pregnancy massage learner guide€¦ · by the end of the 3rd month the nipples and the areola...

Pregnancy Massage

Learner Guide

Massage Schools of Queensland Pregnancy Massage

3

CONTENTS: - Anatomy and Physiology of pregnancy

- Understanding of the stages of pregnancy

- How to help alleviate non pathological discomforts during pregnancy

- Contraindications to massage - Safe and comfortable positioning of client

- Adaptation of massage strokes, areas to avoid

- Massage routine for pregnancy - Postpartum massage


4

ANATOMY AND PHYSIOLOGY OF PREGNANCY

UTERUS

The changes in the uterus during pregnancy have the greatest impact on the positioning of a pregnant woman on the table.

Non-pregnant woman: pear-shaped, almost solid, weighs approx.70g, supported by the round ligament to the labia major, broad ligament to the wall of the pelvis.

Pregnant woman: weight increases 300% to 1100g, size increases up to 1000%, rises into upper abdominal cavity and to the front, displacing organs up and to the side. See pictures on page 4.

Behind the uterus lies the inferior vena cava and descending aorta. They can both be compressed by the big weight of the pregnant uterus when the woman lies supine. This creates a condition called Supine Hypotensive Syndrome.

NON PREGNANT FEMALE


5

PREGNANCY AT 5 MONTHS UTERUS AT BEGINNING OF 9 MONTHS

ROUND LIGAMENT


6

CERVIX Soon after falling pregnant, the cervix will change its consistency and seal the inside of the uterus with the mucous plug.

This mucous plug will be expelled before the birth, several days before to up to a couple of weeks before.

It looks clear with red/brownish streaks gummy, sticky or can be lost over several days in a stringy discharge.

If a woman loses her mucous plug before the 9th month, she should check with her doctor/midwife.

SKIN

There are several skin changes in pregnancy:

Increased blood flow to the skin means that pregnant women will feel warmer than the people around them.

50 % women will get some stretch marks (striae gravidarum), possibly related to the amount of collagen in their skin. The colour will fade 3 -4 months after birth to blend in with the surrounding skin.

Nourishing creams and gentle massaging of the skin can be helpful, but cannot prevent them. Pregnant women should not use Vit A or Retin-A creams, as it can be harmful to the foetus.

Pigmentation changes: Linea Nigra is a dark line that runs from the umbilicus to the pubis area. It is absolutely normal during pregnancy and will fade in the months following delivery.


7

Irregular brownish patches on the face and sometimes the neck also occur, called Mask of Pregnancy, Chloasma or Melasma Gravidarum.

These conditions are increased melanin deposits in the skin brought on by the hormonal changes during pregnancy.

Cuteaneous vascular changes: About 65% of Caucasian women will develop some spider angioma, Spider Nevi or Angiomas, also known as spider veins.

They are caused by an excess of estrogen being produced by the body.

Also blotchy red palms, Palmar Erythema occur with a simlar frequency and will disappear shortly after delivery.

Moles: The growth promoting hormones in the pregnant woman’s body might cause moles to grow, either preexisting or new.

The woman should check with her doctor.

BREASTS

The first signs of pregnancy are often tenderness and tingling of the breasts.

By the end of the 3rd month the nipples and the areola around them will grow larger and darken. The sebaceous glands around the nipples called Glands of Montgomery can enlarge and show up as little bumps.

The breasts will grow according to every woman’s unique constitution.

Already during pregnancy the breasts can occasionally leak some colostrum which this is a completely normal occurance.

Stimulation of the breasts is absolutely contraindicated during the pregnancy, as it stimulates the release of the hormone oxytoxin which stimulates contractions of the uterus.


8

LYMPHATIC SYSTEM The water metabolism changes in pregnancy so that more fluid is retained in the tissues. This is brought on by the hormonal changes which influences thirst and kidney function.

Full term pregnant: +3 l in blood volume +3.5 l fetus, placenta, amniotic fluid

There is a normal oedema happening to most women in their extremities, which accumulates during the day and is usually not noticeable when getting up in the morning.

If there is more swelling in the morning after getting up than in the evening,it is an abnormal oedema and this can be an indication of a dangerous condition called toxemia. It is usually accompanied by high blood pressure and needs to be treated.

CARDIOVASCULAR SYSTEM

Pulse rate increases by 10-15 beats per minute.

Cardiac output is higher, especially when lying on the side.

Blood volume increases by up to 100%

Around 90% women have a heart murmur.

Increased risk of Deep Vein Thrombosis, especially for women who had been on the pill before pregnancy and those with a sitting job.

For your massage that means: -check those conditions with your client, -check for a positive Homan’s sign, -don’t use deep long strokes on the legs but switch your massage techniques to a lymphatic routine for the legs.

Risk of Supine Hypotensive Syndrome When a pregnant woman is lying in the supine position, the enlarged uterus will be pressing on the vena cava, which lies behind the uterus. This is an important vein transporting the blood back from the lower half of the body to the heart. Also the descending aorta can be compressed If the vein is compressed and return of the blood to the heart is diminished as it has many consequences:


9

- Decreased cardiac output - Decreased blood flow to the kidneys - Decreased sodium and water excretion - Increased oedema - Less blood flow to the brain causing dizziness - Compression of descending aorta: - Increase in femoral blood pressure – varicose veins.. - Decreased supply of oxygen and food to fetus causes stress - Possible compression of ureters at the pelvic rim

Dizziness is the last symptom to be experienced and detrimental effects are happening much earlier.

