Pregnancy Leg Massage
By Elaine Stillerman
Pregnancy Leg Massage
By Elaine Stillerman
The other day, I received a phone call from a practitioner who had purchased my MotherMassage Home Study program and was studying it along with a prenatal video. She said there was conflicting information about the appropriate prenatal massage procedure for the legs and wanted an explanation and clarification from me.
I am pretty sure this happens a lot in the bodywork field. One book or source contradicts another, and the student is left wondering which way to go. Within the pregnancy/postpartum bodywork specialty, I can attest to the fact that a lot of different information is being proffered. And if the student hasn't had the advantage of a hands-on class where the anatomy and physiology of pregnancy and postpartum are detailed, then they are left as confused as this student.
I also have seen videos and read books that disagree with my approach to leg massage during pregnancy. So, I have decided to use this column to cite the biological reasons for exclusively using lymphatic drainage protocol on the legs of a pregnant woman and for at least three months postpartum. I readily admit that I am conservative and cautious when it comes to massaging expectant women's legs, but when you consider the physiology behind my decision, I think that you, too, will accept this technique as the most appropriate and safest one for pregnancy and early postpartum. (The extensive research was done for and is excerpted from my upcoming textbook, Prenatal Massage: A Textbook of Pregnancy, Labor and Postpartum Bodywork.)
A woman's body undergoes many physiological and emotional changes during her 40 weeks of gestation to support the pregnancy. Your bodywork has to change along with her to address the discomforts of each trimester, keep her relaxed and prepare her for the task of labor and childbirth.
One of the major systemic changes she undergoes affects her cardiovascular system. These changes support normal maternal metabolism, the increased needs of the pregnancy and provide for fetal growth. The increase in blood volume is commensurate with the woman's weight, the number of previous pregnancies and births she has had, and whether this is a single or multiple birth.1 By the beginning of the sixth week of pregnancy, the increase in blood volume continues through the end of the pregnancy with an average volume increase of 30 percent to 50 percent. This level generally peaks between weeks 16 and 28 and remains elevated until after week 30. There is a slight decrease to about 20 percent by week 40, due to the heavy uterus obstructing the vena cava.2-4
The elevation of blood volume supports the uterus (since as much as 10 percent of maternal cardiac output is redirected to the uterus by the third trimester); protects the mother and fetus against harmful effects of compromised venous return in erect or supine positions; counterbalances the effects of increased arterial and venous flow; increases profusion to other vital organs, especially the kidneys; and compensates for maternal blood loss at birth.5-6
All blood components increase as a result of the additional blood volume. This increase is made up of additional serum protein, neutrophils, enzymes, plasma, platelet count, clotting factors, albumen, white blood cells and red blood cells. Plasma levels increase to 1000 ml by early pregnancy and the red blood cell count is elevated to 450 ml, or about 20 percent to 30 percent.7-9 This explains why some pregnant women develop anemia.
Other cardiovascular changes include an elevated resting pulse,10 slightly lower blood pressure (which is affected by stress levels and her position),11 more sluggish blood flow to the lower extremities especially during the last few weeks of pregnancy,12 and suppressed maternal immune response (starting by the tenth week of pregnancy).13
Let's explore another important cardiovascular adaptation - one which causes us to examine the bodyworks we employ on her legs. In order to protect the expectant mother from hemorrhaging at labor, there is an increase in coagulating factors VII, VIII, IX, X and fibrinogen (fibrinogenic activity) and a decrease in anticoagulants (fibrinolytics).14-16 This activity continues throughout the first few months of postpartum as well. By the end of the first trimester, there is a 50 percent increase in the synthesis of plasma fibrinogen.17
The decrease in anticoagulants along with the vasodilation contributes to a five- to six-fold increase in the risk of thromboembolism during pregnancy.18-19 Blood clots may also develop due to the weight of the uterus slowing femoral and iliac circulation, sluggish blood flow, greater blood volume and higher levels of progesterone relaxing smooth muscle fibers.
Blood clots can form in any vein, but are more prevalent in the deep veins where blood flow is restricted and generally more stagnant. During pregnancy, the veins that might harbor these thromboemboli or deep vein thrombosis (DVT) are the iliac, femoral and saphenous veins of the inner thigh.
During pregnancy, the clots most frequently begin in the veins of the calf muscles or in the iliofemoral portion of the deeper venous system. The left leg seems to be most susceptible.20-22 This is the first reason all deep tissue, ischemic compressions, friction, tapotement and vibration strokes must be avoided - the risk of dislodging a blood clot is greater with deep strokes, including traditional Swedish massage. This is also why pre-treatment evaluations for the presence of blood clots are essential prior to every prenatal and early postpartum treatment. These assessments include evaluating both legs and the Homan check (sign) for the presence of clots in the calves.
