Well Mother Massage Course Project

by Mathilde Barbier, massage therapist

PLAN

INTRODUCTION

PART I:
1.1 Medical option
1.2 Alternative choice
1.3 The massage therapist
1.3.1 Role of the therapist
1.3.2 Boundaries

PART II Massage and Pregnancy
2.1 Therapist and parents
2.2 Massage and the baby

PART III Massage during labour
3.1 Home vs. Hospital?
3.1.1 Home
3.1.2 Can massage be used in hospital and how ?
3.2 How can massage help?

PART IV Massage and postnatal experience
4.1 Body adjustments
4.2 Emotions
4.3 Baby massage

CONCLUSION

Reading references

(1) The New Pregnancy and Childbirth - Sheila Kitzinger (1997)
(2) Rediscovering Birth - Sheila Kitzinger (2000)
(3) Alternative Therapies for pregnancy and birth - Pat Thomas (2000)
(4) Your Body after the Birth - Jane Chumbley (1999)

INTRODUCTION

Our society is based on less pain, quicker action, having an organised timetable leaving little space for nature to manage things as they were designed and this also applies to pregnancy and birth.

In the following essay I will first discuss the pros and cons of the medical care and alternative options a pregnant woman is being offered and what type of choices she has regarding her pregnancy and delivery of her baby.

I will identify the importance and benefits of massage in three sections on pregnancy, labour and post natally.

A discussion on the role of the massage therapist in helping the mother to be in tune with her body and feelings as well as allowing the father / birth partner to enter in contact with the baby and have an active role during the woman's labour

I have based the following essay on my personal experience of working with pregnant clients and their partners over the last 6-month, as well as further readings on the subject of massage and pregnancy.

The examples quoted are extracted from my case histories and I will use my client's first name only (for more details, please refer to the case histories sent separately).

PART I

Every woman expecting a baby faces, at various stages of her pregnancy the dilemma: medical support or alternative, natural birth.
I will attempt to provide a view of the pros and cons of the current medical support system and alternative support the mother-to-be could also receive.
Also, I will briefly present the role, responsibilities and implications for the massage therapist in working with pregnant clients. I will illustrate this at different stages of pregnancy in the following essay.

1.1 Medical option

In medical jargon, the pregnant woman is a 'patient' and her pregnancy is a medical condition.
She is often receiving 'routine care' waiting for results, being examined, monitored, checked, and scanned to see if the baby and her are both in the 'norm' as governed by predefined criteria.
While tests and technology are useful and reassuring, testing has taken over from the mother's intuition and feelings. The medical practitioners feel confident in saying the pregnant woman and her baby are well, only after all the test results.
This might reinforce the insecurities the woman has in her own body, her fears, and helplessness, as she is treated as a passive patient.

A clinic or hospital offers a selection of approaches. The mother to be has to choose from a 'menu' and she is still not guaranteed that when the day arrives to give birth that her initial choice will be available.

Example 1:
L who is due to give birth in July wants a natural birth in hospital but in the 'midwife only' section using the birthing pool. She is confident and for her own peace of mind knows that if anything goes wrong, she can be quickly transferred to the above floor in the medical section. She has been warned that if the day she is in labour there are no midwifes available for a water birth, she won't be able to stick to her initial plans.
She is now nervous about the idea that things might not happen as she wants because of the lack of hospital staff.

The various members of a medical team the pregnant woman is likely to come across are:
· The obstetrician is a specialist, likely to deal with 'high-risk' and complicated pregnancies. If a mother seeks advise with them she will most probably be sent towards their care as it is what obstetricians are trained to manage best.

· The GP who generally doesn't have time to be informed on alternative therapies, will look at the physical and biological problem and won't take time to manage the emotions, psychology, personal values the mother might want to include in her choice in birth.

· The midwife, the non- independent ones will be under the consultant's instructions whereas the independent midwives will be more free to use the whole range of their skills and open their view on what the mother wants.
In traditional medical care, the woman is encouraged to 'switch off' and leave her body / baby in the hands of the experts.

For instance in the case of the epidural. It allows the mother to be controlled and rational, not over-reacting and having uncontrollable emotions during the labour. She then becomes a passive observer to the scene and the Doctor can get on with his job of delivering the baby.

