Massage Therapy in Pregnancy

Anatomy and Musculoskeletal Changes

• Weight gain during pregnancy:
  • Fetus: 7-8lbs
  • Placenta: 1-1.5lbs
  • Amniotic fluid: 1.5-2lbs
  • Uterus and breasts: 5-5.5lbs
  • Blood and fluid: 4-7lbs
  • Muscle and fat: 1-6lbs
  • Total: 20-30lbs
• Posture changes:
  • Ligamentous laxity due to Relaxin and Estrogen
  • Hyperextension and hypermobility of joints
  • Increased risk of injury and sprain, particularly to lumbosacral, sacroiliac, sacrococcygeal, symphysis pubis, hip, knee, ankle, and foot joints
  • Anterior carriage of weight shifts the center of gravity upward and forward
  • Compensatory posture:
    • Weight shifts to the heels
    • Upper back tilts posteriorly
    • Chin thrusts forward
    • Anterior pelvic tilt
    • External rotation of the hips
    • Hyperextension of the knees
    • Possible pes planus (flat feet)

Cardiovascular Changes

• Changes in blood pressure:
  • Heart rate increases by 10-15 beats over pre-pregnancy values
  • Blood volume increases by up to 40% over pre-pregnancy values
  • Cardiac output increases by 30-50%
  • Viscosity of the blood decreases
  • May contribute to cardiac murmurs and mitral valve prolapse
• Decreased peripheral vascular resistance:
  • Causes a drop in blood pressure, most noticeable in the 2nd trimester
  • May result in supine hypotension, causing dizziness and lightheadedness
• Vena Cava Syndrome:
  • Occurs in up to 11% of pregnancies
  • Caused by compression of the inferior vena cava, particularly when lying in supine
  • Can be rectified by having the woman turn to a left side-lying position or positioning the woman with a pillow or towel roll under the right hip

Respiratory Changes

• Increased oxygen demand and consumption:
  • Increases by 14-20%
  • Diaphragm becomes compressed and elevated, decreasing the vertical height of the lungs by 4cm
  • Thorax compensates by expanding in diameter by approximately 10cm
  • Breathing becomes more costal and less diaphragmatic
• Dyspnea (difficulty breathing):
  • Affects 60-70% of people during pregnancy
  • Not due to compression of the diaphragm, but rather a change in proprioceptive information transmitted to the brain

Renal Changes

• Expansion of the kidneys, bladder, and ureters:
  • In response to the increased demands of pregnancy
  • Polyuria (frequent urination) and nocturia (increased urination at night) affect 80-95% of people
  • Compression of the bladder may increase the sense of urgency
  • Stress incontinence may occur, but usually resolves post-partum
  • Bladder distension may also contribute to incontinence
  • Pyelonephritis (kidney infection) may increase during pregnancy

Gastrointestinal Changes

• Decrease in serum glucose levels:
  • Stimulates increased appetite
  • Elevation of taste threshold results in cravings
• Increased absorption of salt:
  • Increases thirst and water retention
• Nausea and vomiting:
  • Common in the first 14-16 weeks due to continued progesterone production and fetal waste being metabolized through the mother
• Decreased intestinal motility:
  • Contributes to constipation

Metabolic and Endocrine Changes

• Hormone Relaxin:
  • Hydrates ligaments during the second and third trimester to prepare the pelvis for delivery
  • Not joint-specific, affects all joints
  • Persons with pre-existing joint instability may notice an increase in symptoms
• Sodium and water retention:
  • Contributes to increased capillary permeability and edema
  • May lead to nerve compression and entrapment syndromes

