Issue link: https://www.massageandbodyworkdigital.com/i/588318
Varicose veins (which increase the risk of deep vein thrombosis) or spider veins are often caused by the fetal demand on the mother's circulatory system. By the end of the pregnancy, swelling is common because women have 40 percent more interstitial fluid being carried by weakened vessels. The swelling is most evident in the mother's legs and feet. In most cases, healthy pregnant women exhibit what is called "gravity swelling." In other words, when her legs are elevated, the swelling is reduced. However, as many as 1 in 4 women can have pitting edema, which may indicate a hypertensive syndrome, or worse. That is why a pretreatment evaluation for pitting edema is so important before each massage. If your finger's imprint remains after a count of 10–30 seconds, do not massage, and have your client call her health-care provider. Another hypertensive syndrome to look for is gestational edema proteinuria hypertension (GEPH). This is a swelling of the hands, face, upper body, or entire body during the early to mid stages of pregnancy. Since this is a preeclamptic condition, massage is contraindicated. Equally important is the 4–5 fold increase in fibrinogenic activity (blood clotting factor) starting early in the second trimester (or late first trimester). This activity continues for 8–10 weeks postpartum. This is the body's defense against severe blood loss or hemorrhaging at labor. But this increases the mother's chances of developing thrombi 5–6 fold. Massage practitioners must be careful to avoid dislodging any clots that may develop within the iliac, femoral, or saphenous veins—the deeper blood vessels where circulation is most stagnant—of her legs. When a clot is present, the symptoms are pain, heat, swelling, spasm over the site of the clot, and difficulty walking. But it is also possible that the clots are asymptomatic. This is why pretreatment evaluations for the presence of blood clots are essential. This also explains why all deep strokes, vibrations, ischemic compression strokes, and traditional Swedish massage must be avoided on the legs (for up to three months postpartum) to avoid dislodging possible clots. So what modality is safe and effective to use on the legs of a pregnant woman? MLD. This superficial modality uses 10–30 grams of pressure (the weight of a quarter) and no lubrication to gently stretch the skin where the initial lymph vessels are. The strokes are performed slowly, "scooping" superficially, proximal to distal, with the direction of the stroke toward the heart. This not only effectively reduces the swelling that most pregnant women experience (which is what often makes the legs and feet so achy), but it is also safe in preventing clots from coursing through the blood stream. (Vessels in the neck are drained first.) It is essential that MLD be used on the mother's legs throughout the entire pregnancy. I strongly suggest practitioners advise their clients of this before they get on the table. Most people believe that since their legs hurt, a deep massage will address that problem. But the cause of the discomfort is the excess fluid and the most effective bodywork technique that enhances lymph flow safely is MLD. It also will safeguard against dislodging blood clots. For more information about MLD, read my Modalities for Massage and Bodywork, 2nd ed. (Mosby, 2015) or Hildegard Wittlinger's Textbook of Dr. Vodder's Manual Lymph Drainage, 6th rep ed. (Thieme, 2003). Appropriate modalities: MLD on the legs and feet AT ALL TIMES. This technique will also address swelling in mom's arms and hands. Never massage directly on top of varicose veins. Sacral lift and left side-lying position for relief of swelling. Respiratory System Shortness of breath is common in early pregnancy due to hormonal adjustments and in late pregnancy from the mother's backward leaning and postural shifting while standing; the myofascial restrictions in her rib cage and pectorals; and the compression of the uterus on her respiratory diaphragm inhibiting normal flexion and extension. But her body uses oxygen more efficiently, even though it feels as if she can't take deep breaths. Appropriate modalities: myofascial release, trigger point therapy, connective tissue massage, and Swedish massage. 58 m a s s a g e & b o d y w o r k n o v e m b e r / d e c e m b e r 2 0 1 5 Rib cage in pregnancy Rib cage in nonpregnant state Rib cage expansion during pregnancy. From J. Coad, Anatomy and Physiology for Midwives, 2nd ed., 2005, London, Churchill Livingstone in E. Stillerman, Prenatal Massage: a Textbook of Pregnancy, Labor, and Postpartum Bodywork, St. Louis, 2008, Mosby, Inc.