Massage and the Pregnant Pelvis

By Carole Osborne-Sheets

First published in Massage Therapy Journal, Summer, 1998, Vol. 37, No. 2

In an informal 1994 survey on prenatal massage, massage therapists cited relief from the aches and pains of pregnancy as a primary motivator for their clients seeking therapy.1 Studies conducted in Sweden reported that 48 to 56 percent of all pregnant women experience backache during pregnancy. They described this pain as generalized fatigue, tightness, and achiness with concentrated areas of pain. Half of these women suffered discomfort in the sacroiliac area, 25 percent complained about the lower back, and for another quarter of these subjects the upper back was most problematic. Many women found months 5 to 9 to be the most uncomfortable, and many reported their first incidence of chronic pelvic and back pain during a pregnancy.2

Prenatal Posture

Back and pelvic pain secondary to pregnancy is the result of: improper posture created by the anterior weight load of enlarging breasts, uterus, and fetus; muscle strain and imbalance; myofascial trigger points; fetal positioning; hormonal effects on ligaments; and referred pain from uterine ligaments. 3 The shift in center of gravity created by the addition of anterior weight in the breasts and abdomen challenges a pregnant woman's structural integrity. As pregnancy progresses, her pelvis will continually rotate anteriorly, tilting the uterus forward against the abdominal wall. This misalignment increases the lumbar curvature and stretches and weakens all of the abdominal muscles. Pressure against the interior abdominal walls subsequently both separates the rectus abdominus at the linea alba (diastus recti) and incites hyperirritable, tender points (myofascial trigger points) in the abdominal muscles that characteristically refer pain both abodominally and posteriorly.

In compensation for lumbar and pelvic misalignment, the woman's head and neck jut forward anteriorly from the optimal vertical line; she leans her upper ribcage more posteriorly; and her pectoral girdle sags into forward rotation.

Increasing weight and misalignment cause the pregnant woman's posterior musculature to become fatigued, tight, fibrotic, and full of trigger points. Increased abdominal and overall weight also encourages external rotation of her hip joints and loss of iliopsoas function in walking. This results in the waddling that so characterizes the pregnant woman's gait. In an effort to prevent falling forward from the increased anterior weight, she hyperextends her knees, often causing cramping of the calves. She tends to collapse her increased weight into the medial arches of her weary feet.4 A fetus with a left or right position preference in the uterus often overburdens that side of the woman's back making it tired and sore with the unbalanced weight load. Some women develop temporary scoliosis from fetal positioning preferences.

These postural adjustments to pregnancy result in strain and pain in the following muscles and muscle groups: levator scapulae, sternocleidomastoid, trapezius, and supraspinatus; pectoralis major and minor; abdominal group; erector spinae, multifidi, rotators, quadratus lumborum, and iliopsoas; pelvic floor muscles; hip rotators, adductors, quadriceps group; gastrocnemius, soleus, and peroneals.

Stressed by the anterior load and an average weight gain of 25 to 35 pounds, the weight-bearing joints and associated myofascial structures of pregnant women are strained and compressed. Greatest impact is felt in the intervertebral and facet joints, particularly in the lumbar spine, as well as the lumbosacral joint, sacroiliac joints, pubis symphysis, and hip joints. All of these strains are multiplied in women who exceed recommended weight gain or carry twins or triplets.

Most importantly, the relationship of the ilea and sacrum at the sacroiliac joint shifts when the enlarged abdomen protrudes anteriorly. As the pelvis anteriorly rotates, the ligaments of these deep pelvic joints are compressed and strained and can become hyper- or hypomobile, in response. Sacroiliac pain is typified by a chronic achiness in the upper medial quadrant of the buttocks, across the iliac crest, or at the posterior iliac spine of the pelvis, and radiating for several inches. Prolonged periods of standing or sitting, walking on high heels, and sitting with poor back support can create additional strain to these joints. Occasionally, one sacroiliac joint's hypomobility will result in excessive mobility in the other. A sharp, stabbing posterior pelvic pain is then often experienced when rolling from a supine position, particularly on hard surfaces.5

The lumbosacral junction is similarly affected by increased anterior weight load. Achiness in the center of the sacral and lumbar areas often indicates strain and compression of the lumbosacral joint.

