Identify your client's trimester according to gestational age.
State the advantages of each positioning choice.
Identify client centered factors that guide positioning choices.
Position a client optimally for her stage of pregnancy, comfort level(s) and objective signs.
Understand that the therapist must position for client well-being & that clients may not always be able to clearly identify issues regarding maximal comfort or the issues related to Supine hypotension.
Re-position a client to alleviate position-induced discomfort.
Negotiate draping for a pregnant client securely and in a boundary conscious way when treating her legs, back and abdomen in side-lying and semi-reclining positions.

Position Options

Every Massage Therapy client needs to be positioned in a way that supports their needs and the goals of the treatment. The following are common (and not so common!) positions.

1. Prone: most often used for back and neck, and posterior leg massage.

2. Supine: used when massaging arms, legs, abdomen, and head, neck and shoulders.

3. Side-lying: used to massage the back, arms, legs, head, neck & shoulders, and abdomen if the client is pregnant.

4. Semi-lying/or semi-reclining: used to massage the entire anterior body and beneficial for the client who is pregnant, hypertensive, has vestibular (balance) issues, or any time the client is not comfortable in a supine position.

5. Forward-leaning: using a massage chair with special adaptation for the pregnant abdomen or using pillowing designed to support the anterior torso and head, neck, and shoulders of the pregnant woman.

Factors Affecting Positioning Choices

Of the 5 options mentioned above, specific consideration must be made to adapt the positioning of the pregnant client relative to the specific trimester of their pregnancy and their physical condition.

Factors affecting what position is chosen include:

Case history information
General health status
Trimester of the pregnancy.
Health Status related to this pregnancy as well as previous pregnancies.
- Including general health & obstetrical history.
History of musculo-skeletal well-being, areas of stress, tension, injury, pain, muscle strain, &/or any overuse or repetitive strain issues.

Stage of Pregnancy and Positioning Choices

The majority of pregnant women in their 1^st trimester (up to 13 weeks gestational age (GA)), can lie in prone or supine with comfort and safety. In the 1^st trimester breast sensitivity/tenderness or nausea/vomiting may interfere with the client finding comfort in the prone position.

As the pregnancy progresses into the 2^nd trimester (14 to 26 weeks GA), and the gravid (pregnant) uterus expands, alterations to positioning must be made for safety and comfort reasons. The third trimester extends from 27 weeks GA to delivery.

Let’s explore the pros and cons of each position relative to your client’s trimester in detail.

The Prone Position

The prone position generally has many advantages, including:

Easy access to structures of the back and posterior legs.
Allows maximum use of the therapist’s weight for increased depth of pressure.
With a face cradle the prone position helps the client maintain symmetrical alignment of upper back, shoulders, and neck which provides more effective care in the event of musculo-skeletal issues in these areas.
Client preference
- Clients who are stomach sleepers may have difficulty resting in other positions due to their preference in sleeping face down.

As the pregnancy progresses some disadvantages arise with the prone position and need to be considered. They include:

As the uterus and baby expand during the 2^nd and 3^rd trimesters, downward pressure from lying prone creates added stress on the client’s body.
The increased lordotic curve of the pregnant client along with the anterior shift in gravity due to the expanding pregnant belly can create musculo-skeletal issues related to the areas of the lower lumbar, gluteal, and leg regions. Increasing the lordotic curve via the prone position may aggravate pre-existing issues.
Relaxation of the ligamentous structures due to the hormonal influence of relaxin can influence joint instability and ligament laxity.
The downward weight of the pregnant woman can increase challenges to the utero-sacral ligament which helps to stabilize the uterus in relation to the sacrum in the pelvis. This could also potentially manifest as increased sacral discomfort.
Challenges to S-I joint stability may also occur in this position. This may increase aggravation to an already irritated S-I joint.
The weight of the therapist as they apply pressure to the lower back area in conjunction with the factors mentioned above present an increased downward force or load on musculature which may already be challenged by the growing pregnant belly.

Prone in the 2^nd and 3^rd Trimesters?

Many massage therapists adjust their prone pregnancy work by utilizing cushioning systems or tables which allow the pregnant abdomen to rest prone in a hollowed structure during the 2^nd and 3^rd trimesters. These devices provide a sling-like type of support for the pregnant prone client.

The individual therapist who wishes to treat a pregnant client using tables/cushions that incorporate prone positioning to be used in trimesters 2 and 3 of pregnancy must be responsible for determining the physical safety of their clients, and will need to express this in their informed consent with the client.

Since side-lying and semi-reclining are very comfortable positions for the pregnant client, and create no additional challenges to her pregnant body, I recommend these two positions as the safest and most effective positions to utilize when providing massage therapy during a pregnancy without complications.

