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September/October 2009 Issue

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Proceed With Caution

Foot/Ankle Massage for Pregnant Clients

By Leslie Stager
[Feature]

Most massage students have heard the warning, “Don’t touch a pregnant women’s ankles,” yet few can articulate definitive reasons for this contraindication apart from a generic fear that it will trigger contractions. Considering the high percentage of miscarriages each year, perhaps there is good reason for caution, yet the warning does not appear to be based on research or even much anecdotal evidence. It does raise questions, however: How did this concern about touching the ankles develop and is there documentation to validate it? Is gentle touch during pregnancy powerful enough to cause harm?

 

As a pregnancy massage specialist and author of the textbook Nurturing Massage for Pregnancy: A Practical Guide to Bodywork for the Perinatal Cycle (Lippincott Williams & Wilkins, 2009), I researched further with the intent of either alleviating unnecessary fears or clarifying what precautions are truly necessary. This article is based on journal research, interviews with bodywork and obstetrical specialists, and personal experience. It explores the “ankle” contraindication, reasons why it developed, and presents the information and conclusions gathered from this investigation.

History of Touch During Pregnancy

For thousands of years, midwives and traditional birth attendants have used touch as an integral part of perinatal care to maintain optimal fetal positioning, to assess a mother and baby’s well-being, to support or stimulate contractions, to relieve pain during labor, and to release a retained placenta or prevent hemorrhage after delivery. Birth was considered a natural event that was not without its inherent risks, but often a skilled attendant—who used her hands to palpate and sense the condition of those seeking her care—helped mitigate those risks.

With the development and expansion of the medical establishment in the early 1900s, doctors—rather than traditional midwives—became the overseers of the birth process. Birth became a medical event and the use of touch as a means of evaluating and supporting pregnancy was eventually replaced by other technologies. Pregnancy was identified as a dangerous and fragile condition with many forms of activity viewed as potential adversaries to a healthy outcome.

In the 1970s, natural birth pioneers, such as Frederick Leboyer, began to promote the idea of a gentle, less medical birth. By the late 1980s, birthing centers became popular as they focused on creating a home-like environment. This movement coincided with the mainstream expansion of natural and complementary healing modalities, such as massage. While some anxieties about the safety of pregnancy were diminishing, massage therapists were being taught that it was potentially dangerous to massage pregnant women.

The 1990s brought increased research about pregnancy health, and prenatal massage finally began to be recognized as beneficial. Research indicated that massage could help decrease stress and the production of catecholamines (stress-related hormones), improve hormonal functions, speed labor, reduce pain from contractions, and increase the frequency and ease with which a mother touched her new infant, benefits known to traditional birth attendants long ago.

Even with a growing body of research, some myths and fears still linger today regarding the safety of perinatal massage. Some students are taught not to massage in the first or second trimester, others learn not to touch the pregnant abdomen. One of the most common myths still propagated, is that massaging a pregnant woman’s ankles can be dangerous, possibly stimulating miscarriage or labor. Despite the prevalence of this contraindication, there is no evidence that ankle massage is dangerous. The concern may have developed from specific information that was gradually altered through oral transmission, eventually becoming generic and essentially useless.

the Contraindication

Understanding the rationale behind a contraindication empowers practitioners with knowledge and the ability to practice more safely. As we examine the warning against ankle massage—which has permeated not only massage schools, but the general public as well—we must seek clarification. What is really meant by the ankles? Is it the boney malleolus or does it include the inner calf and foot? What type of massage it is referring to—all touch, or specifically to effleurage, deep tissue, acupressure, shiatsu, or reflexology? The term massage is not clearly defined, but to be relevant to massage therapists, one might assume that it refers to effleurage or other Swedish massage manipulations. It does not seem to specify acupressure, which is the only technique that actually may have a relevant contraindication.