Hormonal Influences

As early as the tenth week, both estrogen and relaxin, a pregnancy-specific hormone, begin softening connective tissues in preparation for labor. Intended to increase the parameters of the pelvic outlet, these hormones' effects are systemic. The resulting laxity in all ligaments, tendons, and fascia throughout the body contributes to joint instability and more strain on weight-bearing structures, especially in the lumbar spine and pelvis.

Probably relaxin's most detrimental prenatal effect is on the symphysis pubis (See Figure. 1). Softened by relaxin, this pelvic junction of the pubic bones is vulnerable to horizontal sheering strains that are excruciating when one side of the pelvis is either elevated or depressed. Sharp, stabbing pain in the center of the anterior pelvis occurs particularly when rolling over in bed or on a therapy table, climbing stairs, or any movement that creates unilateral strain to the pelvis or requires one leg to move differently than the other.6

Uterine Ligament

Over the 40 weeks (9 lunar months) of pregnancy the uterus expands from plum size to watermelon size. The fundus, or superior aspect, reaches xiphoid process level by term. It is suspended by the supportive structure of its ligaments. Formed of thickened external connective tissue of the uterus, these ligaments include: two broad ligaments extending laterally to attachments in the internal pelvic cavity walls at the ilea (these also support the fallopian tubes and ovaries); two round ligaments arising from the anterior, superior surface of the uterus and attaching in the connective tissue of the pubic mons; the sacrouterine ligament continuing from the posterior uterus to attach to the posterior pelvic cavity wall at the anterior sacral surface. (See figure 2)

These ligaments, as they are inexorably stretched by uterine growth, typically refer pain beyond their attachment sites, as follows:

Broad ligaments: low back, buttock and sciatic-like pain referral pattern, especially in the sixth month, and often disappearing in months 7 or 8.
Round ligaments: diagonal pain from the superior uterus to the groin usually one sided, depending on fetal position; sometimes as extensively felt as the vulvar and upper thigh fascia.
Sacrouterine ligament: achiness just lateral to or beneath the sacrum, especially in last three months.

Pain in one or both buttocks that radiates down the posterior leg is occasionally not referred from the broad ligament. Entrapment and compression of the sciatic nerve may result from severe postural imbalance in the lumbar spine and pelvis or from chronic piriformis tension. Sciatic nerve pain usually "burns" and may be accompanied by tingling, numbness and weakness in the legs. This occurs in only 1 percent of pregnant women.7

Prenatal Massage Therapy

Many types of touch therapy can effectively aid the body of the pregnant woman. Incorporating several types of techniques from those listed below will create a foundation for effective prenatal sessions. Therapists shou1d focus on the muscles and joints listed previously, utilizing techniques that reduce muscle spasms and fibrosis, relieve myofascial shortening and pain, extinguish trigger points, reduce uterine ligament strain, and reeducate efficient structural integrity and body use. Beneficial methods include:

• assisted resisted stretches, including proprioceptive neuromuscular facilitation and muscle energy techniques
• CranioSacral Therapy
• cross fiber friction
• deep tissue massage
• myofascial release
• structural balancing
• passive movements, including joint mobilizations, rhythmic movements or trepidations, strain counterstrain or positional release, stretching, and traction
• reflexive massage, including bindegewebsmassage, foot zone therapy, trigger point, neuromuscular massage, and Oriental methods
• Somato-emotional integration
• Swedish massage

Education

Educational activities also are effective interventions for reducing pain and decreasing stress on weight-bearing joints and myofascial structures.8 Correct and safe abdominal strengthening activities and body-use guidelines, for walking, sitting, sleeping, carrying, and other daily activities, will further reduce strain in the neck, back, and pelvis.9 More efficient movement patterns enhance and reinforce the effectiveness of hands on therapy.

Safety Guidelines for Back and Pelvic Prenatal Massage

In order to safely work with expectant women, practitioners need to modify their normal massage therapy routines in regards to pain level and abdominal pressure. The implications of thrombi in the legs, miscarriage, prematurity and other complications and risk factors also demand adaptations in protocols and may necessitate delaying treatment or not working with certain women.

