Positive Health Online

Introduction

I began working in the field of maternity care back in 1989 when I was pregnant for the first time. Having studied eastern and western approaches to the body through both Massage and Shiatsu, I was amazed at how little support women were being given during their pregnancies. Many therapists were reluctant to massage with me. I could never understand this approach, and still don’t. Pregnancy is essentially, for most women, a time of expression of their health. It is most certainly not a disease. How could bodywork be anything but beneficial? In those early days, I took encouragement from the knowledge that midwives in traditional societies would often use massage therapy, or herbs, as a main part of antenatal care. If you look, even today, at traditional midwives in countries such as Mexico, Japan, Africa and Asia, they are using some form of bodywork to support mothers. In the developed world, the role of the midwife has changed immensely, especially over the past 40 years, with the increase in medically-related births, which has impacted on antenatal care as well. This seems to have affected our approach as bodyworkers. Many therapists tend to look to the medical model to define their approach. However, while I think that it is important to understand the medical model and work with women’s primary care givers, it is also time for us, as bodyworkers, to define our own holistic approach to women in pregnancy.

Types of Bodywork

Most forms of bodywork have some relevance for maternity work, from Aromatherapy and Massage to Reflexology, Indian Head Massage, Shiatsu, Osteopathy and Chiropractic. Of course there are certain types of techniques that are less suitable for pregnant clients. The main objective is for the therapist to understand the main changes in the woman’s body during this time and work accordingly. The main changes which influence our work are the presence of hormones (mostly relaxin and progesterone)
which relax smooth muscles and the increased blood volume in pregnancy. This means that we need to be careful with mobilizations and stretches, and need to understand, in specific detail, the effects on the pelvic and abdominal muscles and ligaments. The increased blood volume means we should not use tapotement style techniques and be alert to the possibilities of varicose veins and, in rare cases, DVTs (Deep Vein Thrombosis).

Myths Surrounding Bodywork

Many myths have grown up around bodywork in pregnancy, and I would like to address a few of the more common ones here.

Risk of DVT

Myth: We have to treat all women as though they are at risk of developing DVT and, therefore, avoid pressure techniques on the legs.
Fact: The risk is minimal. It is important to understand circulatory changes, but work can still be done for the legs. Indeed we could argue that bodywork, by mobilizing the legs, can actually decrease the risk of a DVT occurring.

Firstly, if I actually suspected a woman had DVT I would not work on her at all, and instead would refer her immediately for western care. Yes, the risk of DVT is five times higher than for the non-pregnant client, but this is still insignificant for a healthy woman with no previous medical history. The risk is 0.13 to 0.61 per thousand pregnancies.[1] The reality is that multiple risk factors are often present in women who develop DVT in pregnancy (such as obesity, previous family history, lack of mobilization, other health issues), and I would hypothesize that the risk for a healthy woman is virtually nil.

Therapists sometimes say that due to the increased fluids in the legs, including lymph, we should not do pressure work in the legs. However, while it is true that if the woman is presenting with oedema, we would need to adapt our work; if she was not presenting with oedema she may benefit from deeper work. The muscles of the leg work pretty hard during pregnancy; many women suffer from leg cramps and would benefit from deeper work, both on an energy and physical level.

Abdominal Work

Myth: Avoid working the abdomen.
Fact: Understand the changes in the abdomen as well as the women’s responses, both physical and emotional, to them and work accordingly.

It is important not to do any work that pulls on the uterine ligaments or the abdominal muscles; however, that does not mean that abdominal work cannot be included, even for some women in the first trimester if they wish. There is no real mechanism by which the baby can be harmed, and you only have to consider how deeply midwives will work on the abdomen.

To realize how resilient it is. There are also the benefits of encouraging bonding with the baby and strengthening the abdomen.

First Trimester

Myth: Don’t work in the first trimester. Women who miscarry may blame us.
Fact: There is no evidence that bodywork causes miscarriage. Indeed, in my experience, it may well help reduce the risk of miscarriage or, at the very least, help the woman to feel better and less stressed in the first trimester.

This myth is really based only on fear of litigation.