The following quotes demonstrate the abounding misinformation and various interpretations of this contraindication, as well as the ease with which myths can be perpetuated:

• “Don’t undergo reflexology from a therapist who is not trained to work with pregnant women. Certain reflex points on the lower legs, around the ankles, and in other areas may cause contractions.”1 

• “My doctor told me no foot massage. She said that if foot massage is done incorrectly, it can induce preterm labor.”2

• “… [ankle massage] is safe but there are two points you should avoid. One is in the arch of the foot and the other is on the inside of the ankle about 2 inches up from that ankle bone that sticks out. You can rub gently over those areas but nothing vigorous or constant.”3

• “My friend is a certified pregnancy massage therapist and he won’t massage woman’s feet because he doesn’t want to be sued if something goes wrong. They taught him not to in school.”4

These quotes represent a generalized fear about causing harm during pregnancy. In these examples, the clients of one therapist miss out entirely on foot massage, reflexology gets a bad rap as potentially dangerous in pregnancy, a doctor warns against foot massage, and the location of potent acupoints are described with total inaccuracy.

This demonstrates four common reasons that the prohibition of ankle massage during pregnancy seems to have developed:

1. There is still a common belief that pregnancy is a delicate or dangerous condition.

2. There is misinformation about uterine and ovarian reflexology zones located around the ankles.

3. There is misinformation about acupressure points near the ankles that may be used to support labor.

4. There is an underlying fear of being sued if a woman miscarries after a massage.

a Fragile Condition

The perception of pregnancy as a vulnerable and fragile state, and the fear that miscarriage or contractions can easily be triggered, has developed in part due to unfamiliarity with the birthing process, and in part due to the fact that there is uncertainty associated with any early pregnancy. Miscarriage—birth before 20 weeks gestation—is very common during the first trimester of pregnancy, occurring in about 15 percent of pregnancies annually.5, 6, 7 The vast majority of these occur before 12–13 weeks gestation. According to the Centers for Disease Control and Prevention (CDC), of the 6.40 million estimated pregnancies in the United States in 2000, miscarriage occurred in 1.03 million.8 The numbers are much greater when we consider all the miscarriages that happen too early to be recognized or reported as pregnancies.9

Most miscarriages result from a healthy response to the early abnormal development of an embryo. Other known associations include maternal issues, such as cervical or uterine problems or conditions such as diabetes, infection, or virus. Miscarriage is also associated with increased paternal age,10, 11 as well as maternal drug use. Women who have three consecutive miscarriages in the first trimester have a 35 percent chance of having another miscarriage.12 Women with this experience will often have a significant level of anxiety during consequent pregnancies until well past the time of the previous miscarriage. Massage can be very helpful at this time by encouraging relaxation and self-care, although very deep lower abdominal work that could unintentionally physically manipulate the newly pregnant uterus is contraindicated.

Preterm labor is defined as the onset of contractions that change the cervix and put the baby at risk of being born before 37 weeks gestation. Early contractions without cervical changes can be caused by simple things, such as dehydration or urinary tract infection, while more serious preterm labor can be caused by issues with the baby’s health, a shift in hormones, rupture of the amniotic sac, or infection. Most often the cause is unknown.

Despite the prevalence of miscarriage and the fear of preterm labor, gentle therapeutic massage to the feet and ankles is not an associated cause. According to obstetrician Pete Chandler, as well as midwives Carol Gray and Sue Firman, CNM, if contractions could be intentionally started with a few minutes of effleurage to a woman’s ankles, everyone would use synthetic hormones to avoid medical inductions of labor.

Reflexology Zones

Reflexology has also been, at times, labeled as dangerous during pregnancy. Under the medial and lateral malleoli are reflexology zones related to the uterus and ovaries (Image 1). Not uncommonly, therapists express concern that reflexology might be overly stimulating in the first trimester of pregnancy, or that reflexology or massage to the uterus and ovary reflexology zones will cause contractions. Dwight Byers, director of the International Institute of Reflexology, is emphatic that massage cannot stimulate the uterine and ovarian reflexology zones, and that reflexology itself applied to these zones will not stimulate miscarriage or preterm contractions.

Both Byers and Christopher Shirley, director of the Pacific Institute of Reflexology, describe reflexology as facilitating improved blood supply to the cells of the organs in the corresponding areas of the body. This, in turn, facilitates optimal physiological functioning. Stimulation of the pelvic reflex areas around the ankles produces relaxation and reduction of stress and can be offered safely throughout pregnancy. Rather than dangerous, the effects of reflexology to the ankles may actually reduce the occurrence of miscarriage by helping nurture a healthy maternal environment and supporting the developing fetus.