Pain Level

Maintaining pressure, speed, and intensity regardless of the treatment method used, is essential. Never exceed a pregnant client's experience of pleasure on the borderline of pain. This level of intensity allows for sufficient depth to accomplish the therapeutic goals of most appropriate somatic practices. Maintaining a pleasure/pain level also assures that neither the mother nor the fetus is stimulated to sympathetic arousal.

Pain activates adrenal production of the hormones which elevate blood pressure, heart rate, and respiratory rate and which lower immune function and blood flow to the uterus.10 Since these hormonal signals diffuse into fetal circulation through the placenta, the fetus is similarly negatively impacted.11 Certain techniques require lighter pressure to be physiologically effective. Tissue health, injuries, and other safety considerations which are discussed later in this article often dictate more superficial touch.

Abdominal Pressure

The techniques listed above are effective in relieving back and pelvic pain. However, the massage therapist should insure that application of these techniques will not increase intrauterine pressure, decrease blood flow to the uterus, or create localized, deep pressure into the abdomen.

Increased intrauterine pressure probably is not a significant safety concern in most normal, uncomplicated, low-risk pregnancies. However, it is of particular relevance when there are: abnormalities in placental attachment or function, or higher risk of such conditions; uterine or cervical abnormalities; and, any factor associated with concerns for fetal blood supply, such as high blood pressure, multiple fetuses, or intrauterine growth retardation. Women who have been diagnosed with these conditions often are uninformed about their impact in relationship to receiving massage therapy. Also, some of these problems go undetected until bleeding, cramping, or other overt signs of problems have occurred to warrant further diagnosis.

While the effect of deep abdominal massage techniques on pregnancy has never been specifically studied, increased intrauterine pressure and deep, pointed, or abrupt pressure into the abdomen may increase the risk of miscarriage, premature labor, or placental dysfunctions.12 In this light, the massage therapist must thoroughly evaluate all massage therapy techniques being considered for a pregnant woman. Each technique must be investigated to confirm that its application will not directly or indirectly press into the abdomen.

Many procedures, such as resisted assisted stretches and positional releases, can be modified to avoid this safety concern Further reduce the possibility of increasing intrauterine pressure by only massaging the pregnant abdomen at the skin and superficial fascia level. This precaution also applies to any techniques performed on the lateral abdomen, anterior of the quadratus lumborum. Light, full-handed pressure avoids any possibility of abdominal trauma that may provoke uterine contractions or injure the intestines.

Positioning for massage therapy

Eliminate massage therapy in the prone position entirely after the first 13 weeks gestation, and even earlier if there is more than one fetus or if the fetus is larger than normal at gestational age. After the first three months, safe prone positioning is difficult, if not impossible, even with additional pillows, and/or table and other equipment currently marketed for this purpose. Prone positioning with equipment that doesn't elevate intrauterine pressure often strains the taxed uterine and lumbar ligaments, exacerbating the very causes of many pregnant women's discomfort. The sacroüterine ligament is particularly vulnerable in the prone position.

Supine positioning also involves safety considerations when working with pregnancy-related sources of lumbar and pelvic pain. In this position, the weighty uterus compresses against the inferior vena cava. Extended compression will result in low maternal blood pressure and decreased circulation both to the mother and her fetus (Supine Hypotensive Syndrome) (See figure 4).13 In second and third trimesters, mitigating measures for more extended supine positioning are prudent. Shift the uterus to the left side with pillow support under the right lumbar and pelvic areas during weeks 14 to 22. After 22 weeks, elevate the entire torso to a semireclined angle of at least 45 degrees. Use a densely cushioned therapy table, and provide sufficient supports for the lumbar area and the knees. Always observe these restrictions, especially when the client has been advised by her healthcare provider to never lie on her back.

When the client is sufficiently supported with firm pillows, bolsters, and/or a contoured body cushion, the sidelying position is the safest, most posturally neutral, and most comfortable position to receive prenatal massage therapy. Even in the sidelying position, however, pressure must be applied without rolling the woman onto her abdomen, and her top leg must be aligned horizontally with her hip. This is most important during deep work on the posterior structures when addressing back and pelvic pain.