Example 2:
My client T gave birth to her first child 3 years ago, he was 2 weeks overdue. The medical system decided to induce her when she personally was convinced the baby was on his way. However the doctors decided it was better not to wait any longer as she was in hospital and using a bed, some space and the wait had been long enough for their liking.
The birth went well and very quick but T keeps believing her intuition was the right one, the medical system didn't let her follow her instinct. For her second child she hopes she will be more in control standing for her motherly instinct.

On the other hand, the mother should also accept or seek medical assistance as and when needed. If she feels that it is important and necessary. In that case medical action can be taken quickly.

Example 3:
D) had planned a natural, home, water birth. All her pregnancy was towards this completely medical free experience to welcome her baby in this world.
The water broke almost 3 weeks early but nothing happened. So after 24 hours at home trying everything possible, from Shiatsu points to homeopathy, relaxation, and reiki … the labour didn't start.
She was then sent to hospital to be induced. After a long labour she was still not dilated and finally received an epidural and caesarean section for delivery of her baby.
D and her husband had prepared everything and were completely convinced by the alternative option but they still had to make another choice and accepted the medical system to take over for the safety of the mother and the baby as previously discussed in section 1.1.

1.2 Alternative choice

The alternative approach believes in the body's ability to heal itself.

Choices are given to the mother to be, it is a voluntary decision, an active cooperation, and she takes control of how she wants her pregnancy and delivery to progress.
The alternative option offers the mother the choice to promote her skills, competence and confidence, to be in harmony with her body, to develop her ability to listen to her instincts, to determine what is best for her.

There is no separation between the physical body, emotions and mental. How a woman's body develops has a direct effect on how she thinks and feels and vice versa.
All aspects of the person are taken into consideration, posture, lifestyle, beliefs, values and energy. All have an impact on the person's health and well-being.

However in some cases the medical intervention might be necessary for the safety of the mother and baby.

Example 3:
See D's story mentioned in point 1.2

1.3 The Massage Therapist

1.3.1 Role of the therapist

Before giving any treatment the therapist's primary role is to observe, question, query, explain and listen in order to establish an efficient and effective treatment in harmony with what the pregnant woman desires.

Some medical questions take into consideration general health and fitness, as well as observation on posture, reflection on lifestyle, beliefs and values of the mother.

The physical and mental state of the pregnant woman will also considerably affected by her environment. Her family life, support at home, circumstances of the pregnancy (planned or not, wanted for a long time or not ready for it), previous history of pregnancy, plans for the pregnancy, birth.
All the above details are very important and give a holistic view of the client, which is essential to establishing the treatment, which will be suited best to their individual needs.
Future treatments will have to take in consideration any feedback given after the first session. How the body reacted, feelings and responses during the massage, any after effects and baby's movements.

The role of the massage therapist is to encourage the client to become a partner in her own health, to inspire the mother to listen to her body, get in tune with her energies and the new babies.

In order to work with pregnant women the therapist has to have a full working knowledge of the physiology of the pregnant woman, what is appropriate at the different stages of pregnancy, labour and post natal.

The massage therapist also has to be adaptable and creative during the treatments in order to maintain comfort and relaxation for the mother and baby at all times!

1.3.2 Boundaries

If the therapist has any doubt on a condition or health concern or diagnosis, he/ she must seek medical advise or contact the client's doctor!

Massage can be emotionally disturbing causing the release of emotions that the client has been holding in.
The therapist has to be prepared for possible emotional release, but also has to know that he / she is not a professional in counselling and there is only so much you can do as listener. The presence is essential but the therapist cannot fix all the problems and ought to be very careful when opinion or advice is asked outside of the massage boundaries.

The massage therapist has to ensure they protect themselves, not allowing them to be drained by the client or let their own feelings taking over.

Example 4:
I allowed myself to be judgemental and negative towards the choices of my client H. I had decided that her way of life was not right for the baby, therefore I was making suggestion to motivate her to change. I only wanted to be helpful and thought that what I had in mind was the best. Although I was trying to hold this in, I suspect that the mother and the baby sensed that negative feeling I was carrying with me towards the choice she had made.

