Pregnancy Massage - Eclampsia and Pre-eclamsia

by Angela Wray, massage therapist

TABLE OF CONTENTS

Acknowledgements Introduction Eclampsia & Pre-eclampsia  Statistics When things go wrong  General  Signs and Symptoms of Pre-eclampsia  Conditions and Complications (Pre-existing or Pregnancy Related)  Hypertension  Diabetes  Renal Failure  Diseases and conditions of the kidneys  Complications caused by renal failure Testing for problems  Urinalysis  Blood test Changes to Lifestyle  Diet Treatment  Conventional  Medication  Massage  General  Working with the Birth Partner  Relationship with the Medical Profession  Post natal  Contraception Conclusion Glossary Bibliography

ACKNOWLEDGEMENTS

The author wishes to thank the pregnant women who generously donated their time when volunteering to be case studies for the Well Mother APNT certificate course. Their willingness to discuss their personal experience of pre-eclampsia and eclampsia has been most valuable. Also to the two wonderful fathers who were slightly apprehensive but willing to learn some massage techniques to help support their partners through pregnancy and labour as well as connect with their babies.

INTRODUCTION

When I began taking patient assessments from my four pregnancy case studies, I learned that one of the women (Client D) had experienced pre-eclampsia during her first pregnancy. As this condition may be a contraindication towards pregnancy massage, I asked her many questions about her experience before deciding whether or not I was able to consider her for pregnancy massage.

Based on the information provided during the Well Mother Pregnancy Massage course, additional information from further reading as well as from Client D, I also began to suspect that my other clients were showing signs of pre-eclampsia. I therefore became very interested in this particular condition because I wanted to ensure that I was treating each pregnant woman appropriately. Out of interest in their health and concern about their babies, it seemed an ideal opportunity to research the condition further and follow their progress as a project.

Until I began the research, I had little understanding or appreciation of the seriousness of this condition.

ECLAMPSIA and PRE-ECLAMSIA

Pre-eclampsia is a condition that can affect expectant mothers usually in the last three months of pregnancy. This condition is the milder form of the condition eclampsia. Eclampsia is now less common due to more frequent ante-natal visits when pre-eclampsia can be diagnosed and treated early. Most maternity units will only manage 1 or 2 cases each year.

The cause is still not yet known or understood although a number of theories have been put forward to explain these two forms of the condition. Pre-eclampsia and eclampsia used to be called 'the toxaemias of pregnancy' which may suggest that it is a toxin that is responsible but this has not been proved.

When pre-eclampsia occurs, the blood flow to the pregnant woman's kidneys slows down. This will cause her to retain fluid. The blood flow from the mother to the placenta will then decrease and this reduces the amount of nutrients to the baby.

If pre-eclampsia becomes severe or continues for too long, the baby will not be able to grow properly. It is very important, therefore to make sure that the baby's development is monitored in the womb and regular measurements recorded. This is done by measuring fundal height, feeling the mother's abdomen and by ultrasound.

Pre-eclampsia and eclampsia can also occur after the actual birth of the baby, although this is extremely rare.

Statistics

Approximately 1 in 20 first pregnancies will result in pre-eclampsia.

Most women who suffer from pre-eclampsia in a first pregnancy deliver a normal healthy baby.

There is a higher risk of pre-eclampsia if the mother has any of the following conditions:
· multiple birth (expecting twins, triplets, etc.)
· first time pregnancy
· over the age of 35
· diabetes
· renal failure

Eclampsia is rare, most maternity units will manage only one or two cases each year.

WHEN THINGS GO WRONG

General

Very often a woman with pre-eclampsia is not even aware that anything is wrong: she may have gained excessive weight and her fingers and ankles may appear swollen. However, this is also a fairly common occurrence in any normal pregnancy.

Pre-eclampsia can be very mild and cause no problems. If however, it becomes worse and is not treated it can lead to eclampsia which is very serious for both the mother and baby. It can not only affect the growth of the baby but it can also cause convulsions which are life-threatening.