Signs and Symptoms of Pregnancy

• 1st trimester (0-12 weeks):
  • Implantation of fertilized ovum in uterus
  • Nausea and vomiting, constipation, bloating, and indigestion
  • Fatigue due to hormonal changes and increased stress
  • Increased breast size and tenderness
  • Small weight gain
  • Emotional changes
  • Drop in blood pressure
• 2nd trimester (13-26 weeks):
  • Hormones stabilize
  • Disappearance of breast discomfort and nausea
  • Placenta developed and handling fetal nutrition and waste
  • Visible change in woman's physical appearance
  • Further drop in blood pressure
  • Hormone Relaxin works with estrogen to hydrate and loosen ligaments and pelvic cavity
  • Striae Gravidarum (stretch marks) begin to appear
  • Braxton Hicks Contractions (false labor)
  • Diastasis Recti (separation of the Rectus Abdominus along the linea alba)
• 3rd trimester (27-40 weeks):
  • Uterus is quite enlarged and has regular contractions
  • Fetal compression of bladder, colon, and stomach
  • Fetal position changes in preparation for birth
  • Increased blood pressure
  • Increased water weight gain and edema
  • Shortness of breath due to fetal compression of diaphragm
  • Fatigue due to increased weight gain, loss of sleep, and nocturia

Complications of Pregnancy

• Pre-existing conditions:

  • Diabetes
  • High Blood Pressure
  • Cardiac Abnormalities
  • Neoplasm (tumor or growth)
  • Pulmonary Anomalies
  • Neurological Conditions
  • Systemic Infection
  • Musculoskeletal Conditions
  • Fever
  • Chronic Disability

• High-Risk Pregnancy-Related or Induced Conditions:

  • Preterm Labor
  • Placenta Previa
  • Placenta Abruptio
  • Incompetent Cervix
  • Pre-term Rupture of Membranes
  • Diastasis Recti
  • Gestational Diabetes
  • Pregnancy Induced Hypertension (PIH)
  • Pre-eclampsia
  • Eclampsia
  • Disseminated Intravascular Coagulation
  • Intrauterine Growth Restriction (IUGR)
  • Hydramnios/Polyhydramnios
  • Oligohydramnios### Treatment Aims

• General aims: decrease SNS, promote relaxation, treat conditions, encourage full diaphragmatic breathing, promote general health and nutrition, encourage safe exercise, prepare for delivery, provide emotional support, and monitor for ominous signs

• 1st trimester aims: monitor blood pressure, treat SNS firing, provide symptomatic relief, decrease headaches and nausea, encourage and maintain good circulation, and educate on postural awareness and exercise

• 2nd trimester aims: monitor blood pressure, address postural changes, maintain general health and exercise, address pre-existing conditions, maintain ROM, decrease trigger points, and maintain tissue health

• 3rd trimester aims: monitor blood pressure, decrease SNS firing, decrease physical discomfort and trigger points, decrease edema, decrease breast discomfort, decrease constipation, treat conditions, maintain circulation and tissue health, provide emotional support, and monitor for ominous signs

• Post-partum aims: restore posture and muscle strength, address labor-induced muscle strains or ligament sprains, decrease adhesions, decrease breast discomfort, monitor for Mastitis, and monitor for post-partum depression

Techniques

• 1st trimester: positioning adaptations, avoid deep and vigorous massage, and avoid fascial work over the low back or abdomen
• 2nd and 3rd trimester: client may lie in prone with a "pillow well", side lying, avoid deep pressure over the low back or abdomen, and use techniques such as effleurage, petrissage, and longitudinal stripping
• Post-partum: avoid deep pressure, focus on restoring posture and muscle strength, and address labor-induced muscle strains or ligament sprains

Contraindications and Precautions

• Avoid deep or vigorous massage and fascial techniques over the abdomen or low back in the 1st or 3rd trimester or on anyone with a history of miscarriage
• Monitor blood pressure before each treatment
• Avoid abdominal strain, dizziness, and fainting at end of treatment
• Take precautions for clients with gestational diabetes, lower limb edema, and varicose veins
• Decrease pressure and avoid direct pressure over varicose veins
• Do not forcefully mobilize hypermobile joints especially in the low back, sacrum, and pelvis
• Treatment times may need to be shortened if client is experiencing discomfort

Breast Massage Overview

• Breast massage is indicated in treatment when there is a need to improve circulation and drainage, relieve congestion, and address breast tissue health.
• Consent from the client is essential, and the therapist must explain the rationale for treatment, ensure the client understands their rights, and respect their boundaries.