PART II Massage and Pregnancy

In pregnancy every woman will experience different symptoms, they are all expression of the body's attempt to adapt and rebalance itself. They might not be pleasant or comfortable, they may be physical, hormonal or emotional but they are not abnormal or a sign of illness.
Massage is a wonderful technique for relieving the aches, pains and tensions experienced during pregnancy, because it relaxes the muscles and replaces unpleasant symptoms with a feeling of well-being.
I will also describe how massage can be a means of communication between the pregnant woman, father and baby in later sections.

2.1 Therapist and Parents

A woman can receive massage at any time during her pregnancy.
Although the needs of the mother and the baby will be different during each trimester, the therapist must be very flexible and will offer adapted treatments, from energy work only to deep tissue work, breathing exercises or more active postures.

Each client must have a case history taken before and after each treatment. In the case of a pregnant client extra notes have to be integrated to the questionnaire regarding the medical care the woman is experiencing.

Massage will open up for the mother an awareness of her body if it is not already there it will be encouraging if she has any doubts on the way she feels or what the Doctors said.

It is important to be aware of the different monitoring, scans, diagnostics given to the mother. It doesn't mean massage will be forbidden but extra care will have to be taken not to put mother and baby at risk. The therapist will back up the Doctor's recommendations or questions of concerns if there is any doubt.

For more details on the role and qualities required for the massage therapist to be able to work with a pregnant client see section 1.3.

Example 5:
The midwife told M at 31 weeks that she might have a low placenta. No extra tests have been done while I was treating her but I think it was important to bare in mind this 'possibility' and adapt the exercises and movements to the situation.

Massage won't replace ante-natal classes but is an excellent complement. The classes are more 'demanding' as the mother has to be in control all the time with or without her partner. Massage offers a release, and allows the mother to be in touch with some parts of her body she might not be able to reach (feet, shoulder blades) and therefore relax. Touch is way to re-unite all areas of the body, physically and emotionally.

In part 3 I will describe how massage can be particularly helpful during labour, it is important for the parents to 'practice' new therapy to assist during the labour and not leave it to the last minute.
A woman is pregnant every second of the pregnancy, she cannot escape the experience. No matter how much the father reads about pregnancy, he will never experience it the same way. Massage is a non-verbal communication offered to the parents, which is based on the touch.

Through the power of touch the father can be more aware of the body tensions the woman is experiencing. Being held firmly can be comforting and reassuring for the mother.
Touch can also be as simple as stroking a hand, holding shoulders, hugging, even a glance is a 'contact'; it doesn't have to be given by a skilled massage therapist.

It is sometime a relief for the mother to be able to rely on the massage therapist to demonstrate some strokes or tips to them and their birth partners. As long as both parents are happy to enter the experience.

Example 6:
K asked me to organise a treatment with her and her husband as she really wants to receive massage in labour from him and she doesn't know how to show him what to do. She said that he is not a 'natural' and she thought that with professional advise he will be more willing to learn. The session started with a lot of reserve and discomfort from the father. After a little while his touch became more assured and confident. I felt like disappearing for a while and let them continue without my input so I went quiet until they got me back into the conversation and their experience!

It is important for the father (or birth partner) to know how he/she can participate during the labour be supportive and active. If both parents have spent some time together sharing their experience of massage it will come more naturally when time for labour comes.

The therapist can encourage the parents to work through the massage by breathing together, showing how the partner can relax the massaging hand and the woman to relax through its contact.
The partner can massage a part of the body while the mother tries to relax this area under their hand, breathing and visualising the relaxation. The father / birth partner can feel if the muscle is relaxed or not, then move on to another part of the body once they feel any discomfort has been removed. This may be a particularly useful technique during the labour.

2.2 Massage and the baby

For the father, massage and touch of the mother's abdomen is the first way to enter in contact with the baby, to feel it kicking, playing, and to more fully understand that there is life and it is real.

Massage is not only pleasant & beneficial for the mother but it also has a direct / indirect effect on the baby as they are both linked physically, emotionally plus the baby is completely dependent on the mother for protection and food.