Regular antenatal appointments are crucial because a number of routine tests are conducted which may help to diagnose pre-eclampsia. Blood pressure is taken as well as a urine sample. It is important that these antenatal appointments are more frequent towards the end of a pregnancy when pre-eclampsia is more likely to develop.

Very high blood pressure and large amounts of protein in the urine indicate the threat of eclampsia. The mother may look extremely bloated due to fluid retention. She may also begin to experience headaches, blurred vision, or sensations of flashing lights (similar to migraine) as well as having pain just below the ribs. This can lead to feeling extremely ill and vomiting. It is imperative that the mother is treated urgently otherwise she could have fits, kidney failure and coma.

It has been said that pre-eclampsia is not easy to predict. If it is recognized early, it is possible to improve the symptoms by strict rest either at home or in a hospital.

It is a very delicate balance to try to keep both the mother and baby safe. The baby needs to stay in the womb long enough to mature and be able to survive after delivery. However, if the pre-eclampsia is left untreated for too long then it could be fatal for the mother. Careful monitoring of both mother and baby is therefore vital.

If the mother does have an eclamptic fit, her blood pressure will be lowered with drugs. Labour will then be induced and the baby delivered either normally or by emergency caesarean.

Usually the mother's blood pressure will return to a normal level after the birth of her baby. She will also pass large amounts of urine which will in turn reduce the swelling. There is a chance that the condition will recur in the next pregnancy, but it is usually less severe.

Signs and Symptoms of Pre-eclmsia

Sign / Symptom Cause
Swelling of the arms, legs, face, hands Build up of fluid
Severe headache / disturbed vision Hypertension
Loss of appetite Uremia
Nausea / vomiting Uremia
Irritability / edginess / moodiness / memory loss / confusion / depression Uremia
Tiredness / weakness / pale complexion Anemia
Shortness of breath Anemia or fluid build-up
Itching Increased phosphorus in the blood / dry skin
Decreased urination Decreased amount of blood being filtered by the kidneys

Conditions and Complications (Pre-existing or Pregnancy Related)

Hypertension (High blood pressure)
During pregnancy, blood pressure is checked at every antenatal appointment. A rise in blood pressure can be the first sign of pre-eclampsia, also known as Pregnancy Induced Hypertension (PIH), or Pre-Eclamptic Toxaemia (PET).

If blood pressure rises it increases the supply of blood for processing. This increased level of blood to the kidneys means an extra workload and more urine will be created.

Hypertension can increase the chance of stroke or heart attack.

Diabetes
Long term or poorly managed diabetes can cause the blood vessels to decrease in size and therefore not allow enough blood to go through the kidneys.

Renal Failure
The kidneys receive their instructions from the pituitary gland which produces Vasopressin which is an antidiuretic hormone. If there is a hormone imbalance it could cause the kidneys to produce too much urine and the body would become dehydrated.

Alcohol and caffeine do not affect the kidneys directly, however they slow down the pituitary's hormone production and the kidneys produce urine more rapidly. If these substances are taken in excess the body will become dehydrated.

Nicotine in cigarettes increases the production of the hormone. Heavy smoking will cause the person to urinate less frequently.

Diseases and Conditions of the Kidneys
Hemolytic Uremia Syndrome (HUS) / Thromobocytopenia Purpuria (TTP) - are immune conditions. They have associated blood abnormalities such as anemia and low platelet counts. E Coli bacteria can be the cause of these conditions and although they are rare, they can cause kidney failure.

Nephritis - is the general term for inflammation of the kidneys often caused by infection by bacteria. There are two types of kidney inflammation.

'Pyelonephritis' and 'Glomerulonephritis' which is one of the leading causes of renal failure. Most infections can be controlled by antibiotics.

Polycystic - the kidneys develop cysts that enlarge and destroy normal tissue. This condition is genetic and inherited from parents.

Renal Cancer - one or both of the kidneys develops a cancerous growth. This can affect how they work and will need to be removed.

