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Partnership in Pregnancy and Childbirth - A Specific Massage Programme

by Anne Haines and Linda Kimber(more info)

listed in women's health, originally published in issue 141 - November 2007

Due to rising intervention rates and use of epidurals for labour pain, women are searching for alternative methods of pain relief which do not include pharmacology, thus optimizing their opportunity to normalize childbirth.[1,2] Interest in complementary therapies is increasing and they are becoming more popular in the maternity setting. Women are offered more choice in place of birth; these options include: birth at home, in a stand-alone midwife led unit (MLU) or an integrated MLU, the latter being a midwife-led environment adjacent or on the same site as an obstetric unit. The other option is an obstetric unit where their care will be managed in partnership with obstetricians.[3] The latter care package is suitable for women with risk attached to their pregnancy but where normality can still be achieved for some women.

Whatever their choice of birth place, women need to feel safe, secure, and in a conducive physical environment, to allow their bodies to remain in control of the birth process. This will be achieved in part by antenatal preparation, communication and shared decision-making during pregnancy, with a clear care pathway for labour and birth. This preparation time is necessary to provide the couple with familiar tools to support them as they embark on the transition to parenthood. It is equally important that the main supporter (usually the partner) is well-equipped and confident with the birth process. This allows for a mutual understanding of how best to acknowledge and action their shared wishes. If complications arise, the couple is stronger and better able to support each other and feel comfortable with the deviations from their planned pathway for birth. The ultimate outcome is one of a sense of control over the birth process, confidence, and wellbeing as they embark on parenthood. This cannot be stressed enough, as so many couples these days get caught up in technology and interventions that they neither understand nor necessarily require, skewing their birth options, which may lead to a sense of disappointment and failure. Health professionals need to be mindful of these negative outcomes as they navigate the fine line between evidence based care, good outcomes for mothers and babies and their need for involvement and choice.

The LK Massage Programme®

The use of complementary therapies is increasing in the maternity setting. One that has been used for many years, and in many cultures, is massage.[4] As a midwife, you witness many forms of touch therapy, from the fast rubbing of the limbs often performed by the grandmother or aunt in attendance in Asian cultures, to a more rhythmic movement performed unconsciously by other birth attendants to offer support, closeness and unspoken comfort. It feels a natural response to any fear or stress to offer touch. Birth, in many cultures, is supported by female relatives, but over more recent years in the western culture it has become the norm to have the partner, often male, as the primary birth support for the woman. They often report anxiety over the birth process, feeling like a spare part, unsure how best to support their partner at this critical time. Women need confidence in their ability to give birth without obstetric intervention.

The worries experienced by partners can be considerable and rarely voiced. This cycle of fear and reduced confidence can inhibit the birth process and create disruption within the family unit, therefore, affecting informed decision-making and control.

One of the main aims of the LK Massage Programme® is to reverse this loss of confidence and provide the couple with a simple, easy to learn coping strategy that can be transferable to a variety of birth settings. Importantly, the Programme gives the partner an active role and he/she becomes integral to the birth process, and at that crucial preparation time during the last month of pregnancy.

The LK Massage Programme® is reliant on three main elements: specific massage techniques on the back, arms and legs, linked with rhythmic breathing and visualization, a conducive physical environment[5,6] and an understanding of the neuroendocrine responses to massage and how this relates to the natural changes in pregnancy and childbirth.

Massage for Relaxation and Pain Relief

The LK Massage Programme enhances maternal neuro-hormonal and uterine adaptations and promotes the endogenous pain modulatory systems of late pregnancy and labour.[7] Massage for relaxation and relief of discomfort during pregnancy can be implemented in very much the same way as for any other condition, except for the mechanics of positioning the woman as her uterus gets larger and considering the different safety issues. Many women who visit therapists regularly for massage, as a very pleasant way of pampering and relaxing themselves, will continue during pregnancy.

However, when considering the use of massage for relaxation and pain relief in labour and birth, we enter an acute episode rather than treating a chronic discomfort. When in labour the woman will often experience acute pain for limited periods of time as contractions come and go, followed by a relaxation phase. Women will usually breathe more quickly, or possibly hyperventilate at times of painful contractions which increase as labour progresses. The LK massage techniques synchronize with a slow breathing rhythm linking with a simple focusing element where women are asked to concentrate on the massaging partner’s hands and follow them as the massage is being performed. This will have the direct effect of guiding the woman into a slow breathing pattern, this combined with the physical responses to massage creates pain relief and deep relaxation – the woman is encouraged to enter a hypnotic state and withdraw into her personal space allowing the natural and somewhat primitive rhythms of her body to take over.