The position of the baby in a woman's pelvis at the end of her pregnancy will have a major influence on the kind of labour she will have and the way the baby will be born.
The pregnant woman can improve her chance of giving birth with a minimum of difficulties, if she can influence the position of her baby towards the end of the pregnancy.

There are number of ways to teach the 'optimal foetal positioning' to a mother particularly during the last 6 weeks of pregnancy.

Adopting specific postures and exercises. Using upright and forward leaning postures will help and this can be integrated to the woman's every day life. A number of exercises such as the all-fours position have been described in the case study joined to this essay.

While the mother is adopting comfortable positions for the baby to move, the baby can also be encouraged to turn by massage and positive thinking.

I have noticed that in most of the massages I have given to pregnant women at more than 32 weeks of pregnancy the baby seemed to move a lot as soon as the mother was lying on her side and relaxing.
The energy work applied to the kidney / uterus meridian, as well as clockwise rotations on the abdomen or gently pressure on the mother's out breath seemed to have a powerful effect on the baby.

Visualisation can also be introduced during these sessions although some parents are unwilling to take on this idea. For the parents trying to visualise the baby, the pains, the body's reactions is often a challenge. It can however be extremely rewarding and opens up a new form of communication between the mother / father and baby.

PART III Massage during labour

3.1 Home vs. Hospital

3.1.1 Home

When a birth is taking place at home, it is a full 'Family Event', where privacy is maintained and the mother-to-be can receive personal attention as required.
In the early stages of labour the woman can carry on with her normal activities, and pay attention to the other children (if there are any).
The entire family can be present or whoever the mother wants to have around.

Midwifes are usually present and a relationship has often been established in the previous months leading up to the birth.
The birth partner / father has a bigger role and responsibility by being directly involved with the midwifes. They might simply be in the 'background' as observers ready for intervention when necessary.

A home birth may be quite challenging to organise, getting the midwife's availability and reorganising the house, but all this effort is often worth it to be able to give birth in their own home.

3.1.2 Can massage be used in hospital and how?

(Hospitals might have a 'midwife only' section with birthing pools, but not all the hospitals are equipped that way. For the purpose of this section I will consider 'hospital' as medical birth only.)

Very often as soon as a pregnant woman in labour enters a hospital she is placed in a wheel chair to be moved around and then lies on a bed until delivery.
She will see different Doctors and Midwifes if the labour is long and be in a very sterile environment with machines, monitors, and movement around where there might not be any space for privacy.
In the medical environment if a woman in labour feels the need to stand up, move around and be active, it might not be allowed or possible as a result of hospital rules and regulations or fear of insurance claims in the event of an accident. If she refuses to listen she will be a 'difficult case' and disrupt the Doctor's routine

The birth partner can have mixed feelings about being involved and is often powerless to assist.

In more traditional cultures the pregnant woman would be surrounded by women in her family, grand mother, mother, aunts, sister, female friends for support and advise. Nowadays the modern families, births and people are more 'isolated' as a result of factors mentioned above (not allowed due to the rules).

Only the birth partner(s) are allowed in the hospital and some procedures might not include them. The woman might be left alone, distracted or alarmed by other labours or emergencies taking place around her. Disruptions will also make concentrating on relaxing and remembering things they have learned for birth harder.

3.2 How can massage help?

Birth partners have an enormous impact on the course of the labour, just by being there in the moment. They are the anchor, and expected to be strong and confident so when the mother loses her confidence she can by a glance or touch carry on and feels supported.
Pressure points, stroke or holding, massage will be most effective if it has been rehearsed before hand by the couple (see part 2.1).

The presence of the birth partner can help to recreate a familiar environment and intimacy for the mother.

In labour massage is the most helpful way that a partner can help ease the pain and reduce the feeling of isolation. It is often relaxing for the giver as well as the receiver
Sometimes the mother doesn't want to be touch, her needs can change very fast and the birth partner has to adapt promptly in response to these changes.

Example 7:
For the birth of her first child, S didn't want to be touched towards the last stage of labour but she felt then an uncontrolled need to have her feet held and massaged which her husband did, applying stronger and stronger pressure. This rhythm helped her to focus on her breathing and also to have constant contact with her husband.