Nephron Damage - can also be caused by:
Drugs and Poisons - anti-inflammatory drugs, such as paracetamol and aspirin may cause damage if large amounts are taken regularly.

Injury - from a kidney punch or car accident (for example).

Complications caused by Renal Failure
Hypertension - can increase the chance of stroke or heart attack.
Anaemia - causes tiredness and weakness. This is treated with medication and additional iron.

TESTING FOR PROBLEMS

Urinalysis - a urine test will check for the presence of protein. Protein in the urine indicates that the kidneys filters are letting it escape from the blood.
"Casts" - when the tubules are inflamed, solid matter (cells, fats, proteins) solidifies to the exact shape of the tubule. These casts are flushed out by urine.

Blood Test - to check if the blood contains too much urea. If it does it indicates that the kidneys are failing to get rid of the protein wastes.

CHANGES TO LIFESTYLE

Diet

It would be beneficial to monitor and modify the diet if necessary because most of the wastes and extra fluids in the blood come from the food eaten. Eating a healthy diet during pregnancy and pre-conception will give the mother and baby optimum chance of preventing complications during pregnancy.

Kidney failure affects menstruation and therefore pregnancy is less likely to occur. If a woman wants to become pregnant, it is best in either the early stages of kidney failure or after a transplant. If a woman has conceived whilst suffering from kidney failure it is vital to control the intake of protein, potassium, sodium, phosphorus and fluids.

Minerals to control foods containing high amounts of the mineral
Potassium - Potatoes, tomatoes, bananas, oranges, broccoli, chocolate and salt substitutions
Phosphorus - Dairy products, nuts, colas, chocolate
Sodium - Processed meats, bacon, crisps, pickles

* Consulting a qualified and experienced nutritionist who would work on an individual basis to balance all these nutrients would be highly recommended.

TREATMENT

Conventional Treatment

The conventional treatment ranges from
· rest at home or in hospital
· drugs to lower the high blood pressure
· early delivery of the baby by induction or caesarean

Medication

May include:
- Aspirin
- Iron tablets
- Antihypertensive drugs
- Methyldopa
- Labetalol
- Nifedipine
- Hydralazine

Massage

General
It has been generally taught that pregnancy is a contraindication to massage. Many massage therapists have been unwilling to treat a pregnant woman out of fear of causing miscarriage, particularly in the first trimester. If massage was given, the abdominal area would often be avoided. The advanced 'Massage and Pregnancy' training offered by Well Mother gives the already qualified massage therapist additional knowledge and skills to treat a pregnant women with confidence in all stages of pregnancy.

Pregnancy as a whole is a wonderful and natural event. Massage can only enhance the experience if used appropriately. Massaging the abdominal area as well as using energy techniques offers the opportunity for mother and baby to connect and bond even during the early stages of pregnancy.

It is important to understand how both the mother and baby are developing in each trimester of pregnancy. At each stage, a different approach to massage needs to be considered to accommodate the changes that are occurring to them both. These changes also lead to different conditions that will require caution during massage. Pre-eclampsia is one of these conditions.

The decision to massage a woman with pre-eclampsia depends on the severity of the condition. The condition can vary from being very mild to being so severe that eclamptic fit is imminent.

In milder cases of pre-eclampsia, pregnancy massage would be beneficial for the woman's well-being and in turn is best for baby. Three of the main signs of pre-eclampsia are oedema, protein in the urine and raised blood pressure. In each case, the effect of massage can have a positive or negative effect.

