The Benefits of Prenatal Massage

The Beneficial Effects of Pregnancy Massage

by Kate Jordan, HHP, NCTMB, CSCS

This article first appeared in the August 2007 issues of "Massage Magazine."

Pregnancy is trendy. From expectant celebrities on the covers of People and Vogue to national television features on the do's and don'ts of the pregnant state, the experience of pregnancy has come out of the closet – literally. Women are anxious to learn what's best for their bodies and their babies as they move through the 280 days of pregnancy, labor, and the postpartum period.

Pregnancy massage and massage for labor and postpartum recuperation is the newest option for women who want an optimum pregnancy outcome. As more therapists are trained to provide pregnancy-specific massage therapy, many women are being exposed to its potential and enjoying its benefits.

The profound physiologic changes produced by pregnancy necessitate bodywork approaches that both enhance well-being and can address specific dysfunctions that accompany this state. Medical research has begun to show the importance of autonomic nervous system dysregulation on pregnancy outcomes. It is especially in this area that massage can have a profound benefit on pregnancy outcomes.

Six months pregnant, Marcy arrived at my office for her first pregnancy massage appointment in a state of high anxiety. She'd learned the previous week that her placenta was attached low in the wall of her uterus. Marcy's first baby had arrived prematurely; she worried that if her obstetrician put her on bedrest, she'd be unable to care for her son, Justin, or continue working part-time as an attorney. As she settled on the table for a session of side-lying pregnancy massage, I had two therapeutic intentions. I could educate Marcy about the likelihood that her low-lying placenta would move upward as her uterus expanded, and not endanger her pregnancy. I could also apply soothing and appropriate skin stimulation that would inhibit the outpouring of stress hormones that her anxiety was producing.

When women experience stress in pregnancy, blood levels of the neurotransmitters cortisol, adrenaline and norepinephrine surge. Conversely, levels of dopamine and serotonin are suppressed by stress; low levels of these hormones are associated with mood states like anger and anxiety. Not only would Marcy's continued anxiety fuel more anxiety, it would lead to increased levels of these stress hormones in her body. Recent studies have shown extensive effects on the growing fetus of stress experienced by pregnant mothers. Not only do infants of stressed moms show higher levels of cortisol and lower levels of serotonin and dopamine, they seem to cry and fuss more as babies, and perform less well on such measures of infant development as the Brazelton scale.

Doctors in New York City studied expectant mothers who were in the area of the World Trade Center when it was struck on September 11, 2001. They found that their infants had smaller head circumferences and were more likely to suffer post-traumatic stress disorder.

Pregnancy massage delivered with a nurturing touch can lower circulating levels of cortisol and norepinephrine, increase levels of serotonin and dopamine, and measurably affect a pregnant woman's anxiety and depression Tiffany Field has reported that the decrease in stress hormone production after massage lasts as long as two weeks. Thus two-week intervals are a good baseline for pregnancy massage sessions. . Pregnancy massage also lower blood pressure; since elevated blood pressure is a marker of potential complications in pregnancy, this intervention can provide substantial benefit for women who are at risk.

With the enormous demands placed on the circulatory system during pregnancy - blood volume may increase up to 60% over pre-pregnancy levels - massage is useful in supporting the return of blood to the heart and increasing blood flow to the uterus and placenta. In animal studies, skin stimulation of the abdomen, leading to enhanced circulation, has been shown to promote normal placental development. As pregnancy progresses and the uterus enlarges and presses deep into the pelvic bowl, venous return to the heart is hampered. Gentle lymphatic drainage in the third trimester relieves symptoms of edema, and heaviness in the legs and feet.

Feelings of ambivalence about her pregnant state, fears for her baby's well-being, and fear of labor are common in pregnant women. Massage therapists will likely spend more time with their pregnant clients than their obstetricians, midwives. The educated therapist has a significant opportunity to provide skilled therapeutic touch, reassurance and education to her pregnant client.

Anna Lisa came to my office for massage in her 4th month of pregnancy. Her pregnancy was troubled; she was estranged from her baby's father, and unbeknownst to her employers, she was attempting to continue her career as a model. Her pregnancy was complicated by body image issues that had led to her bulimia as a teenager. During her pregnancy massage sessions, my therapeutic goal was to nurture this emerging mother, as well as her baby, by reassuring her about her appearance and offering encouragement for her to touch and welcome her enlarging belly.

Reva Rubin, a nursing professor at the University of Pittsburgh's nursing school was able to show that mothers who received what she called “appropriate, meaningful touch” - back stroking delivered by office nurses during prenatal visits - were later able to touch their own babies in a “meaningful, effective and caring” way. Other research has shown that the more touch mothers receive in pregnancy, the more likely they are to stroke, smile, and talk to their infants, and thus to bond with them.

With more mothers with children under of the age of three in the workforce, infants and young children are often cared for in group settings where there is infrequent touching by caretakers. Child carriers have replaced arms and laps as holders for many babies and young children. Pregnant women who have received massage are far more likely to later massage their babies.