Although there is often a preparation time during pregnancy, the couple has to be flexible as the labour might change the approach on what feels right or not

PART IV Massage and postnatal experiences

The first few weeks after giving birth are a confusing time both physically and emotionally. The mother often has no control over her body changes.

4.1 Body adjustments

Whether the birth was natural or medically assisted, the body suffers aches and 'new pains' both internally and externally given the incredible strain put on the mother's body.

The woman's body is not what it was before pregnancy and the mother might not like her body, not be comfortable in it, might not accept the unavoidable changes. Feels empty and lonely having had a large part of her removed in the form of the baby.

Example 8:
A mentioned that she had turned into a 'milk factory', constantly breastfeeding and no longer having the constant feeling of togetherness.

Touch through massage can help the mother reconnect with her body again and acknowledge the changes it has undergone.

In the case of a woman immobilised after a caesarean section, massage will increase the circulation and stimulate the lymphatic system. It may also encourage milk production. Gentle strokes on the abdomen will stimulate the 'repositioning' of the organs.
The mother is also exposed to exhaustion; massage will help her to re-gather her energy in the vital parts of the body where it is most needed.

After observation, the therapist may make suggestions on postures to adopt, avoid in every day life, during breastfeeding, to assist in the recovery from the birthing experience.

It is also the time to introduce gentle breathing exercises to relax the body and slowly tone the muscles back to their pre-pregnancy form.

4.2 Emotions

There is so much happening before, during and after birth, everybody is focused on the new arrival and the mother might feel lonely and excluded. Her feelings might be very ambivalent, overwhelming joy and doubts, fear. A complete mix of contradicting emotions that can lead to confusion and possibly postnatal depression.

If the mother doesn't get support at home, the responsibility of the baby can be enormous and take over her whole life where she doesn't exist as a person any more, she become more a dependence for the baby.

The massage therapist has to remember the boundaries and not get involved in counselling, but can also provide care and needed attention to the mother where in post birth she might be lacking.

Example 9:
J spent a lot of time on her own at home with the baby, no relatives around. Her partner was away on business most of the week. My weekly visit seemed to be a time she was looking forward to. Although she was not allowing herself to have this hour of massage on her own but wanted to have an eye on the baby at all times. She also needed to talk a lot about the baby, her worries, and loneliness. I was feeling that the massage was not a time of relaxation for her body and mind but more a 'break' in her isolation and long days on her own with her daughter. Gradually, month after month J relaxed a little bit more every time until she freely enjoyed the power of massage in itself without the distraction of the baby when she was over 5 month old.

4.3 Baby massage

This is not the main subject of the discussion but I wanted to mention the power of baby massage as a way to communicate love to the child.

During the whole pregnancy the baby was constantly receiving gentle massage in the mother's womb from the natural the movement in the mother's body.

A lot of medical procedures and products used during pregnancy and labour relieve the mother's discomfort but could certainly have an adverse effect on the baby.

After this 'traumatic experience' of birth (natural or medical), touch is comforting for the baby. If the mother is breastfeeding direct contact with the mother will be immediate and regular but for the father, massaging the baby is a way of establishing the first form of communication with the baby.

CONCLUSION

In a large number of cases involving pregnant women, the attention is often directed at choosing a level of pain relief and ways to reduce the time spent in labour, instead of making the experience of pregnancy and labour an expression of who they are and what they believe in and can achieve with their bodies.

Pregnancy is a state of health. Nature rarely does anything without a purpose and the labour is a way to tell the mother that the baby is ready to come into the world. The medical profession views labour differently.

Massage offers the mother the option to listen to her body and follow her intuition, communicate with the baby and make the father / birth partner's involvement real and active. It is also a way to help the baby to get into the right position for the labour and birth in a completely natural way.

Although, the medical option of the labour might be chosen by the mother and father, massage still has a very important role in the whole process. The conditions of labour might not always make massage easily available but the power of touch mustn't be excluded from the whole experience.

Not every one relaxes in response to the same stimulus but the therapist's role is to facilitate by making some suggestions, observations, and adaptations. To advise, listen and encourage the mother to trust her body and feel what is right; so the father, the baby and her are strongly linked together as a team to go through pregnancy, labour, during and after birth.