Lymphatic massage of arms and legs will reduce oedema by forcing the excess toxins into the excretory system to be eliminated. However, if the pre-eclampsia is severe, massage would in fact add more strain for the kidneys. Protein in the urine is already a sign that the kidneys are struggling to process the wastes.
Hypertension responds well to a relaxing massage. When the woman is relaxed and comfortable her blood pressure will usually lower. Stimulating massage techniques should be avoided as it may have the opposite effect. Downwards strokes, away from the heart will also aid in reducing blood pressure. Palming down the Governing Vessel is also effective. Tiran describes massage alone as being extremely beneficial for the hypertensive woman, and for those admitted antenatally a simple back or foot massage could be effective in lowering the blood pressure. Its cumulative nature means that its optimum effects are obtained when the massage is repeated regularly (Tiran, 2000). McArdle describes her care of a woman with impending eclampsia who was not responding to intravenous therapy. Essential oils were massaged into the mother's back and legs for half an hour until the blood pressure decreased to within relatively normal limits. She posed the question, 'Was it due to the continuous infusion of drugs, was it due to the essential oils or was it due to the massage?' (McArdle 1992)

Headaches may also accompany high blood pressure and a relaxing face massage with cranial holds and occipital balancing are particularly useful as well as palming down the Governing Vessel. Client 'A' felt immediate relief of congestion and headache.

Yates describes pre-eclampsia and hypertension as indicating a failure of Kidney energy, often linked with Liver energy rising and Spleen energy failing to descend. She says that 'it is useful to work even in extreme cases, provided the mother is under observation in hospital' and suggests a range of shiatsu techniques in her book 'Shiatsu for Midwives'.

Whilst working on my case studies, all pregnant women stated how wonderful they felt after treatment. Unfortunately Client 'A' experienced eclampsia that resulted in emergency caesarean at 38 weeks. 'C' experienced pre-eclampsia but her pregnancy also resulted in caesarean due to fetal distress - the cord had wrapped around the baby's neck and arm. Both 'A' and 'C' had little or no experience with massage or any other form of complementary therapy. They both had very busy lives and demanding jobs and felt guilty for relaxing or taking time out for themselves.

Client 'B' had been enjoying massage and reflexology for over four years but stopped all treatments during her last pregnancy. She was delighted to volunteer for pregnancy massage during her second pregnancy. Always enjoying the treatments, she usually fell asleep. 'B' was in tune with her body and felt very connected to her baby. She worked part-time and enjoyed her job that she did not find stressful. She enjoyed and had no guilt about finishing work for maternity leave. At 40 weeks however, she was beginning to show possible signs of pre-eclampsia. Massage helped relieve all symptoms and she felt wonderful afterwards. Labour began six days later. By the time she arrived at the hospital she had dilated 7cms and within 45 minutes she had delivered a healthy baby boy. She has since said that she completely believes her easy labour and delivery was due to having received massage on a regular basis.

Working with the Birth Partner
During the course of my case study work, I was privileged to have two birth partners volunteer for massage training. It was the second pregnancy for both women and they appeared on the surface to be quite well. 'D' however, had a history of pre-eclampsia with her first pregnancy that resulted in a very traumatic labour and delivery by emergency caesarean. Because of her history, she was under close supervision by her midwife and consultant. 'D' was very keen on trying massage throughout her pregnancy which she believed would assist in having a more natural childbirth experience. Her partner had also found the first pregnancy experience difficult as he felt helpless and inadequate. He was keen to learn how to massage his partner effectively as well as connecting to baby by gentle abdominal stroking and holding techniques. I felt extremely lucky to be able to guide and mediate, enabling both mother and father to communicate effectively with each other and then bringing it all together to include connecting with baby. Mother and father were very excited and pleased with themselves as well as with each other. The session ended with them both feeling more confident about their abilities to communicate with each other and the possibility of experiencing a less traumatic birth second time around.

Relationship with the Medical Profession
I have been lucky enough to find that the community midwives in my area are very supportive of my work with pregnant women. They have referred women to me for treatment and encouraged them to seek out massage, especially if experiencing stress, anxiety, aching legs or any muscular tension.

The small local hospital has a wonderful maternity ward, with dedicated staff working there who are fully aware of the benefits of complementary therapies during pregnancy. Many of the midwives based there are already trained reflexologists and aromatherapists. Unfortunately, they are often understaffed and cannot always find the time to provide a massage service. They may give a pregnant woman a bottle of aromatherapy oils to use at home, however this service is also declining due to lack of funding. Midwives are pleased therefore to be able to refer pregnant women to private complementary therapists.