Case for Breast Massage

• Breast tissue health requires adequate circulation and drainage, which can be obstructed by habitually poor posture, tight-fitting undergarments, breast implants, and surgical scarring, leading to breast congestion, chronic pain, and protective holding patterns.
• Knowledgeable and trained therapists can effectively perform massage techniques and hydrotherapy to enhance blood and lymphatic flow, treating scars and fascial restrictions that contribute to chronic pain and reduced range of motion.

Anatomy and Physiology

• The breast contains specialized glandular tissue within the layers of subcutaneous superficial fascia, positioned directly under the skin and sitting over the muscles of the chest wall.
• The breast relies on fascia and suspensory ligaments (Cooper's Ligaments) for structure and support, and massage therapists should avoid techniques that stress or stretch these structures.
• Breast tissue anatomical boundaries: upper (lower edge of the clavicle), lower (1" below breast contour), medial (sternal midline), and lateral (anterior edge of Latissimus Dorsi).
• The glandular structure of the breasts is composed of 15-20 lobes that produce and deliver milk to a nursing infant, with each lobe having 20-40 lobules that open into ductules.

Arterial Supply and Venous Drainage

• The branches of the Subclavian artery supply the breast with blood.
• Venous return originates from a venous plexus deep to the areola and drains into the Internal Mammary Vein running lateral to the sternum and the Axillary vein in the Axilla.

Lymphatic Supply

• The skin surface of the breast and areola are richly supplied with tiny, valveless lymphatic channels that run through the breast into the loose connective tissue.
• Lymphatic channels drain from superficial to deep, and 75% of breast lymph drains into the axillary nodes.
• Other lymph nodes that drain the breast include the internal mammary chain, rectus abdominus, and subdiaphragmatic nodes.

Causes of Breast Pain

• Brachial Plexus Nerve Entrapment Conditions
• Trigger Points
• Cervical Rib
• Angina Pectoris
• Gall Stones (Cholelithiasis)
• Esophageal Lesions
• Pulmonary Tuberculosis
• Pregnancy or hormonally related breast congestion
• Lactation
• Mastitis
• Duct Ectasia
• Fibrocyctic Breast Disease
• Repetitive Arm Movement
• Restrictive Clothing

Assessment and Treatment

• Assessment involves taking a detailed case history, observing postural factors, palpating the breast tissue, and checking for ominous signs such as nipple retraction, discharge, or hard, non-tender lumps.
• Treatment aims to reduce pain, edema, and congestion, improve local circulation and tissue health, and encourage mobile scar tissue.
• Techniques used may include hydrotherapy, Swedish and lymphatic drainage, trigger point therapy, joint play, and relaxation, depending on the reason for treatment.
• Contraindications include mastitis, post-surgical infection, active infection, and undiagnosed lumps.

Self-Care and Prognosis

• Clients can be taught self-care techniques such as hydrotherapy, self-massage, and stretching and strengthening exercises.
• Prognosis depends on the cause of the condition being treated.

Infant Massage

• Infant massage is a treatment that can be provided to infants from 0-3 years old, with adaptations for different age groups.
• The massage duration varies with age:
  • 0-3 months: 15-20 minutes
  • 3-6 months: flexible duration
  • 6-8.5 months: incorporates more limb movement and music
  • 8.5 months-3 years: may need to happen in smaller segments

Developmental Stages

• 0-3 months:
  • Multiple neonatal reflexes
  • Infant adopts "inutero posture" (legs, arms, and head flexed)
  • Infant more comfortable in warmer temperatures
• 3-6 months:
  • Infant more acute to external stimuli
  • Tonic changes in soft tissue (muscles, ligaments, tendons)
  • Infant becoming more mobile (rolling, wriggling, reaching, holding)
• 6-8.5 months:
  • Infant actively mobile (lifting upper body, pulling, sitting)
  • Infant engages with surroundings (playful, giggling, recognition)
  • Infant regularly changes positions
• 8.5 months-3 years:
  • Crawling, exploring, very curious and busy
  • Child may not want to lie or sit still for long periods