Types of Techniques

Over the years I have developed a lot of special types of techniques for pregnant women. One of my favourite is work over the ball, during the third trimester and for labour. Another is a lot of special abdominal techniques which often include breathing and visualizations. Mothers usually love these, especially from mid-second trimester on when they can feel their baby move. I also try to include the partner in this work, as much as possible.

Case Study

LC
LC came to me in pregnancy suffering from heart and kidney problems. The obstetric supporters were extremely concerned throughout her pregnancy, and she had many check-ups and much monitoring. In the first trimester they were worried about her high risk of miscarriage. In the second trimester they were worried about premature labour and the risk of pre-eclampsia. In the third trimester they were convinced that if the baby was born it would need special care and would probably need to be delivered by Caesarean (C) section.

Obviously LC was very stressed. Work in pregnancy included relaxation and a space to talk through the issues and choices. It also included therapy to reduce blood pressure and energy work for the kidneys and heart.

I visited LC in hospital where she was during the last few weeks. After each session her blood pressure and kidney function stabilized. She was induced at 36 weeks due to concerns about maintaining the pregnancy, and I went and did work during the labour. Contractions were established due to the bodywork, and the baby was born with no form of intervention a few hours later. LC was delighted and the medical team surprised.

This case illustrated the importance to me of working to offer support with high risk women, even those with pre-existing medical complications. Bodywork can support their bodies during difficult times, and may even prevent a lot of the complications developing.

The Role of the Therapist

It is interesting to note that antenatal care, as we understand it, is very much a 20th century phenomenon. It became established along with the growth of orthodox medicine, and was defined by a narrow objective medical perspective. This means that as medical technology becomes increasingly available, e.g. earlier and greater numbers of scans, tests for HIV/AIDS and, in birth, increased foetal heart monitoring, antenatal care has become more and more biased in this direction. Midwives spend more time explaining the risks and benefits of the various tests, and as a result have less time to focus on what I would consider to be the fundamentals of maternity care, i.e. basic self-care in the form of information, advice, suggestions, and discussion on topics such as diet, exercise, and the hands-on side of midwifery.

When I teach therapists, I always include work on how they can support the mother to look after herself, both emotionally and physically. I see our primary role as bodyworkers is to ‘support the wisdom of the body’. Therapists are often surprised that I am making sure they are aware of how exercises to support good posture in pregnancy and diet affect pregnancy. Therapists themselves need to be aware of their own expertise in these fields of exercise and nutrition, and refer on if necessary – but often it is the basic information which is required and is effective. It is this kind of information and support that women often lack. Therapists think that this is more the role of the midwife – but sadly this is not the case. Often, the reality is that the midwife has a very short relation-ship with the mother, as the frequency of the appointments are being cut down, therefore, she does not see the same midwife more than a couple of times. As a result, it is hard to build up a relationship where the mother’s needs can be explored and supported.

In view of this, role of therapist has blended with many of the recent roles of the modern midwife. And we may be the first person that the mother talks to about her pregnancy, or we may well be the person that she sees most during her pregnancy, maybe even during birth, and postnatal care.

A therapist who is not a midwife needs to be clear about her role. She is not there to give medical advice, check blood pressure, or the  position of the baby (even though she may have a good idea!),  nor can she do anything if the woman is bleeding or her blood pressure is escalating. However, sometimes the mother may not be happy with the care she is receiving and may question some of the decisions which are being made. A therapist has to be careful not to question these decisions directly but support the mother to access the information she needs so that she can make the right choices for herself.

As therapists, we need to make sure that our client is the primary agent. We can actually apply tools used in midwifery to inform our practice. Five steps of evidence-based midwifery are quite useful to us.[2]

1.    Finding out what is important to the woman and her family (to help plan a treatment and guide the advice we may need to give);
2.    Using information from clinical examination (in this case for us as therapists whatever our case history taking involves);
3    Seeking and assessing information to inform decisions (what the evidence surrounding the treatment says and what impact the evidence suggests it may have);
4.    Talking it through (how does the client feel about her treatment? what benefits does she gain?);
5.    Reflecting on outcomes (i.e. to plan the next step in the treatment plan – what do you need to amend, keep or withdraw to refine for next time?).

We need to really examine what it is that we are offering the women in our care.