Massage Techniques

The flats of the hands perform long stroke, slow rhythmic effleurage movements when massaging the back, legs and arms. The techniques are directional and rhythmic, supporting upright positions, and are performed with each contraction with a rest in between. This is essential as labour can continue in an active phase for between eight to 12 hours. The woman’s partner will be the primary massaging person during this time; therefore, the techniques need to be kept simple and easy to sustain.

It is important to remember that the woman guides the pressure exerted during the massage. However, the pressure used during the last month of pregnancy needs to be less than when the woman is in active labour. The lower back massage is used primarily for pain relief, as it is firm effleurage with deep pressure strokes.

The arms, legs and uterine massages are primarily for relaxation using light to moderate effleurage movements.[8] This deep relaxation encourages sleep and nesting during the last month of pregnancy in preparation for labour and birth. It is suggested that undisturbed sleep during pregnancy can lead to a shorter labour.[9]

Classes for Women and their Chosen Birth Partner

The Programme is taught between 35-37 weeks of pregnancy. Massage induces a rise in central oxytocin; therefore, couples are asked to practise in the evenings to induce maternal relaxation and enhance sleep.[10] The aim of the class is to give an overview of the Programme, and also for the partner to learn the basic principles of the techniques – importantly the relationship between the massage strokes and the mother’s breathing. Safety aspects such as body movement and posture are advised and corrected during the practical session.

Once taught, the couples are asked to practise at home three times a week until the last week of pregnancy when the practice schedule varies for first time mums and those who have birthed before. Due to the individuality of this programme and each woman’s pregnancy, follow up for advice is provided by the individual therapist/trainer. Specialist advice is from Childbirth Essentials®; guidance is offered to couples if their pathway changes and their labour needs to be induced or they need an elective caesarean section. The antenatal preparation that the Programme offers is equally beneficial in either case.

During Labour and Birth

When in labour, women take the advice of their midwife or obstetrician, possibly with support from their doula. Those with uncomplicated pregnancies are recommended to stay at home, working with the Programme for as long as they wish. Some women will plan a home birth and therefore, have no need to break off from the massage for the journey to their chosen place of birth. Those planning to birth in a hospital or MLU will link into the visualization technique, concentrating on their slow rhythmic breathing control for the journey.

On arrival, they will need support to arrange the room to accommodate upright positions and free movement for labour; dim lighting and quiet will have been practised at home and this should be facilitated within the unit. The massage is then recommenced, and they need time to link into this prior to further examination. It helps if the care provider understands the philosophy behind the Programme and can facilitate these fundamental needs. The Programme encourages the couple to be self-contained, and will be very familiar to them both by the time active labour commences. They should be able to link into the rhythm quickly, the partner becoming intuitive to the mother’s needs. Routine labour care can be facilitated whilst the massage continues.

There are key times during labour when the mother may need extra support. This is usually as the contractions become stronger between five to six centimetres, and again just before full dilatation, as her body will involuntarily become expulsive. Birth partners may need support from the midwife or doula at this time as they may not have experienced this change in behaviour before. This is when it is gold standard for the midwife or doula to be familiar with the Programme, but even if they are not, normal reassurance and positive encouragement can support both mother and birth partner through this change.

If women have a complex labour, the LK Massage Programme® can still be used. It is particularly useful for women who are very anxious, often due to a previous poor experience, or those wanting a natural birth when their care is provided primarily by obstetricians with a more medicalized model of care. Women can be supported to work in partnership with their obstetrician and midwife to agree on a safe individualized care pathway to meet their wishes and those recommended by the professionals.

Safe monitoring of the baby and progress of labour can be facilitated whilst the mother exercises her choice for upright positions and use of massage as her coping strategy for labour pain.

The massage continues through to the birth of the baby. Techniques will have been shown to allow the birth partner to massage from the side and, therefore, allow the midwife access to support the emerging baby. Experience shows that most mothers in a physiological labour will follow their body and use very little effort to birth their baby, reducing stress and increasing oxygenation to the baby during this stage of labour. The baby should emerge and be lifted on to the mother’s chest immediately following birth and be left skin to skin until it has suckled for the first time.

Regardless of mode of delivery, the mother should be offered skin contact with her baby in the same warm, secure environment as was created for labour.

Importance of Partner Involvement

The LK Massage Programme® offers couples techniques to prepare them for childbirth and support them through the process. Regardless of the final mode of delivery, couples report a sense of control and are able to make choices. Often, they emerge as new parents with a sense of achievement and that they both contributed to the birth of their baby. A sense of amazement that it worked!

Partners respond positively to this involvement and ‘having a job to do’, and report that by performing the massage it relaxes them and provides a supportive link between them and the labouring mother. Unspoken communication is very strong and invaluable during labour when the mother should be undisturbed but made to feel secure. The creation and maintenance of this partnership is vital at this critical time.