The Supine Position

While most clients are comfortable in supine when they aren’t pregnant, they become increasingly uncomfortable as the pregnant abdomen grows. The most common issue which impairs client comfort is Supine Hypotension Syndrome. In this syndrome the weight of the gravid uterus causes compression on the inferior vena cava (and the aorta) with the result of ‘hypotension, bradycardia, dizziness, light-headedness, nausea, and even syncope (fainting) if she remains in the supine position too long.’ (Henderson 2004 p. 192)

Most texts describe the signs of supine hypotension as fairly dramatic. Shortness of breath and dizziness are the most common presentations seen by the massage therapist often result in the client speedily and instinctively needing to change position ie. to sit up or roll onto their side.

At what stage of pregnancy does supine hypotension occur with the pregnant client?

There is no absolute answer to this question and texts vary in on this point. For example, two midwifery texts give very different guidelines. Mayes edited by Henderson and Macdonald (2004) suggests that the supine position should be avoided throughout the entirety of the 2^nd and 3^rd trimester. Myles textbook edited by Fraser and Cooper (2003) however, suggests avoidance of the supine position only late in the 2^nd trimester.

The Society of Obstetricians & Gynecologists of Canada has guidelines for pregnant women and the supine position that are midway between Mayes and Myles. ‘Some women may experience symptomatic hypotension from compression of the vena cava by the pregnant uterus and should modify these (strengthening and weight training) exercises to avoid the supine position after approximately 16 weeks’ gestation. (SOGC Clinical Practice Guidelines. Exercise in Pregnancy & the Postpartum Period. No. 129. June 2003. p. 4)

Patient comfort, the size of the belly and whether she sleeps in a supine position need to be integrated with these guidelines to help you and the client make an informed decision about her treatment position.

There is also a simple adaptation to minimize the risk of supine hypotension during pregnancy. General consensus in obstetrical and midwifery texts suggest that a pillow, rolled towel, or ‘baby wedge’ pillow can be placed under the right hip. This tilts the gravid uterus off of the inferior vena cava and reduces the possibility of supine hypotension occurring (Henderson 2004).

Positioning the entire client in side lying also has the same effect. Most resources state that left or right side lying are equally effective at relieving postural hypotension (Manbit.com)

Clients have reported to me that the right hip pillow is effective for procedures like ultra-sound where the technician needs access to the abdomen as fully as possible. And I have found that it often works just fine for the pregnant client in 2nd trimester if they prefer it to side lying. However, this position creates some asymmetry in the body. Given that our goal is help create as much musculoskeletal balance as possible, side lying may have more efficacy for minimizing added stress on the body.

A great image of the effect of a pregnant woman rolling to a side lying position is viewable at: http://www.manbit.com/oa/oaindex.htm

Side Lying

Side lying is a natural for most women during their pregnancy. Sometimes, discomfort can occur on the weight bearing joints particularly the shoulders and hips as a result of lying on the side and with the increased weight gain during pregnancy. Adequate pillowing should, however, alleviate discomfort in this position during massage.

I recommend a minimum of 5 pillows as well as a baby wedge for support.

One to two pillows placed under the head serve to increase the distance between the ear and shoulder.
Two to three (or more) pillows between the legs or under the superior leg if the inferior leg is extended.
A pillow in the mid torso might also serve to help provide support in the thoracic and waist area while also creating a crevasse of sorts for allowing the shoulder to rest more comfortably.
A body cushion for side-lying is also often well received by clients.
As well, a towel or particularly a baby wedge is wonderful for increasing the support of the side lying abdomen and minimizes lateral twist on the trunk as the baby in 3^rd trimester can create torque due to its’ growing weight.

Women who have difficulty getting comfortable in bed or on the massage table may find an egg-carton mattress very helpful for alleviating discomfort. This is utilized in some hospitals for clients on prolonged bed rest. Side lying should present no increased risk of harm in the majority of pregnant clients unless they disclose particular issues related to lying in this position.

Semi-Reclining

Women who are well supported within a semi-reclining position often breathe a sigh of relief and demonstrate a big smile when they experience the comfort of this semi-upright position.

Mayes’ Midwifery demonstrates utilization of the 45 degree wedge as valuable for both exercise and relaxation practices (p. 388).

For massage clients care should be taken to ensure they are not slumping as they settle into the wedge. I often place an additional 3 pillows on top of the wedge to increase comfort. This increases the angle of recline to closer to 60%. As well, the sacrum and lower lumbar region need to be well supported.

For some clients with pain in this area, I will also add a rolled up towel for lumbar support. The client’s neck and head should also be supported so that they are not in a hyper-extended neck position.

Forward Leaning

This is an excellent position to teach labour support techniques to the partner or labour support provider/doula. The chair must be well supported with pillows on the seat and in its’ front.

I often have clients straddle the chair (provided no symphysis pubis dysfunction exists!) and lean their arms onto a well pillowed massage table. This provides full access to the back area as well as partial access to the gluteal and hip region. Sitting in this position also gives the client the

kinaesthetic sense of opening the pelvis, something she needs to practice in order to birth her baby. The client can also practice this within the massage therapist's office or at home with the use of a physio or ‘birthing’ ball as we refer to it.