Best not to place a pregnant woman in the supine position at any stage of her pregnancy, definitely not after the first trimester. (see chapter on positioning your client – from page 15 onwards)

There is no need to advise clients not to sleep in the supine position as the body has its own wisdom and it is better not to worry the woman if she wakes up lying supine.

METABOLIC CHANGES Fat metabolism: there will be an extra store of fat during the second trimester of pregnancy to be available for labour. It is normal for pregnant women to have higher cholesterol and other lipids levels in the blood.

Of course a pregnant woman will have an increased appetite and will gain weight; a normal weight gain is at least 3 kg by the end of 5 months, then approx. ½ kg per week. This means a total weight gain of approx. 4-6 kg by the end of term. If a woman has started the pregnancy overweight, less weight gain is desirable.


10

MUSCULOSKELETAL SYSTEM

ELASTICITY OF TENDONS, LIGAMENTS, FASCIA

As the pregnancy progresses, the mother's body releases different hormones that have been labelled as "relaxins". These hormones have the effect of increasing ligament and tendon elasticity causing the joints of the body to become unstable. This is important in the delivery process so that the pelvis will be able to expand allowing the baby to pass through the birth canal. However, during the pregnancy unstable joints coupled with the dramatic changes in uterine and abdominal size can lead to numerous structural imbalances in the body. Abdominal Wall

PROGRESSIVE LORDOSIS As the centre of gravity shifts in the pregnant woman’s body, there will be a progressive lordosis happening in the lumbar spine. This is quite normal, but if lower back pain develops, the massage therapist can help to relieve the tensions and teach your clients the pelvic tilt (only to be done standing or sitting, NOT supine or on all fours)

ABDOMINAL WALL

The abdominal wall musculature (abdominis recti) experience a lot of extra tension and pressure during pregnancy and will fairly often develop a separation in the midline called diastasis. This results in a severe loss of muscle tone and needs to be healed through corrective exercises in the 6 weeks after delivery.

Failure to correct this separation means future lower back problems, “jelly belly”, problems in the next pregnancy with the baby lying in breech or feet first or transverse


11


12

CHECKING FOR DIASTASIS RECTI In the first week after delivery you should check for Diastasis Recti: - Woman supine with bent knees, feet on the table shoulderwide, hands are cupped

under her head. - Place you fingers along the midline of her belly. - Ask her to raise her head and shoulders towards her chest, keeping her elbows

pointed outwards. - This isolates the recti abdomini, they feel like rubber bands. - Check with your fingers for a gap 1 – 5 finerwidths wide. - If you find a gap let her feel it with one of her hands.

Modified sit ups to close the gap and regain muscle tone

Just as in checking for D.R. , Elbows pointing outwards, lift head and shoulders towards chest . Sets of 5 x 5 times a day for the first 2 weeks, then Sets of 10 x 5 times a day

It will take about 4-6 weeks of daily work to close the gap

GASTROINTESTINAL SYSTEM

As the pregnancy continues, the stomach and intestines are displaced laterally by the growing uterus. This slows down the emptying of the stomach and can commonly cause heartburn (reflux, Pryrosis). Also constipation and resulting hemorrhoids can be a problem.

Also it is very difficult to locate the appendix and therefore heat or heat packs are contraindicated for the flank area for women having any sort of discomfort as there is always the possibility of appendicitis and heat can lead to rupture of the appendix.

URINARY SYSTEM The bladder increases its size during pregnancy, thickens and so decreases its internal volume and there will be an increased frequency of urination especially in the first and third trimester.

Theis means pregnant women often need a pee break after ½ hour of massage. If women experience frequent bladder infections they probably don’t drink enough water.


13

STAGES OF PREGNANCY

FIRST TRIMESTER

0-13 weeks Emotional and hormonal adjustment period This is when most miscarriages happen, the foetus is settling in.

Common issues: Mood swings, Anxiety or uncertainty about being pregnant, weight issues,

Discomforts: Nausea, Fatigue, tenderness in the breasts

SECOND TRIMESTER

13-27 weeks Also called the period of radiant health as most physical symptoms of the first trimester disappear, women generally feel very good. Mentally and emotionally it is a period of letting go of the old self and preparing for the new motherhood, also often a period of re- evaluation of the relationship with her own mother. Around 16-20 weeks the quickening happens, when the woman can feel the baby moving for the first time.

Usually few discomforts

THIRD TRIMESTER 28 weeks to delivery Also called the period of watchful waiting. The baby’s movements are getting stronger, the pregnant woman’s size is increasing and She is getting ready to deliver the baby into the world. Psychologically, a period often of intense dreaming, possibly worries about her own body or the baby’s health, insecurities about being so big.