Blood clots

Avoiding deep, pointed, and/or ischemic compression to the pregnant abdomen also eliminates pressure into the dangerous inguinal area where blood clots can form. Blood clotting capacity escalates during pregnancy to four-to-five times non-pregnant levels. As fibrinolytic activity (clot dissolving) dramatically decreases, women are protected from potential hemorrhaging during childbirth; however, at the same time, this process also increases the risk of formation of blood clots (thrombi).14

Clot formation is greatest in veins in which blood is moving slowly or is stagnant. The veins most likely to harbor clots during pregnancy are the iliac, femoral, and saphenous.15 (See Figure 6.) This is due to restriction of iliac and femoral venous return caused by the weight of the uterus on these vessels and to hormonal influences on both vascular smooth muscle and on blood and fluid volumes. Respect the likelihood of clots and their potential harm once they are freely circulating. Do not press deeply into the abdomen, especially in the inguinal area. Perform no tapotement on any leg surface. Also use only soft, whole-hand pressure throughout the medial surface of the legs where these veins traverse. Eliminate deep, pointed, or stationary (ischemic) pressure on the medial leg that is sufficiently sustained to restrict localized blood flow. This rule applies, regardless of the type of technique and its potential benefits.

Miscarriage and Prematurity

Miscarriage (spontaneous abortion) is a natural termination of pregnancy before the fetus has reached viability and is most common in the first trimester. Preterm labor involves regular contractions that dilate the cervix after 20 weeks and before the end of 36 weeks gestation. One of the most common symptoms of premature labor and miscarriage is low back-pelvic pain that is referred from the contracting uterus. However, there are usually other identifying symptoms, such as bleeding or amniotic fluid leakage, abdominal cramping, or regular uterine contractions. Musculoskeletal back pain usually is relieved with a change in position or activity, while referred organic pain is not. Ask the woman's physician to rule out miscarriage, preterm labor, or other possible causes of back pain, such as urinary tract infection, neurological dysfunctions, eclampsia, or prior, unresolved injuries. Take full prenatal and medical histories, and evaluate thoroughly at each massage therapy session.

Certain maternal conditions, high-risk factors, and complications of pregnancy increase the risks of miscarriage and prematurity, including:

• miscarriage or preterm labor in previous pregnancies;
• decreased blood flow to the uterus caused by placenta abrupto, placenta previa, diabetes, systemic lupus and other autoimmune factors, pre-eclampsia/eclampsia (GEPH), overdistension of the uterus from multiple gestations, and polyhydramnios;
• abdominal trauma or surgery;
• premature rupture of membranes;
• maternal diethylstilbesterol (DES) exposure in utero resulting in uterine abnormalities;
• incompetent cervix and other uterine anomalies;
• urinary tract or vaginal, uterine, or fetal infections
• chromosomal abnormalities;
• fever;
• altered nutrition leading to low maternal weight gain;
• smoking, radiation, alcohol, abused drugs, especially cocaine, and other teratogenic agents;
• emotional stress;
• heavy work load at home or on the job;
• maternal age over 36. 16chromosomal abnormalities;

Cautions

There should be no question of protocol or any doubt as to whether a massage therapy intervention was harmful. Some sobering facts of American maternity care are very relevant to massage therapy practitioners. Among them are that more than 75 percent of obstetricians and gynecologists are sued; more than one third of these are sued more than three times; and, nurses and other perinatal healthcare providers are increasingly being included in these lawsuits.17 Massage practitioners are wise to be aware of the litigious atmosphere in childbearing.

Here are four added precautions that could avoid erroneous, but costly, legal problems:
1) Do not touch the abdomen of a first trimester woman or anyone whose risk of miscarriage or preterm labor is high.
2) Always ask permission to gently touch any woman’s abdomen.
3) Strictly adhere to midwives’ and physicians’ restrictions regarding abdominal massage.
4) If untrained in prenatal massage safety issues, do not work on pregnant women, particularly those experiencing complications or high risk factors in their pregnancies.

Ligament Laxity

Symphysis pubis separation demands three special considerations in choosing and performing massage therapy. First, rolling over is painful with this condition, so minimize position changes. Second, firm, reliable bolsters and other supports are essential in all positions in order to prevent extended tugging on this joint as a woman receives treatment. Third, eliminate any technique which creates traction on the pelvic and hip joints or which compresses the pelvis unilaterally.