Risk/Benefit Model

We need to work from risk/benefit model. We need to keep up-to-date on the latest thinking on the type of bodywork that is indicated with different situations, which in pregnancy is a bit of a minefield, as there are no really good texts to inform our practice. There is a lot of misinformation out there which serve to perpetuate the above myths. It is therefore important to make contact with therapists who have a lot of clinical experience in the field, and to also make sure they have good basic training in the specifics of pregnancy work, or birth work, or postnatal care.

Working to Integrated Care

We are offering an additional approach to medical interventions. We must not imply that we are replacing the standard medical care that our clients require to ensure healthy pregnancies, but instead we offer ways which may be less interfering, i.e. massage therapy for headaches rather than taking medication. We can also work at supporting the client in her emotional wellbeing, through the space we have to talk, work with breathing and visualizations and connections with the baby. This space sadly, is often lacking in the more medical approach to pregnancy. Our care may be extremely effective, but at other times medical care is crucial to the wellbeing of the mother, i.e. in times of placental abruption, or pre-eclampsia, the mother may need to have emergency medical treatment. We need to know where our model of care is most effective and appropriate, and when to refer on.

Giving Good Holistic Support to Mothers

We can teach breathing and relaxation techniques. We can teach exercises which are useful in prenatal and labour preparation, i.e. stretches, squats. We can help clients integrate physical changes by encouraging postural awareness. Most importantly, we can reinforce the existing learning the client has and encourage them to learn  valuable new skills.

We can provide regular sessions of one to 11/2 hours. By utilizing listening skills we can hear concerns or fears which may not be overt. We can teach massage and self-care strategies to the mother, and we can also include the partner in our work, e.g. by teaching them how to massage the mother in pregnancy and during labour.

Challenges to the Therapist and Developing New Techniques

This kind of work can be both challenging and rewarding. I do find that with my pregnant clients I often build a closer relationship as they go through such life changing experiences. For me it has meant a constant questioning of the ‘established myth of types of techniques’ suitable in pregnancy. As part of this, I went to study with obstetric Physiotherapist Elizabeth Noble in Boston, USA, as she had challenged many of the ‘Old’ views on exercise in pregnancy.

Too often therapists are guilty of treating the pregnant woman as sick, without really understanding the underlying emotional and physiological changes occurring in the body. It has been a continuing challenge for me to incorporate these insights into my work so that I can develop and refine techniques which meet the new challenges working with pregnant women pose. Recently I had a client who had damaged lumbar vertebrae, was in her third pregnancy, after two previous difficult pregnancies, and had severe back pain, even in the first trimester. I had to address these issues. She was used to bodywork so I was able to explore techniques with her sacrum and lower back, which I would normally use later in the pregnancy. She found them effective. I worked a lot with her, in collaboration with a chiropractor, and I find that chiropractors and osteopaths have a lot less hang ups than massage or shiatsu practitioners about working with the pelvis, even in the first trimester. I know that bodywork is safe and is effective in the first trimester but there is so much negative information written about the ill-effects of bodywork that even I have to take a step back from it sometimes.

I have learnt to respect that often less is more, as the pregnant body tissue is so much more elastic than the non-pregnant body that change happens so much more readily.

What I have learnt most is the old truth – listen to the body. The aim of bodywork for me is to support the client to be more aware of what is going on – and in pregnancy this includes awareness of the baby. I do see my role as ‘enabling mothers to become more aware of their bodies and babies, and to trust in the wisdom of the body’. Our body’s wisdom will tell us if things are going well, but equally alert us to the fact if things are not going well. We can then seek medical care.

Ultimately, our role as bodyworkers is to work alongside the best of medical care. This way, we can provide truly integrated health care – as this is the way forward in the 21st century.

References

1.    Kierkegaard A. Incidence and Diagnosis of Deep Vein Thrombosis Associated with Pregnancy. Acta Obstet Gynecoll Scand. 62 (3): 239-243). 1983.
2.    Pace and Percival. The New Midwifery: Science and Sensititvity in Practice. Churchill Livingstone. 2000.

Bibliography

Inch S. Birthrights: A Parent’s Guide to Modern Childbirth. 2nd Ed.  Greenprint, London. 1989. 
NMC. Midwives Rules & Standards. NMC. London. 2004.