Discomforts: Back pain, Oedema, Fatigue, Frequent urination, not being comfortable sleeping, heartburn

LABOUR Massage can be very helpful during labour and there are doulas which are also educated in the appropriate massage techniques for labour


14

DISCOMFORTS

NAUSEA

Keeping blood sugar levels up Acupressure wristbands Pericardium 6 Acupressure point

FATIGUE

Normal part of the first and third trimester. Women need to listen to their bodies

ROUND LIGAMENT PAIN Sudden movements may cause spasming of the round liganment which is made of uterine tissue and can contract.The spasms can last 5 minutes or more. Check with healthcare provider. Do NOT apply heat – contraindicated during pregnancy!

Helpful hints: flex knees towards abdomen until pain subsides

Soak in a warm bath From lying on the back turn to the side and push up Avoid sudden jerky movements Support abdomen and knees with pillows

HEARTBURN Eating frequent smaller meals, supporting upper body with pillows to not lie flat. Tums (Calcium carbonate)


15

HEADACHES In the first few months of pregnancy headaches are common and sometimes even later. Massage is very helpful.

BACKACHES (NON PATHOLOGICAL)

The uterosacral ligament attaches to the fascia if the sacrum and will cause a progressive lordosis. Therefore backaches are very common for pregnant women especially in the third trimester.

Massage is very helpful plus teaching the woman how to lift well and how to tilt her pelvis correctly. Encourage going for walks and swimming, warm baths or not too hot tubs

Pelvic rocking, strengthening the abdominal muscles and relaxing the back muscles

EXCESSIVE FLUID RETENTION It is normal and healthy for a pregnant woman to develop some fluid retention, but lymphatic drainage for the extremities especially will help any discomforts that are experienced with this.

CARPAL TUNNEL SYNDROME

Because of the increase of fluid in the tissues, Carpal Tunnel Syndrome can appear and be very painful. Use acupressure points, Lymphatic Drainage, splinting at night, Changing movement routines

SLEEPLESSNESS

Massage is generally a great remedy for sleeplessness as it activates the Parasympathetic nervous system.


16

CONTRAINDICATIONS TO MASSAGE

Positive Homan’s sign Breast/Nipple massage

Supine position after 13 weeks High blood pressure Abnormal oedema

Heat/Heat packs to abdomen All non pregnant contraindications

POSITIONING

Fowler’s position

Named for Dr George Fowler early 1900s, placing the woman’s head about 20 inches above the table. This can be done with wedges and pillows or an adjustable massage table.

This is a comfortable position for the last trimester to massage the head, neck, shoulders, arms and legs, hands and feet.


17

LEFT LATERAL LIE This is the very best position for a whole body massage for the pregnant woman. Her blood circulation works at optimum, it also lowers the blood pressure.

Use pillows under the head, in front of the chest for the arm and under the upper leg. The lower leg is stretched out. Attempt alignment of the shoulders, hip and knee, so the spine is straight and have the woman lie close to the edge of the table with her back.

RIGHT LATERAL LIE

Second best position, place in the same way.

PRONE POSITION

Avoid the prone position as the uterus extends backwards towards the spine and gravity plus the pressure from the massage will push the big blood vessels against it, similarly to the supine position.

SUPINE POSITION Definitely contraindicated for the last 2 trimesters, not recommended for the whole pregnancy. Can easily create Supine Hypotensive Syndrome.


18

LEFT LATERAL TILT To finish the massage and be able to massage and manipulate the neck instead of the flat supine position which is contraindicated.

Placing a rolled up blanket or long pillow under her right side from the shoulder to the hip to raise this side approx. 15 degrees. This will let the uterus roll towards the left flank avoiding pressure on the vena cava and descending aorta, preventing Supine Hypotensive Syndrome.

VENA CAVA IN SUPINE AND LATERAL TILTED POSITION


19

POST PARTUM

Post partum massage can start as early as 3 days after delivery, a very gentle massage at that stage.

It helps with postnatal depression, relieves the trauma the body went through, soothes sore muscles, helps blood and lymphatic circulation and nourishes the mother on all levels.

After 2 weeks the uterus has shrunk and descended into the pelvic cavity, it will take another week to shrink fully to its pre pregnancy size. During this period gentle massage also helps the body to re-adjust.

Concerns that need to be addressed:

Milk in breasts - provide ample padding. Flabby skin - reassurance and gentle massage with nourishing oil. Weight gain - lymphatic stimulation. Hormonal crashes - massage helps to regulate the hormonal balance. Broken Sleep - nurturing. Depression - massage has been proven to be extremely helpful.

Deep Vein Thrombosis - still a concern, so avoid long sweeping strokes up the legs, still use lymphatic techniques.

Diastasis Recti - most important issue during this time to check for this condition and help the woman regain abdominal muscle tone.

After 4 weeks:

I found Deep Tissue massage around the hips and lower back especially very helpful for women to regain normal posture. Very often the sacrum has been slightly misplaced during labour and all the surrounding tendons, ligaments, muscles and connective tissue need some help to regain balance again.

(Recommended reading: Bette Walters, Massage during pregnancy)

pregnancy massage learner guide€¦ · by the end of the 3rd month the nipples and the areola...

Documents