By using the Programme couples spend more time together, focusing on their baby in utero and relaxing together. Invariably, with women working later in their pregnancies and leading busy lives, the practice schedule allows them ‘time out’ to concentrate on the impending birth and for the couple to spend undisturbed quality time together. This essential preparation encourages an improved sleep cycle and confidence in their ability to birth their baby as naturally as possible. They embark on labour and childbirth with less anxiety and a positive belief in what they can achieve. This positive outlook breaks down the fear-pain cycle and reduces the inhibitors of natural birth.

Professional Training

It is beneficial if professionals caring for mothers in labour have an understanding of the Programme and its benefits; this enables them to support the partner fully and make suggestions to utilize the techniques to optimize the Programme during labour. Professionals with interest in the Programme are commonly doulas, midwives and therapists, including members of the National Childbirth Trust (NCT) who have access to pregnant women and partners during pregnancy. The training for professionals working with the LK Massage Programme® consists of a series of courses, reinforced by corresponding DVDs. The Basic course offers the same basic techniques as the couples are taught, including model of care, optimal environmental conditions and scientific background, most specifically the neuroendocrine system. The Basic course is a prerequisite for the Trainers course which allows professionals to train couples in their area. The Advanced course is recommended for professionals who will be supporting women in labour; the course includes a more in-depth view of the neuroendocrine system and current research as well as advanced massage techniques, mostly creating rotational and rocking movements. These techniques have been designed to encourage normality when labour becomes more complex or delayed. It is important that there is equity across the country and access for all.

Conclusion

There is no doubt that new fathers benefit from a structured model to help integrate them into the birth process which has historically been a female domain. They can provide an active and valuable role to support the essence of natural childbirth. Who better to understand their partner’s needs and desires for each unique birth experience? The partnership concept journeys further, involving midwives and other health professionals to truly understand the needs of women and their families at this precious time – the birth of their baby.

References

1.    Ramnero A, Hanson U and Kihlgren M. Acupuncture Treatment During Labour – A Randomized Controlled Trial. Br J Obstet Gynaecol. 109: 637-644. 2002.
2.    Cho A-S, Chao A, Wang T-H, Chang Y-C, Peng H-H, Chang S-D et al. Pain Relief by Applying Transcutaneous Electrical Nerve Stimulation (TENS) on Acupuncture Points During the
First Stage of Labour: A Randomized Double-Blind Placebo-Controlled Trial. Pain. 127: 214-220. 2007.
3.    Department of Health. Maternity Matters: Choice, Access and Continuity of Care in a Safe Service. 2007.
4.    Kitzinger S. Re-discovering Birth. Little Brown and Company. London. 2000.
5.    Haines A and Kimber L. Improving the Birth Environment (part 1). The Practising Midwife. 8: 1:18 – 20. 2005.
6.    Haines A and Kimber L. Improving the Birth Environment (part 2). The Practising Midwife. 8: 2: 25-27. 2005a.
7.    McNabb M, Kimber L, Haines A and McCourt C. Does Regular Massage From Late Pregnancy to Birth Decrease Maternal Pain Perception During Labour and Birth? A Feasibility Study to Investigate a Programme of Massage, Controlled Breathing and Visualization from 36 Weeks of Pregnancy Until Birth. Complementary Therapies in Clinical Practice. 12: 222-231. 2006.
8.    Lund I. Massage as a Pain Relieving Method. Physiotherapy. 86: 12638-654. 2000.
9.    Lee KA and Gray CL. Sleep in Late Pregnancy Predicts Length of Labour and Type of Delivery. Am J Obstet and Gynaecol. 191: 2041-6.
10. Lancel M, Kromer S and Neumann ID. Intracerebral Oxytocin Modulates Sleep-Wake Behaviour in Male Rats. Regulatory Peptides. 114: 145-152. 2003.

Further information

For information about the professional courses for midwives, doulas, antenatal educators and complementary therapists, or classes for pregnant women, plus the DVD Towards Natural Childbirth and Beyond for women and partners, and other related birth aids, you may contact Tel: 01865 372686; Mobile: 07765192048; info@childbirthessentials.co.uk; www.childbirthessentials.co.uk

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About Anne Haines and Linda Kimber

Anne Haines MSc RM RN IBCLC is a Practising Midwife/ Manager with specialist knowledge about VBAC (Vaginal birth following caesarean section) and a special interest in normalizing childbirth.

Linda Kimber SCM SCN is a Complementary therapist, Research Midwife with specialist knowledge of pregnancy and labour massage. Both are Directors in Childbirth Essentials® which was set up in 2006 and has a philosophy of Promoting a Positive Birth Experience for All. They work closely with Mary McNabb MSc SCM SRN who is their scientific adviser and has specialist knowledge of reproductive biology.

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