Draping of the Pregnant Client

In reality, draping the pregnant woman is no different than draping any client. Side lying draping can make some massage therapists and students nervous. However, with sufficient practice, this can become a quick and easy activity.

Side Lying Draping Protocol (Courtesy of Lisa Ivany, Atlantic College of Therapeutic Massage)

Secure pillows under client's head
Place another pillow under her arm for comfort and stability
Straighten top hip and knee
Flex bottom hip and knee
Secure the top sheet at the hip level
Take the back corner of the top sheet and bring it over the top leg, making sure the sheet undrapes to above the knee
Bring the same corner underneath the top leg to create a fan which will be used to cover the gluteals
Bring the top sheet upwards to undrape the greater trochanter and posterior superior iliac spine
Move the fan under the top sheet and pull the top sheet securely against the gluteals
Holding the sheets in place, ask client to flex their top hip and knee and extend the lower hip and knee
Readjust the draping and securely tuck the top sheet under the lower gluteal area
Place two pillows under the flexed knee for client comfort

Undraping Protocol

Remove pillows from under knee
Ask client to extend top hip and knee and flex lower hip and knee
Untuck top part of sheet and pull it and the fan section down over the gluteals
Take the bottom part of the sheet and bring it back over the leg.

Note that the CMTO Standards of Practice 12 (http://www.cmto.com/pdfs/CPH%2012.pdf) lists specific modifications for the birthing client.

Temperature Regulation

For many pregnant women, the realities of pregnancy and the abundance of hormones in play during this time can make for a rather ‘heated’ experience. Clients who may tend toward being easily chilled, or who enjoy blankets and heating modalities such as hydrocollators, thermaphores, or hot water bottles during their non-pregnant M.T. treatments, may find they are just too warm for these additions. Along with ensuring that we do not increase the systemic temperature of the pregnant client, focusing on client comfort may demand that sheets are the primary covering during the session.

With these options for effective positioning and draping, there really is no need for a client to be in an uncomfortable situation! Positional and draping comfort is crucial to a satisfactory pregnancy massage experience, and ensuring these preliminary activities are well-performed will add much to a pleasant and therapeutic pregnancy treatment.

Biography

Cindy McNeely, R.M.T. has been practicing in Ontario since 1985 and teaching since 1988.

Trimesters: Massage Therapy Education was created by Cindy and Allison Hines, R.M.T. in 1995 to raise the standards of Perinatal Massage Therapy throughout North America.

In 1995 they created the first Canadian Level III Perinatal Hospital Massage Therapy program which has trained R.M.T.’s and students from 4 Ontario Massage Therapy colleges to date. This program works within the High Risk Pregnancy Units, Labour & Delivery, Postpartum, and Transitional Care Unit (with infants in the hospital). As well Cindy and Allison have provided in-service trainings about Massage Therapy for other Perinatal healthcare professionals.

In 2001 Trimesters collaborated with the Atlantic College of Massage Therapy (http://www.actmonline.com) to create the most comprehensive College-based Perinatal Training available in Canada – a 125 hour program devoted entirely to M.T. during Pregnancy, Birth, Postpartum, and Infants & Children.

For 2008 training dates or for more information about their trainings, visit their website at http://www.trimesters.on.ca.

References

Byrne H: Supine Hypotensive Disorder during Pregnancy. BeFit-Mom. at: http://www.befitmom.com/supine.html accessed May 12, 2008.

College of Massage Therapists of Ontario. Draping Standard available at http://www.cmto.com/pdfs/CPH 12.pdfaccessed May 12, 2008

Engebretson JC, Littleton LY: Maternal, Neonatal, and Women’s Health Nursing. Thomson Delmar Learning. 2002.

Fraser DM, Cooper MA Editors: Myles Textbook for Midwives, 14^th Edition. Churchill Livingstone. U.K. 2003, 192.

Henderson C, Macdonald S. Editors: Mayes’ Midwifery: A Textbook for Midwives. 13^th Elsevier Ltd. 2004, 386.

Knuppel R, Drukker J: High-Risk Pregnancy: A Team Approach, 2^nd Ed. W. B. Saunders Co. USA.. page 19

Society of Obstetricians & Gynecologists of Canada/CSEP Clinical Practice Guideline: Exercise in Pregnancy and the Postpartum Period. June 2003, No. 129.

Watterson L: Aortocaval Compression. At http://www.manbit.com/oa/oaindex.htm accessed May 12, 2008.

World Health Organization: Pre-operative Procedures. http://www.who.int/reproductive-health/impac/Clinical_Principles/Operative_care_C47_C55.html

Link to Trimesters' Web Site

Online Courses

Massage Therapy Practice.com