Another compelling reason to employ the light, slow strokes on the pregnant woman's legs is the increase in interstitial fluid. By the third trimester, pregnant women have 40 percent more fluid in their bodies and consequently, more swelling in their lower extremities. Restricted femoral and iliac circulation, the weight of the uterus, myofascial restrictions of the pelvis and gravity all work against lymph re-absorption. (For most of these women, the swelling is not a problem, but for 25 percent, this edema can be problematic. The swelling, considered "pitting" by a pre-treatment evaluation, can be a symptom of a serious and dangerous condition called pre-eclampsia. If the swelling is pitting, massage must be avoided.)23
The most efficient and safest modality to enhance lymph circulation is lymphatic drainage. And although the changes in her cardiovascular system don't generally start until late in the first trimester or early in the second trimester, following lymphatic protocol throughout the entire pregnancy and for at least three months postpartum is the safest, most appropriate way to treat her tired, sore and achy legs. This technique uses pressure of no more than 5-7 grams and works toward the heart, starting form the proximal aspect of the limb, and follows the slow rhythm of the lymph system. It includes, but is not limited to, lymphatic effleurage, circular petrissage and lymphatic compression.
The best way to learn hands-on techniques is, of course, in a classroom setting. But that may not be possible for some of you. So, if you need to get the basics from a home study program, book or video, examine the rationale behind the bodywork modalities that is provided. If the explanation is sound and based on facts, then you can be assured that the choices you make are the right ones.
- DeCherney, Alan and Pernoll, Martin A. Current Obstetric & Gynaecologic Diagnosis & Treatment, 8th edition. Norwalk, CT: Appleton and Lange, 1998.
- The Merck Manual of Diagnosis and Therapy, Gynecology and Obstetrics, Sec. 18, Chapter 249.
- Cunningham, F., et al. Williams Obstetrics, 21st edition. New York: McGraw-Hill, 2001.
- DeCherney, op cit.
- Leifer, Gloria. Maternity Nursing: An Introductory Text, 9th edition. St. Louis: Saunders, 37, 2005.
- Kowdermilk, Deitra Leonard, RNC, PhD, FAAN and Perry, Shannon E., RN, CNS, PhD, FAAN. Maternity & Women's Health Care, 8th edition. St. Louis: Mosby, 357, 2004.
- DeCherney, op cit.
- Monga, M. Maternal cardiovascular and renal adaptation to pregnancy.
R. Creasy & R. Resnick, eds. Maternal-fetal Medicine 4th edition. Philadelphia: W.B. Saunders, 1999.
- Fraser, Diane M. and Cooper, Margaret, A. eds. Myles Textbook for Midwives, 14th edition. Edinburgh: Churchill Livingston, 190-191, 2003.
- deSweit, M. The Cardiovascular System. Chamberlain G., Broughton Pipkin F. eds. Clinical Physiology in Obstetrics. Oxford: Blackwell Science, 31-33, 1998.
- Letsky, E. The Haematological system. Chamberlain G., Broughton Pipkin F. eds. Clinical Physiology in Obstetrics. Oxford: Blackwell Science, 71-79, 1998.
- Lowdermilk, op cit 358-359.
- Girling, Joanna C. Physiology of pregnancy. Obstetrics, Anaesthesia and Intensive Care Medicine. Medicine Publishing, Abingdon, Oxon, Online, 167-170, 2001.
- Symonds, E. and Symonds, I. Essential obstetrics and Gynaecology 3rd edition. Edinburgh: Churchill Livingstone, 26-31, 130, 1998.
- Coustan, D. Maternal physiology. Chamberlain G., Broughton Pipkin F. eds. Clinical Physiology in Obstetrics. Oxford: Blackwell Science, 71-79, 1998.
- Girling, op cit.
- Toglia, Marc. R. MD and Weg, John, G., MD. Venous thromboembolism during pregnancy. The New England Journal of Medicine, 335 (2), 108-113, 1996.
- Bergqvist, A. Hedner, U. Pregnancy and venous thrombo-embolism. Acta Obstet Gynecol Scand., 62, 449-453, 1983.
- Bergqvist, A., Bergqvist, D., Hallbrook, T. Deep vein thrombosis during pregnancy: a prospective study. Acta Obstet Gynecol. Scand., 62, 443-448, 1983.
- Hull, RD., Raskog, GE., Carter, CJ. Serial impedance plethysmography in pregnant patients with clinically suspected deep-vein thrombosis: clinical validity of negative findings. Med J Australia, 155, 253, 1991.
- Fraser, op cit, 364-365.