Byers agrees with the midwives: “If it was that easy to stimulate labor, reflexologists would have a big business running reflexology-induced abortion clinics and pregnant women, partners, midwives and doctors would use this noninvasive method for inducing labor.”

Suzanne Enzer, a midwife, nurse, reflexologist, and author of the Maternity Reflexology Manual (Soul to Sole Reflexology, 2004), says that reflexology cannot, does not, and will not make the body do something unnatural. The balancing and harmonizing qualities of reflexology will enhance the woman’s own self-regulating mechanisms. Reflexology may give a boost of energy and tip a woman into labor if her body was already prepared to birth, but cannot induce labor otherwise.

The primary danger with reflexology during pregnancy, many reflexologists say, is the use of very deep pressure by inexperienced practitioners that can cause pain and/or damage to edematous tissues. Deep pressure that is painful also causes stress, counteracting the benefits of nurturing touch.

 

Acupressure Points

Another common reason cited for avoiding massage to the ankles is the fear of stimulating acupressure points that might trigger contractions. Again, misunderstandings abound regarding the use, locations, and methods of accessing acupoints, as well as the differences between acupressure as opposed to acupuncture prohibitions. Some acupuncture contraindications exist to prevent causing direct harm using the needling technique. These points are not necessarily contraindicated for acupressure.

Acupressure and shiatsu can be used to support the induction of labor when desired; however, in order to have any hope of encouraging uterine contractions, a different type of touch is required than is provided by general massage. Acupressure typically requires applications of direct pressure stimulating specific points over a period of hours or days in order to have a lasting and cumulative effect. Even then, many skilled practitioners are not successful in inducing contractions.

Acupoints that are often considered useful in efforts to stimulate contractions are located on the inner leg, hand, sacrum, and one adjunctive point just posterior to the lateral malleolus—Bladder 60 (Image 2). However, there are discrepancies in massage and acupressure texts regarding prohibited acupoints. A variety of points around the ankles are sometimes listed as contraindicated, including Kidney 3, Kidney 4, Kidney 5, Kidney 8, and Bladder 62.13, 14, 15  These points can be used to support labor, calm the mind, beneficially influence the uterus, drain heat, move blood, or relax the back. But they are not considered points that trigger contractions and are not standard contraindications during pregnancy.

Bladder 60 is the only point around the ankle that the majority (but not all) of the sources I researched referred to as contraindicated. It has properties of drawing energy downward and is often used in combination with other points when attempting to induce labor.

Acupuncture and acupressure specialists indicate that there are no blanket contraindications for acupoints and some suggested that the stimulation of acupuncture points to help induce labor or dislodge a fetus may be “way overrated.” Chad Dupois, LAc of the Chattanooga Acupuncture and Wellness Center writes, “As with all of acupuncture, nothing is ever set in stone. There are people/styles [of acupuncture] who regularly use contraindicated points during pregnancy.” An example of this is a study investigating the use of acupuncture for reducing back pain in pregnancy that used the ankle point Bladder 60 on subjects between 12–30 weeks pregnant, with no ill consequences.16

Acupressure has its own rules of practice and contraindications and can be very powerful when properly applied. But the question being explored here is whether massage can stimulate these contraindicated acupoints, resulting in serious consequences. Bronwyn Whitlocke, LAc and author of Shiatsu Therapy for Pregnancy (Spinifex, 1999), says gentle massage or acupressure applied to the ankles with the intention of relieving discomfort will not cause harm or induce labor. Instead, it can help reduce edema in the feet and therefore be beneficial. She finds acupressure to be more subtle than acupuncture. When working with a woman due for labor, she stimulates points hourly with deep and continuous pressure over 2–3 days in order to affect the type of cervical changes that she might see in a shorter time span with acupuncture. One session on the ankles in an effort to promote labor will not be effective.