During the course of completing the case studies, I often relied upon the results from the ante-natal check-ups. Due to time constraints both on myself and the medical profession, I tended to use the client as a go-between for information exchange. If I was assured by the clients' feedback from her midwife or consultant, as well as her medical record, I would treat her accordingly. Upon reflection and now after gaining more experience and confidence I would in fact be more likely to share my views, findings and any concerns with the client's midwife or consultant.

Post-Natal
Gentle post-natal massage for women who have experienced pre-eclampsia is soothing and reassuring. If delivery was by caesarean, care must be taken around the scar and holding techniques may be more appropriate. Client 'A' found it very comforting to have a post-natal massage two weeks after emergency caesarean delivery. She particularly appreciated being able to discuss the traumatic birth in detail with me and felt that having someone else acknowledge the difficulties she had experienced extremely beneficial.

Contraception
It is important to realize that the hormones in the contraceptive pill are similar to those released during pregnancy. Women who have had pre-eclampsia during pregnancy seem to be more likely to develop raised blood pressure while on the contraceptive pill. A woman on the contraceptive pill who has suffered pre-eclampsia during pregnancy must have her blood pressure checked regularly. If it starts to rise, she may need to change to another form of contraception.

CONCLUSION

Pre-eclampsia is complex and still not yet fully understood by the medical profession. Initial diagnosis is based on blood pressure measurements and dipstick testing of urine, both of which can be inaccurate and therefore unreliable. Early diagnosis of pre-eclampsia is important and may prevent life-threatening eclampsia.

The decision to massage a woman with pre-eclampsia depends on the severity of the condition. In milder cases pregnancy massage would be beneficial for the woman's well-being and in turn is best for baby.

My experience with massaging pregnant women has been extremely rewarding. All women involved in the case studies either had a history of pre-eclampsia or showed signs of it developing towards the end of their current pregnancy. All women, without exception reported feeling much happier and healthier after massage treatment.

Although two of the women experienced complications at the end of their pregnancy, they still felt that the massage treatments had helped them cope both ante-natally and post-natally by teaching them how to relax, focus and connect with their baby. During their pregnancy, these two women had focused much of their energy on their busy jobs, wanting to work right up until their due dates. They felt the need to keep busy at all times and guilty if they were not performing chores. Often the massage treatments were the only time they allowed themselves to completely relax and connect to their baby.

The other two women (both on their second pregnancies) were surprised and delighted to experience a short labour and natural delivery. They were both convinced this was due to the massage treatments' they had received! Is it also a coincidence that their partners were volunteers for massage training?

The most rewarding experience for me has been teaching basic massage skills to the birth partners. Enabling the couple to effectively communicate with each other verbally as well as through massage and to see them connecting to their baby at the same time has been a privilege. Surely these new skills have given the mother and father confidence and a greater sense of awareness and control that led to a more positive childbirth experience.

GLOSSARY

Anemia - decreased red blood cell production
Hypertension - high blood pressure
Lactic acid - waste product from working muscles
Platelets - forms part of the blood for coagulating purposes
Renal - kidney
Uremia - a build up of waste products in the blood

BIBLIOGRAPHY

Kitzinger, Sheila The New Pregnancy and Childbirth
Penguin Books Ltd., 1997

Long, Dr Maxine. The Family Encyclopedia of Medicine and Health Robinson Publishing, 1999

Tiran, Denise and Mack, Sue
Complemantary Therapies for Pregnancy and Childbirth
Bailliere Tindall, 2000

Yates, Suzanne and Evans, Julie
Well Mother APNT Certificate Course in Massage and Pregnancy - Course Manual 1997 - 2003

Perinatal Instituate
www.perinate.org

Royal College of Obstetricians and Gynaecologists
www.rcog.org.uk

Virtual Hospital
www.vh.org