Experiencing regular massage during pregnancy can improve pregnancy outcomes in other significant ways. Tiffany Field found that women who received pregnancy massage had fewer premature births. In 2006, more than 470,000 women in the U.S. delivered their babies before term (37 weeks or less), putting the infants at greater risk for neurological, developmental and other deficits.

As more women undergo fertility treatments, the number of multiple births has risen in the U.S. Mothers of twins are seven times more likely to deliver prematurely; mothers of triplets or more infants are 20 times more likely. Regular pregnancy massage supports a woman in carrying multiples closer to term. Kate Bateman, who practices at Kadlec Medical Center in Richland, Washington, recently worked with a woman pregnant with triplets who was hospitalized for a month. She described her 15-30 minute massage from Kate as “the highlight of my day.”

Between 4 -10% of pregnancies are considered high-risk, because of maternal circumstance (e.g. over age 40, history of miscarriage), a chronic condition the mother suffers (diabetes, rheumatoid arthritis), or complications like high blood pressure that may have developed during the pregnancy. Women in high-risk pregnancies often benefit the most from pregnancy massage. Ning immigrated from China as a teenager. I had seen Ning four years previously for massage during an uneventful pregnancy. This time, her baby had a serious heart defect, and she was naturally very concerned for the baby's health. Her high-risk specialist readily approved of pregnancy massage as an adjunctive treatment. Ning received weekly massage for the last 12 weeks of her pregnancy, delivering a baby who appeared so healthy that the neonatal nurse thought it must be her older sister who had the heart defect.

I strongly recommend that practitioners providing massage therapy to clients in high-risk pregnancies request medical releases from the individual's pregnancy care provider. Not only do release forms acknowledge a therapist's scope of practice, they can allay the fears of a pregnant woman or her family members on the appropriateness or safety of massage for a high-risk pregnancy.

Bedrest is often used as a strategy to prevent or postpone pre-term labor, and to treat other complications of pregnancy. Laurie Aronovici is a labor and delivery nurse at Henrico Doctors Hospital in Virginia. She provides massage therapy for patients who have been admitted to the antepartum floor of the hospital on bedrest for a variety of pregnancy-related issues. The hospital provides information about her services in packets provided to these patients. Some travel to her office by wheelchair; those on strict bedrest receive massage in their hospital beds. Bedrest leads to reduced cardiac output and stroke volume, which decreases the ability of the cardiovascular system to return blood to the heart. This effect can be even more pronounced in pregnant women because of the increased thoracic pressure from the enlarging uterus. Gentle Swedish massage and lymphatic drainage techniques can aid venous return to the heart, and enhance blood flow to the placenta of a woman on bedrest.

Women placed on bedrest, whether at home or in the hospital, also show higher levels of anxiety, depression, and complaints than matched controls not placed on bedrest. Massage therapy is useful in reducing stress and relieving the musculoskeletal dysfunctions that result from prolonged bedrest. In the hospital setting, massage services are often provided in the hospital bed, with allowances made for positioning restrictions dictated by the patient's doctor. Massage applications can range from “just the feet,” to relaxation/comfort massage, to application of specialized techniques like Strain CounterStrain.

Holly Boyle provides antenatal massage at Anne Arundel Medical Center in Maryland. Patients who are on bedrest, or who demonstrate anxiety or the presence of emotional issues, receive doctors’ orders for twice-weekly massage. Holly has seen consistent reductions in pregnancy-induced hypertension (PIH), anxiety and musculoskeletal pain, and increased circulation with reduced edema in her hospitalized patients.

Many pregnant women are aware of the existence of doulas, or specially trained birth attendants. They may not know that there are massage therapists trained as both labor assistants and touch therapists, who can provide sophisticated and skilled touch support and intervention during labor. Labor massage is useful to women having unmedicated or medicated births. Labor progress is significantly impacted by a mother's psychological state. The uterine muscles contract in a non-productive way when a woman is in a state of high sympathetic arousal, which can be caused by fear, anxiety, or severe pain. Psycho-social factors condition each individual woman's experience of her labor; an experienced therapist can work with a laboring woman and empower her to cope with the intense stimulus of labor. This work includes focused touch and specific techniques which reduce pain perception and stimulate productive labor contractions.

Deborah Strauhal, a pregnancy massage therapist in private practice in San Diego, has worked as a volunteer doula at the University of California San Diego Medical Center. She has found that younger women are more vulnerable and less prepared for the emotional roller coaster of labor, and that skilled touch and reassurance can ease their way in the often alien to them environment of the hospital birth setting. Sometimes massage therapists providing labor support do even more. Mary Beth Hastings of Takoma Park, Maryland recently provided pregnancy massage for a client throughout her pregnancy, and contracted to provide labor massage at her birth in a freestanding birth center staffed by nurse-midwives. The client's labor progressed more quickly with her support than the midwives expected. As the mother felt her baby moving down the birth canal and no midwives were available, Mary Beth helped move the baby out of her mother's body and into the world.