 Debra Betts, LAc, RN, and author of The Essential Guide to Acupuncture in Pregnancy and Childbirth (Journal of Chinese Medicine, 2006) finds Bladder 60 to be stimulating to the uterus. She feels that general massage could stimulate this acupressure point and cause an undesirable result if combined with Spleen 6 (on the medial calf) and used with strong pressure over a period of time on a woman who is susceptible and sensitive to acupressure points or who is at high risk for miscarriage. The concern is greater, she states, with pregnancies earlier than 12 weeks or later than 36 weeks, when the risks of miscarriage or preterm labor are greatest. She suggests avoiding touch to this and all the contraindicated acupoints during pregnancy.

On the other hand, Suzanne Yates, bodyworker, antenatal educator, and author of Shiatsu for Midwives (Books for Midwives, 2003), says that she often gently massages around the ankles with light pressure as she connects with the mother’s womb. “I have done this kind of work for 18 years now and not had any problems. Indeed, I feel it is of benefit. In the first trimester, it is calming and supporting the flow of the jing, an important energy which nurtures the baby.”

Stephanie Halderman, EMT, director of the Eastern Holistic Center, has been instructing acupressure and massage for pregnant women for years, and says she has not learned of Bladder 60 being a contraindicated point. “B60 is not a forbidden point, so it is safe to massage. Light, gentle, full strokes [effleurage] is fine and will not induce labor around the ankles (but focused work can),” she says.

Kensen Saito, director and co-founder of the International Academy of Tokyo in Canada and author of Shiatsu-doh (Cross Media, 2004), trained under Tokujiro Namikoshi, the founder of shiatsu whose motto was, “The heart of shiatsu is like a mother’s love. Pressing the human body stimulates the fountains of life.” Saito says that safety is the key to treating clients. He works gently on the whole body with pregnant women, including the ankles in most cases. The only danger and concern Saito expresses is the improper application of pressure that may be too deep and strong. This type of intensive pressure application would be injurious to both the tissues and the emotion of the client, he says.

In the End

Ultimately, the ankle massage warning seems to refer to stimulation of acupoint Bladder 60. The other ankle points that pregnancy massage sources have labeled with concern do not have properties that bring on contractions, and may actually support a pregnancy. So the question remains: what is the likelihood of causing significant or dangerous contractions by stimulating Bladder 60 with stroking and squeezing along the Achilles tendon for a few moments during a foot massage?

The likelihood seems remote for several reasons: massage therapists typically do not repetitively massage one specific spot posterior to the ankle for extended periods; general effleurage does not have the same effects as acupressure; and Bladder 60 is not generally used alone or as a primary contraction stimulator. This is not to say that one should rub the Achilles tendon with gusto for hours on end. Nurturing, gentle touch is always expected and appropriate during pregnancy.

Clarifying contraindications can reduce both therapist and client’s fears about the delicacy of pregnancy and improve awareness about the prevalence of miscarriages unrelated to external forces. If we have concern about stimulating Bladder 60 with effleurage and want to avoid it, then to be consistent, we must, as Betts says, also avoid massage to areas of all the prohibited points. Ironically, the more powerful contraindicated acupoints on the hand (Large Intestine 4), inner calf (Spleen 6), and sacrum (Bladder 32) have not formerly elicited massage contraindications.

Alternatively, we can offer nurturing gentle massage that includes those areas, while following more critical and relevant guidelines for safety in positioning, pressure, and observation for thrombosis and varicose veins. And we can educate the public on the benefits and safety of prenatal massage along the way.

 Leslie Stager, RN, LMT, is a perinatal massage specialist, doula, writer, and hospice nurse. She has taught perinatal bodywork at the Oregon School of Massage since 1993, initiating the 60-hour Maternity Massage certification program in 2007. She is the author of Nurturing Massage for Pregnancy: A Practical Guide to Bodywork for the Perinatal Cycle (Lippincott Williams & Wilkins, 2009) and the instructor on the DVD, Mastering Pregnancy Massage. Her other DVDs, Mothertouch: Nurturing Touch for Birth and the upcoming Touch Techniques for Birth, are based on her experience attending hundreds of hospital and home births. Reach her at touch4birth@gmail.com.