All of a pregnant woman's ligaments are easily overstretched due to the softening hormonal effects. Overstretched ligaments result in joint instability and more pain. Minimally invested with elastic fibers, ligaments do not tighten after excessive lengthening. Therefore, modify assisted resisted stretches, positional release, Swedish gymnastic movements, range of motion, and other passive and active movements to avoid overstretching of joint structures.

Other complications

In addition to miscarriage, premature labor, and placental dysfunctions, other physiologic complications to a normal gestation may occur. These include gestational diabetes and several types of hypertensive disorders of varying severity.

Massage therapy is contraindicated when any such complication arises, until it is resolved or until after consultation with the pregnant client's healthcare provider. Those who work with these women also will require a written release from the woman's healthcare provider. The prudent and cautious therapist who is not fully educated in maternity massage therapy will refer these women to other more qualified, certified practitioners.

In high-risk pregnancies, either the mother or the fetus has a significantly increased chance of disability or death. Most of the conditions considered high risk will not be negatively impacted by massage therapy. In fact, massage therapy may be invaluable in reducing the negative effects of a pregnant client's heightened anxiety and inactivity, and, in some cases, can help reduce the amount of bed rest which is often prescribed. Communicate with her healthcare provider, procuring a written recommendation for therapy. With the further risk involved, it is advisable that therapists refer these women to more qualified, certified practitioners if not comprehensively trained in prenatal massage therapy.

Conclusion

There are safe and effective ways for the massage therapist to address the most common pregnancy complaints originating from the pregnant spine and pelvis. Pregnant women experience numerous other structural, physiological, and emotional changes and discomforts that also respond well to specific, therapeutic techniques. Further study of the many other relevant intricacies of pregnant physiology and psychology and thorough, hands-on training are highly recommended.18

References

1. Unpublished survey of graduates of authors former pregnancy training program,1994.
2. Ostgaard, l-LC. and Andersson, G.$.J., et al, “Prevalence of back pain in pregnancy,” Spine 17(1): 53-55 (January) 1992.
3. Attal, R., Friedman, MI., McNitt-Cray, J.L, “Orthopedic problems in pregnancy.” The Physician and Sportsmedicine, 18:93-105, 1990
4. Noble, Elizabeth, P.1., Essential Exercises for the Childbearing Year. Harwich, MA: New life Images, 1995 (4th edition), pp. 20, 225.
5. Ibid., p. 54.
6. Ibid., p. 53.
7. Op. Cit., Ostgaard, p. 54.
8. Ibid., p. 86-88.
9. Op. Cit., Noble, p. 81 -1 46.
10. Gorsuch, R.. and Key, M., “Abnormalities of pregnancy as a function of anxiety and life stress,” Psychosomatic Medicine, 36: p. 353, 1974.
11. Catz, Charlotte. Prevention of embryonic, fetal, and perinatal disease. HEW, p. 123, 1976.
12. Gilbert, Elizabeth Stepp, and Harmon, Judith Smith. Manual of High Risk Pregnancy and Delivery. St. Louis, MO: Mosby-Yearbook, Inc., 1993, pp. 265,~41 6.
13. Ibid., p. 40.
14. Ibid., p.7.
15. Alexander, Doug. “Deep vein thrombosis and massage therapy,” Massage Therapy Journal 32(3):56, 1993.
16. Op. Cit., Gilbert and Harmon, pp. 265,416.
17. Osborne-Sheets, Carole, Deep Tissue Sculpting: A Technical and Artistic Manual for Therapeutic Bodywork Practitioners. San Diego: Body Therapy Associates, 1995 (3rd edition).
18. Ibid., p.160.

Author: Carole Osborne-Sheets, a somatic practitioner since 1974, began developing infant and prenatal massage therapy in 1980. She has trained thousands of therapists and other perinatal specialists over the past two decades. She is author of Pre- and Perinatal Massage Therapy and of Deep Tissue Sculpting, and co-founder of the International Professional School of Bodywork in San Diego, California, USA.

Text and illustrations Copyright 1998 Carole Osborne-Sheets. Figures 1,3,4, :Adapted from LifeART Copyright 1989-97 by Tech Pool Studios, Inc., USA. Used with permission. Figure 2: Copyright Childbirth Graphics, Division of WRS Group, Waco, TX. Used with permission.