Issue link: https://www.massageandbodyworkdigital.com/i/1276187
56 m a s s a g e & b o d y w o r k s e p t e m b e r / o c t o b e r 2 0 2 0 Unfortunately, with the high rate of asymptomatic infection and the testing limitations, your clients and/or you may or may not be infected at any point in your treatment interactions. Consequently, I believe it is most responsible to modify all maternity massage therapy protocols as though each expectant or new-mother client has, or has had, this infection. Adaptations for respiratory and placental efficiency and the prevalence of blood clots have always been critical factors with pregnant and postpartum massage therapy clients, even prior to the emergence of the coronavirus. COVID-19 appears to increase these concerns significantly. Let's next consider these respiratory, positioning, and blood-clotting factors and the ramifications for safe practice. RESPIRATION, PLACENTAL FUNCTION, AND POSITIONING A common, though not universal, symptom of COVID-19 is shortness of breath. As a result, be sure to assess and think through positioning's effect on maternal and fetal oxygenation for each individual. Common nursing practice 9 and obstetrical research 10 point to side-lying positioning during pregnancy, left or right, resulting in better maternal and fetal oxygenation and outcomes when compared to other positions. There is a slight advantage to the left side-lying position over the right that, in normally progressing pregnancies, is usually irrelevant. With coronavirus, however, a recent small study showed some negative effects and compromise in placental functioning when expectant people are infected. 11 As of yet, there is no data regarding how long after infection this reduction in placental function may last. Recommended Side-Lying Positioning Guidelines With these considerations in mind, I now recommend the following regarding side-lying positioning: While some of this information is reassuring, pregnant women are disproportionately affected by respiratory illnesses in general, and thus they may be at higher risk for contracting COVID-19. Managing your practice hygiene then is critical. Physiological and mechanical changes in pregnancy increase susceptibility to infections in general, particularly when the cardiorespiratory system is affected, and encourage rapid progression to respiratory failure. 8 As data gradually emerge regarding the effects of COVID-19 infection on pregnant, birthing, and postpartum people, the implications for us when they become our clients evolves too, and it is likely to remain ambiguous and incomplete. If you are seeing childbearing massage therapy clients, staying currently informed is an ethical imperative. NOT SO FAST TO THE TREATMENT ROOM Coronavirus or not, pregnancy's common companions of back, pelvic, and hip pain continue to bring clients seeking relief from our work. And the additional stress of the pandemic for those expecting a baby can be overwhelming. Regardless of need, any expectant clients with COVID-19 symptoms, presumed or suspected infection, or positive test results should not be receiving massage therapy while ill or contagious. If they had credible exposure, they should undergo 14 days of isolation to prevent spread if they are infected. Because of the varied severity of symptoms and recovery time, best practice is to seek medical or midwifery review of every pregnant client's unique condition and request any massage therapy limitations or contraindications specific to that person. Even with that clearance, you may want to delay for at least three months after illness. • Use left side-lying exclusively or for most of a given session, especially if other respiratory compromises are evident, such as shortness of breath (not illness related), postural breathing restrictions, or obesity; asthma, respiratory allergies, or a cold; multiple gestation; other placental abnormalities; or gestational hypertensive disorders (Image 1). • Use left and right side-lying positioning with clients who do NOT have any of the compromises listed above and whose pregnancies are proceeding normally. • After COVID-19 recovery, continue using left side-lying exclusively, or almost exclusively, unless you consult with the client's physician or midwife for other positioning clearance, since ongoing placental effects are still undetermined. Recommended Supine Positioning Guidelines If you work with a pregnant client in the supine position, then prevention of supine hypotensive syndrome is of increased importance, especially since your client may be asymptomatic and/or untested. Supine hypotensive syndrome is decreased blood pressure caused by the enlarged uterus compressing the inferior vena cava sufficiently to reduce venous return. Symptoms include uneasiness, dizziness, weakness, nausea, shortness of breath, or other discomforts when clients are lying flat on their back, although some report no symptoms (Image 2). I recommend a strict adherence to the following positioning guidelines for all your pregnant clients. • Limit any supine time to 3–5 minutes if you do not make one of these positioning adaptations. • From weeks 13 to 22, adapt supine positioning by placing a wedge under the client's right lower torso