Notes

1. Colleen Moriarty, “Soft Touch,” Fit Pregnancy. Available at www.fitpregnancy.com/style/113?subsection=beauty& (accessed July 2009).

2. Online discussion. Available at http://forums.online-sweepstakes.com/showthread.php?t=639959 (accessed July 2009).

3. Ibid.

4. Ibid.

5. The Merck Manual of Medical Information, 2nd ed., M.H. Beers, ed., (Whitehouse Station, N.J.: Merck & Co., 2004-2005).

6. Early Pregnancy Loss: Miscarriage and Molar Pregnancy, ACOG Education Pamphlet Item #AP090 (American College of Obstetricians and Gynecologists, 2002).

7. R. Rai and L. Regan, “Recurrent Miscarriage,” Lancet 368, (2006): 601-11.

8. S. Ventura et al. “Estimated Pregnancy Rates for the United States. 1990-2000: An Update.” National Vital Statistics Report from the U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, 52, no. 23 (June 15, 2004).

9. A.J. Wilcox et al. “Early Loss of Pregnancy,” New England Journal of Medicine 319, no. 4, (1988): 189–94.

10. K. Kleinhaus et al. “Paternal Age and Spontaneous Abortion,” Obstetrics & Gynecology 108, no. 2 (2006): 369-77.

11. R. Slama et al. “Influence of Paternal Age on the Risk of Spontaneous Abortion.” American Journal of Epidemiology 161, no. 9 (2005): 816-23.

12. “Report to the NACHHD Council,” National Institute of Child Health and Human Development, NIH, DHHS. Division of Epidemiology, Statistics, and Prevention Research (DESPR), NICHD. (Washington, DC: U.S. Government Printing Office, 2001). Available at www.nichd.nih.gov/publications/pubs_details.cfm?from=&pubs_id=128 (accessed September 2007).

13. Elaine Stillerman. Prenatal Massage: A Textbook of Pregnancy, Labor, and Postpartum Bodywork (St. Louis: Mosby Publishing, 2008).

14. Carole Osborne. Pre and Perinatal Massage Therapy (San Diego: Body Therapy Associates,1998).

15. Bette L. Waters. Massage During Pregnancy, 2nd ed. (Mesilla, NM: Blue Water Press).

16. N. Kvorning et al. “Acupuncture Relieves Pelvic and Low-back Pain in Late Pregnancy,” Acta Obstetricia et Gynecologica Scandinavica 83 (2004): 246-50.

 

 

 

Legalities

Despite the difficulty of intentionally inducing contractions with bodywork, one of the greatest fears therapists have about working with a pregnant woman is doing something that could cause her to miscarry or experience preterm labor. Not only would the burden of guilt be unbearable in thinking that your nurturing touch caused a miscarriage, but potential litigation is frightening as well. Could a massage practitioner be held responsible for a miscarriage if they did indeed rub the ankles of a pregnant woman? I could uncover no legal evidence of a case where massage to the ankles was shown to be related to miscarriage.

As for anecdotal evidence, none of the experts interviewed for this article knew of any successful lawsuits. Enzer had heard of two unsuccessful lawsuits against reflexologists—one in the United Kingdom and one in Australia—where the reflexologists were accused of causing a miscarriage with their work. The outcomes were in favor of the reflexologists, but tensions and fears increased.

One massage therapist reported that years ago at a spa in California, a massage therapist was unsuccessfully sued when a pregnant client suffered a miscarriage after the massage. The therapist was accused of rubbing the client’s ankles and causing the miscarriage, but there was no evidence to support the case.

We live in a litigious culture, and miscarriage can breed fear and angst for women, leading them to seek a reason for their loss. However, there is no research or evidence to support a lawsuit accusing a therapist of causing a miscarriage by rubbing the ankles.

 

 

 

Ultimately, It’s Her Call

Some clients will have heard that touch to the ankles must be avoided during pregnancy. If they are hesitant or concerned despite your reassurances, by all means abide by their wishes. The ankles will not miss a little touch, and the mother will feel more relaxed knowing you are respectful of her concerns.

 



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