another hypertensive syndrome to look for is gestational edema proteinuria hypertension (GEPH). This is a swelling of the hands, face, upper body, or entire body during the early to mid stages of pregnancy. Since this is a preeclamptic condition, massage is contraindicated.
Equally important is the 4–5 fold increase in fibrinogenic activity (blood clotting factor) starting early in the second trimester (or late first trimester). This activity continues for 8–10 weeks postpartum. This is the body’s defense against severe blood loss or hemorrhaging at labor. But this increases the mother’s chances of developing thrombi 5–6 fold. Massage practitioners must be careful to avoid dislodging any clots that may develop within the iliac, femoral, or saphenous veins—the deeper blood vessels where circulation is most stagnant—of her legs. When a clot is present, the symptoms are pain, heat, swelling, spasm over the site of the clot, and difficulty walking. But it is also possible that the clots are asymptomatic.
This is why pretreatment evaluations for the presence of blood clots are essential. This also explains why all deep strokes, vibrations, ischemic compression strokes, and traditional Swedish massage must be avoided on the legs (for up to three months postpartum) to avoid dislodging possible clots.
So what modality is safe and effective to use on the legs of a pregnant woman? MLD. This superficial modality uses 10–30 grams of pressure (the weight of a quarter) and no lubrication to gently stretch the skin where the initial lymph vessels are. The strokes are performed slowly, “scooping” superficially, proximal to distal, with the direction of the stroke toward the heart. This not only effectively reduces the swelling that most pregnant women experience (which is what often makes the legs and feet so achy), but it is also safe in preventing clots from coursing through the blood stream. (Vessels in the neck are drained first.)
It is essential that MLD be used on the mother’s legs throughout the entire pregnancy. I strongly suggest practitioners advise their clients of this before they get on the table. Most people believe that since their legs hurt, a deep massage will address that problem. But the cause of the discomfort is the excess fluid and the most effective bodywork technique that enhances lymph flow safely is MLD. It also will safeguard against dislodging blood clots.
For more information about MLD, read my Modalities for Massage and Bodywork, 2nd ed. (Mosby, 2015) or Hildegard Wittlinger’s Textbook of Dr. Vodder’s Manual Lymph Drainage, 6th rep ed. (Thieme, 2003).
Appropriate modalities: MLD on the legs and feet AT ALL TIMES. This technique will also address swelling in mom’s arms and hands. Never massage directly on top of varicose veins. Sacral lift and left side-lying position for relief of swelling.

Respiratory System
Shortness of breath is common in early pregnancy due to hormonal adjustments and in late pregnancy from the mother’s backward leaning and postural shifting while standing; the myofascial restrictions in her rib cage and pectorals; and the compression of the uterus on her respiratory diaphragm inhibiting normal flexion and extension. But her body uses oxygen more efficiently, even though it feels as if she can’t take deep breaths.                                                
Appropriate modalities: myofascial release, trigger point therapy, connective tissue massage, and Swedish massage.

Digestive System
As the baby grows and the uterus enters into the abdominal cavity, the organs of digestion and elimination are compressed and slightly displaced. Hormonal influences, particularly progesterone, slow down their functioning to help the mother assimilate as much nutrition as possible for her and her baby. But the sequelae of sluggish digestion can be heartburn, gas, constipation, and hemorrhoids. The weight of the uterus on the mother’s intestines and the myofascial restrictions in the pelvis slow down digestion and elimination.
Esophageal reflux is also common, particularly as the uterus expands into the abdominal cavity. Lying down can exacerbate the symptoms for these women, so treatment must be given in a semi-sitting position, with the upper torso at an angle of 45–70 degrees, or sitting upright in a chair or on a stool (not a chair massage apparatus).
At least two-thirds of all pregnant women develop nausea and vomiting of pregnancy (NVP, a.k.a. morning sickness). Wait until her nausea subsides before massaging your client, and treat the acupuncture point Pericardium 6 on both forearms (hold for a count of 6–10 seconds, repeating a total of 6–10 times) as part of your massage. The Spleen 3 acupuncture point on both feet helps balance hormones and can help with NVP.
Appropriate modalities: Swedish massage, reflex points on the feet (using 10–30 grams of pressure), acupuncture points, myofascial release, and connective tissue massage.    

Urinary System
The mother’s growing uterus puts pressure on her bladder and ureters, which can contribute to urinary incontinence. The bladder loses tone and becomes edematous, and since her immune system is suppressed, urinary tract infections are not uncommon.

Integumentary System
One of the first signs of pregnancy is often the darkening of nipples and areolae. The mother might notice a dark line from her pubic bone to mid-stomach: the linea nigra. Rashes; hives; acne (improved or worsened); dry, flaky, or itchy skin; and chloasma (the “mask of pregnancy”) are all possible as a result of hormonal changes. Stretch marks—which cannot be prevented—may have a genetic component. Her skin darkens faster, as elevated levels of melanocyte-stimulating hormones protect her against sunburns.
Avoid local massage to all skin irritations.

