Positioning Concerns for Prenatal Massage Therapy
The question most practitioners consider first when contemplating massaging pregnant women is how to accommodate that ripe belly. Safety, comfort and therapeutic effectiveness affect both prone and supine positions during pregnancy. These same considerations point favorably to working with expectant women while they lie on their side.
Prone Positioning Restrictions
While stomach sleeping may be a safe, comfortable resting position, once sufficient pressure is applied for an effective massage this is no longer a reliably comfortable and safe position. Prone positioning on a flat therapy table can exert strain on the lumbar, pelvic, and uterine structures. Prone positioning shortens posterior musculature; compresses and anteriorly displaces the lumbar vertebra and lumbosacral junction; rotates the sacroiliac joints; and increases strain on the sacrouterine ligaments. Prone position, particularly in later pregnancy, often aggravates the causes of many women's back discomfort.
Pillows or specialized equipment that is marketed for pregnant clients can mitigate these problems, but neither pillow props, body cushions, pregnancy pillows, most on-site massage chairs, nor tables with cut-out ovals completely solve the problematic aspects of prone positioning. These alternatives can either (1) further strain posterior structures and the taxed uterine ligaments, or (2) create increased intrauterine pressure, particularly when you apply sufficient pressure to address the posterior structures therapeutically.
In most uncomplicated, low-risk pregnancies, some increase in intrauterine pressure is acceptable. Additionally, during the first 13 weeks the anterior iliac spines usually protect the uterus from increased pressure. Use the prone position in the first trimester, but keep in mind that avoiding increased intrauterine pressure is of particular relevance when there are placental abnormalities, or a higher risk of such conditions. Be cautious if there is heightened concern about fetal blood supply or uterine competence. Women diagnosed with these conditions are often uninformed about their impact on receiving massage therapy. Some of these problems go undetected until screening tests are performed, or until bleeding, cramping, or other overt signs of problems have occurred to warrant further diagnosis. Prone positioning, even in the first trimester, can be problematic when the embryo is larger than normal, with twins or other multiples, and when the mother is obese. Use sidelying and semi-reclined positions after the first trimester with all pregnant clients to avoid the risk of excessive intrauterine pressure.
Some other considerations: Prone positioning exerts pressure on sensitive, enlarged breasts. Because of increased mucous production and the inadvisability of using alleviating medications, many women become unacceptably congested in prone position. Some women are uneasy with "lying on their baby." Finally, the confines of face cradles often hamper verbal and emotional sharing.
For the comfort and safety of the pregnant woman, eliminate the prone position after the first 13 weeks, regardless of your or the client's perception or preferences in this regard. Use caution and make reasonable adaptation for its use in the first trimester.
Supine Positioning Guidelines
Prenatal supine positioning also involves safety considerations. In this position the weighty uterus rests against the inferior vena cava. Extended compression of the vena cava will result in low maternal blood pressure and decreased maternal and fetal circulation (supine hypotensive syndrome). Some women report uneasiness, dizziness, shortness of breath, or other discomforts when lying flat on their backs, although others seem entirely content; however, with or without notable negative effects, decreased fetal circulation occurs, particularly if the placenta is embedded posteriorly.
Some healthcare providers advise never lying supine, primarily when there is increased concern about fetal oxygenation. Though it appears safe throughout pregnancy for most women receiving massage therapy to lie on their backs briefly, for a two to five minute maximum, always follow these instructions when present. In second and third trimesters, be prudent and take mitigating measures for more extended anterior work. Options in early pregnancy include use of pillow support under the right side of the torso to shift uterine weight toward the left. After 22 weeks, elevate the torso to a semireclined angle of 45°-75°. Use the sidelying position as both a prone and supine alternative.
For all of the reasons above, sidelying (lateral recumbent) position offers maximum safety and comfort throughout all pregnancies. When sufficiently supported by pillows, bolsters, and/or cushions, most women can relax in this position. Sidelying minimizes strain on any of the uterine ligaments or on the musculoskeletal structures. It prevents increased intrauterine pressure, increased sinus pressure, and it tends to encourage somato-emotional integration. Physicians and midwives recommend the sidelying position to help ensure placental and fetal circulation when complications occur and in many high risk pregnancies. The left sidelying position allows maximum maternal cardiac functioning and fetal oxygenation, though most pregnancies are perfectly safe with mom on either their left or right side. The safest position for prenatal massage thereapy is the sidelying position, regardless of possible inconvenience to or preference of the practitioner.
Here are the basics of comfortable and safe sidelying positioning: Use several sizes of firm and soft pillows, a long body pillow, and/or a contoured bodyCushion. Support the woman’s head so that her cervical spine is aligned with her torso, and not hyperextended or sidebent. Use sufficient support to accommodate the space between the acromioclavicular joint and the head so that her shoulder is not uncomfortably compressed beneath her upper torso weight.
Tuck a small foam wedge or pillow, approximately eight inches square and two to four inches thick, under her abdomen near the pubic bone to support the uterus and prevent uterine ligament and lumbar strain. Place another similarly-sized pillow under her waist to support the lumbar spine if her hip and waist proportions are markedly different. Provide an additional pillow to support her upper arm, relieving pressure on tender breasts and preventing anterior torso rotation.
Extend her bottom leg, and position it on the table posterior to the other leg to avoid restriction of venous flow. For the uppermost leg, place supports of sufficient height and density to maintain a horizontal line between hip, knee and ankle, and to moderately flex this hip and knee. This will prevent strain on the sacroiliac joints and the lumbar spine, and anterior rolling of her torso. Proper leg height also mechanically assists in the reduction of leg edema, and provides relief from painful varicose veins.
The almost fetal sideling position offers psychological comfort for most pregnant women. Nestled comfortably on her side, she may feel more able to talk about her excitement, and her concerns, without the obstruction of a face cradle, as when prone, or the confrontational effect of talking face-to-face, as when supine.
The next time you have a pregnant client, you now have a basic overview of why, when, and how to position her. You may also want to learn more prenatal physiology, how to adapt your work for pregnancy’s demands, and specific prenatal therapeutic massage and bodywork techniques.
Carole Osborne-Sheets is the author of and Pre- and Perinatal Massage Therapy, and a contributor to the upcoming textbook Teaching Massage Therapy, as well as numerous other publications. She is the 2008 recipient of the AMTA Jerome Perlinski National Teacher of the Year Award. The work outlined in this article is adapted from portions of the author’s textbook Deep Tissue Sculpting.
For these and other books, click here.
For information about her certification program, Pre- and Perinatal Massage Therapy, and other hands-on workshops, click here.