After a baby is born, postpartum massage therapy can alleviate the musculoskeletal complaints of new mothers and provide emotional support and nurturance during their critical life transition. At Holly Boyle's hospital, postpartum women are seen within eight hours of a vaginal birth, and 24 hours after a C-section or other complication of delivery. Patients receive one 20-minute postpartum massage session. Normally this session is not done using lubrication unless the patient requests her own cream or oil. Except for compression stockings and socks, clothing is not removed, and then only if the patient has already been active and the attending RN notified. Postpartum massage in the hospital setting provides relief of low back or pelvic pain, relief of the pain of spinal headache caused by epidural anesthesia, relief of reflex shoulder pain after C-section, and general relaxation and sleep promotion. Holly has found that the presence of the massage therapist can be a tactful way for the new family to usher out family and friends who have stayed too long!

Later, in the therapist's office, postpartum massage can address the musculoskeletal discomfort induced by long hours of baby feeding and baby care, as well as residual dysfunction that may have developed during pregnancy or labor. Postpartum women need help in reorienting their bodies to post-pregnancy structure: otherwise, they tend to maintain anterior positioning of the shoulders and pelvic girdle, leading to neck, upper back, and low back pain later in life. The skin and superficial fascia of the abdomen can be treated immediately after birth to minimize the distortion of connective tissue layers that so often follows pregnancy.

Pregnancy massage is now being offered throughout the United States in a wide variety of settings. Individual practitioners like Gina Buonpane, who owns Every Mother Massage in Oakland, California, specialize in working with pregnant women and their partners through all phases of the childbearing experience, including classes for expectant fathers to prepare for labor. Other practitioners work in obstetricians’ offices. Laurie Aronovici was sent by a large OB-GYN practice to learn pregnancy massage after one of the doctors did an informal survey of 300 of their maternity patients. They all ranked pregnancy massage as the number one addition they would like to see in their doctors’ practice. Some massage therapists work in fertility clinics where massage therapy has been seen as useful in relieving the high levels of anxiety experienced by women and their partners undergoing fertility treatment. Many U.S. hospitals now offer massage therapy as part of complementary care; therapists work standard shifts, usually seeing patients in one-hour blocks in treatment rooms, and in 15- to 30- minute blocks in hospital rooms. Some hospitals also employ massage therapists to provide labor support on an as-needed basis under the direction of attending labor and delivery nurses.

In Madison, Wisconsin, Lisa Shepherd works with an acupuncturist who specializes in pregnancy and fertility issues. She sees most of the acupuncturist's patients in conjunction with hers, as does Meredith Gade who works with a chiropractor in Virginia who specializes in women's issues. Physical therapy clinics specializing in women's health also employ massage therapists.

One of the most rapidly-expanding settings for pregnancy massage is the spa. Day spas, hotel spas and destination spas are beginning to offer pregnancy massage to guests. As with other spa services, this may be a setting in which therapists are not adequately trained to provide a safe and appropriate pregnancy massage.

Medical Massage for Pregnancy

As women move through their pregnancies, they often develop musculoskeletal dysfunction that is unique to the pregnant state. Common pregnancy-specific dysfunctions include cervical myospasm, especially of the scalenes and sub-occipitals; upper back pain from the levator scapula and trapezius muscles and upper ribs; intercostal neuralgia, quadratus lumborum and piriformis strain; lumbo-sacral, sacroiliac and pubis symphysis dysfunction; and adductor strain.

Medical massage using myofascial release, muscle energy technique, Strain CounterStrain, assisted-resisted stretching, acupressure and other reflex techniques can target and alleviate these sometimes disabling conditions of pregnancy.

Karen came to me late in her fifth month of pregnancy. She was limping badly. I had seen her five years previously as a patient during her first pregnancy. She was an engineer, and didn't really “need” massage at any other time in her life. At 39, Karen was pregnant with twins; she had already gained 45 pounds and was experiencing severe right hip pain which made it impossible for her to sleep and difficult for her to walk. Using a combination of techniques, we were able to relieve Karen's condition in three weekly sessions. I encouraged her to use a specialized hip pillow for the remainder of her pregnancy, so she could remain comfortable.

Medical massage is also extremely useful in the postpartum setting. Unlike the Scandinavian countries, for example, there is no provision for “after care” of postpartum women in America. A fellow long- distance cyclist referred Kristin to me. An athletic trainer, Kristin had been comfortable cycling and racing until after the birth of her second child. For the next two years, she experienced severe pain in her right hip that prevented her from biking more than five miles without pain. We found the source of her pain in her psoas muscle. After two treatments, she has recovered enough to resume intense training.

Because of the profound effects of massage on major body systems - the autonomic nervous system, the circulatory system, the musculoskeletal system - any pregnancy massage done with appropriate positioning, observing contraindications for technique and location, will have significant benefits for the pregnant woman, the outcome of her pregnancy and her future family.

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