Endocrine System
This system becomes the master arbiter of all the changes that take place during pregnancy (labor and postpartum). There are elevated levels of estrogen and progesterone, which contribute to her emotional ups and downs, encourage fat stores in her body, and affect smooth muscle function. Increased progesterone also prevents the uterus from contracting too firmly to start labor. The pituitary and adrenal glands increase in size.
Hormones prepare the mother’s body for lactation, and the hormone relaxin, which is secreted in higher amounts between weeks 10–14, softens all connective tissue to allow her pelvis to widen for childbirth and all articulations to stretch for uterine growth. Relaxin softens the connective tissue throughout the body, resulting in lax fascia, ligaments (including the uterine ligaments that have to stretch as the uterus grows), and tendons. This contributes to joint instability and strain on weight-bearing joints as well as pelvic hypermobility and lower-back discomfort. Relaxin slows down femoral lymph absorption, which contributes to swelling in her lower extremities. The effects of relaxin stay in her body 4–6 months postpartum.

Neurological System
Most of the changes that occur to the nervous system are mitigated by the mother’s posture. Carpal tunnel syndrome and de Quervain’s syndrome are often caused by her protracted neck compressing the lower cervical vertebrae, swelling in her hands, and relaxin softening the flexor and extensor retinaculum that holds the carpals in alignment.
Sciatica in early pregnancy is most likely caused by the softening effect of relaxin on the sacroiliac joints. As pregnancy progresses, sciatica is often caused by the pressure of the heavy uterus on the sciatic region, an occiput posterior presentation of the baby, tight hip rotators (especially the piriformis), the stretching of uterine ligaments, the diastasis recti, and the anterior pelvic tilt. Sciatica is rarely caused by nerve root damage or herniated discs during pregnancy.
Sleep disturbances and headaches are also brought on by her constipation, hormonal changes, and physical discomforts.

Appropriate modalities: lymphatic drainage on the arms, myofascial release, appropriate stretches, reflex treatment points, trigger point release, strain/counterstrain, and use of appropriate body mechanics.

For more information on the treatment of neurological discomforts of pregnancy, read my Prenatal Massage: A Textbook of Pregnancy, Labor, and Postpartum Bodywork (Mosby, 2008).

Reproductive System
During pregnancy, menstruation and ovulation cease and the uterus grows to five times its normal volume. What started out as an organ weighing 2 ounces becomes a 2-pound home for the baby, placenta, and amniotic sac.
A first-time mom might not be aware of it, but her uterus is contracting throughout her pregnancy. These pre-labor Braxton Hicks contractions are not labor contractions, but serve very distinct purposes: they strengthen the uterus for labor and encourage circulation between maternal and fetal circulatory systems.
A new organ develops to support the baby: the placenta. This organ continues to grow and mature throughout pregnancy and serves numerous essential functions. It stores, manufactures, or elaborates the hormones (i.e., estrogen and progesterone) that support the pregnancy; it metabolizes fats, proteins, and carbohydrates so the fetus can assimilate these nutrients; it aerates fetal blood and takes waste products away; and it has bacteriostatic properties so the mother’s body doesn’t expel it.
Within the uterus, the baby is encased in an amniotic sac filled with amniotic fluid. This fluid is the perfect temperature for the growing baby; acts as a shock absorber against any trauma to the mother’s abdomen; permits the baby to grow symmetrically; prevents body parts from adhering to one another; provides a fluid environment so the baby can move its body parts; and is swallowed in small amounts to encourage and strengthen the sucking and swallowing reflexes at birth.
Bear in mind that you are not just massaging the woman on your treatment table—mother and baby are inextricably linked.

Benefits of Prenatal Massage
• Alleviates common discomforts of pregnancy.
• Decreases chronic muscle tension, normalizes joint range of motion, and restores postural balance.
• Elevates mood and encourages loving maternal care.
• Fosters deeper breathing and enhances internal respiration.
• Minimizes nausea and stimulates peristaltic activity.
• Prepares women emotionally, mentally, and physically for labor.
• Reduces pain.
• Reduces anxiety, stress, and tension.
• Speeds up venous and lymph circulation, brings nutrients to tissues, eliminates waste products, reduces swelling, eases varicose veins, and normalizes blood pressure.
• Supports a healthy in utero environment.

Notes
1. Marjorie R. Sable, “Pregnancy Interventions May Not be a Useful Measure for Research on Maternal and Child Health Outcomes,” Family Planning Perspectives 31, no. 5 (1999): 249–50.
2. Ibid.
3. Ibid.
4. Pathik D. Wadhwa, “Study Suggests Maternal Stress and Stress Hormones May Influence Fetal Brain Development,” University of Kentucky Chandler Medical Center, March 11, 1999, accessed October 2015, www.uky.edu/PR/News/MCPRNews/1999/maternal%20stress.htm.

Elaine Stillerman received her New York-state massage license in 1978 and began her pioneering work in prenatal massage in 1980. She is the developer and instructor of the professional certification course MotherMassage: Massage During Pregnancy and her most recent text is Modalities for Massage and Bodywork, 2nd ed. (Mosby, 2015). In 2013, she was the inaugural winner of the Alliance for Massage Therapy Education’s Educator of the Year Award and was also inducted into the World Massage Festival’s Massage Hall of Fame. Learn more at www.mothermassage.net.



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