Pre-Term Infants

• Can be kept in Neonatal Intensive Care Unit (NICU) for any length of time
• Kept in incubator or radiant warmer to maintain body temperature
• Birth weight: 500 grams (1lb 1 oz) to 2500 grams (5lbs 8 oz)
• Many facilities see the value and benefits of touch therapy in premature infants and newborns

Neonatal Reflexes

• Moro/Startle reflex: 0-6 months
• Sucking reflex: continues until infant is weaned
• Rooting reflex: as long as infant is nursing
• Grasp reflex: 0-5 months; foot lasts up to 8 months
• Babinski reflex: toes curl up; adults: toes flare open
• Blink reflex: present at birth
• Withdrawal reflex: present at birth
• Tonic Neck reflex: 0-3 months; helps during active labor

Establishing Consent

• Massage is something you do WITH the infant, not TO the infant
• Obtain consent from the infant before starting the treatment
• Speak directly to the infant, use their name, and ask if they are ready for the massage
• Establish eye contact, rub hands together, and show open palms to the infant
• Observe the infant for physical signs of consent or refusal
• Acceptance cues: continued eye contact, stilling, smiling, cooing, babbling, reaching out, or bringing hands to mouth
• Refusal cues: breaking eye contact, turning away, crying, fussing, expressions of discontent, squirming, or flailing

Establishing a Routine

• Establish a routine to help the infant become more comfortable with massage treatments
• Consistency helps the infant (and parent) incorporate massage into their daily routine
• Ways to establish a routine:
  • Consistent time of day (e.g., before nap or sleep time)
  • Consistent day(s) of the week
  • Performing the treatment in the same room/spot
  • Playing the same music during treatment

Treatment Goals and Considerations

• Primary goal: reducing stress in the infant
• Secondary goal: forging and strengthening maternal/paternal bonds with the infant
• Length of treatment: dictated by the infant (within reason)
• Observe for "refusal cues" during treatment
• Treat the infant on a blanket-covered pillow to help trap heat
• Use a cold-pressed, unscented oil (e.g., Safflower, sunflower, or fractionated coconut oil) as a medium

Ideal GSM Techniques

• "Touch Relaxation" technique: a firm static contact that teaches the infant to locate and relax tense areas
• Chest treatment:
  • "Touch Relaxation"
  • Grasp the infant under the arms and place thumbs on the sternum
  • "Milking" stroke of the rib cage
  • "Belly button smile" technique
• Legs/Feet treatment:
  • "Touch Relaxation"
  • "Milking" and "wringing" strokes
  • Treat the foot specifically
• Abdomen treatment:
  • "Touch Relaxation"
  • "Water wheel" technique
  • "Belly button smile" technique
  • Clockwise abdominal treatment
• Arms/Hands treatment:
  • "Touch Relaxation"
  • "Milking" and "wringing" strokes
  • Treat the hand specifically
• Face treatment:
  • Obtain "special permission" from the infant
  • Work from the forehead down
  • Thumb strokes from the midline outwards
  • Circular fingertip/thumb kneading over the cheeks
  • Long strokes from behind the ears to the underside of the chin
• Back treatment:
  • "Touch Relaxation"
  • "Water wheel" technique
  • Circular kneading over the entire back
  • Stroking down the entire back from shoulders to waist

Contraindications and Precautions

• Ensure light pressure throughout the treatment
• Discontinue treatment if the infant withdraws consent
• Avoid massaging over open skin
• Avoid massaging when the infant has an undiagnosed fever
• Avoid massaging at the site of acute infection
• Take special care when massaging infants on medications
• Massage can usually be performed in most states of ill health, with simple, soft touch being therapeutic and soothing

Baby Colic

• Definition: episodes of crying more than 3 hours per day, more than 3 times per week, in an infant between 2 weeks and 4 months old, who is otherwise healthy
• Causes: officially unknown, but several theories have been proposed
• Assessment/Differential Testing: diagnosis is accomplished by the process of elimination, assessing/testing to remove all other possible causes of infant distress

Learn about the role of massage therapy in a healthy pregnancy, including treating aches and pains, and acting as an educator and advocate for the pregnant person.