Massage Techniques for Labor

MASSAGE TECHNIQUES FOR LABOR

Article Published in:  "A Midwife’s Touch," by Elaine Stillerman.  © 2008 Midwifery Today, Inc. All rights reserved.

[Editor’s note: This article first appeared in Midwifery Today Issue 84, Winter 2008. Portions of this article were taken from Prenatal Massage: a textbook of pregnancy, labor and postpartum bodywork, by Elaine Stillerman.]

  1. Start your massage between contractions with an effleurage (long, gliding stroke) in her mid-back down to her sacrum, in the direction of the muscle fibers. The pressure should be as deep or light as she prefers. She can be sitting on a stool, leaning over a bed or pile of pillows, or side-lying. Gradually work deeper into the lower erector spinae muscles from T11 to the sacrum using your fingertips, thumbs, knuckles or elbows across the muscles fibers from the lateral borders of the erector spinae to the transverse processes of the spine and down to the lumbosacral joint.
  2. Stroke up her entire back from the sacrum, up the spine and over her shoulders. Massage around and over her shoulders and up her neck.
  3. When a contraction starts, apply counter-pressure at the site of any pain or discomfort. Keep your wrist neutral and alternate between using your wrists, knuckles, elbows or knees (on her sacrum). Hold this counter-pressure throughout the contraction—and remember to breathe.
  4. Use the sacral lift during a contraction to reduce the pressure of the fetal head on the spinal nerves, relieve lower abdominal pressure, ease engorgement of hemorrhoids and support the bulging pelvic floor. Place your hand low on her sacrum and lift upwards and slightly towards her umbilicus. (This stroke cannot be performed on anyone with coccyx pain or subluxation.) Use your knuckles, forearms, shoulder, knee and foot as alternatives to your hands. Hold this for the entire contraction. This is best performed when the mother is sitting down, but can be very effective in a side-lying position using only your neutral fist. Fold a small hand towel or dry wash cloth over your knuckles to prevent bone-on-bone discomfort.
  5. During a contraction, use the pelvic tilt, done with your client on her side. This elongates the lumbar spine, stretches the compressed muscles and reduces lower back pain. Use your fleshy forearm on her top hip and gently pull toward her head while your lower hand is on her sacrum gently pulling toward her feet. A variation of the pelvic tilt is the knee press, also performed with your client on her side. Sit behind her and secure your hip directly next to her sacrum. Lean over and clasp your hands around her top knee. Position her hip at a right angle and pull her knee toward your hip. For additional support, press your body onto her hip, thereby providing a pelvic squeeze at the same time.
  6. If she has backaches, try the pelvic press or hip squeeze (locate the center of her buttocks and using your fists with your wrists neutral, squeeze in and slightly up—forming an X—and hold for contraction). An acupuncture point can release a lot of back tension during labor: Gall bladder 34 is found in the depression anterior and inferior to the small head of the fibula on both legs. Hold both points at the same time for a count of 10, repeating a total of 10 times.
  7. Another acupuncture point that minimizes pain is found posterior to the outside corner of the nail of both little toes. This point is Bladder 67. In China, this point is needled to stop the pain of labor. (It is also needled or treated with moxibustion [heated herbs] in the 37th or 38th week of pregnancy to turn a breech presentation.) A recent study of this ancient Chinese technique has proven it to be effective in relieving labor pain. Large intestine 4 is found in the webbing of the thumb and index finger. Although contraindicated during pregnancy, when an ice massage is given to this point on the left hand for 20 minutes or until the 4th contraction, whichever came first, pain was cut in half. Icing the right hand reduced pain by 19%.(12)
  8. To speed up labor at any stage, use pressure on certain acupuncture points, especially when used during a contraction. Hold each point bilaterally for the duration of the contraction, releasing only to relieve your fingers. These points are: Large intestine 4, found in the webbing of the thumb and index finger; Liver 3, found on the top of both feet about 2 inches down from the first and second toes, where the foot bones meet; Spleen 6, the expression of Female Energy, found on both legs approximately 2–2½ inches from the top of the medial ankle bone, under the tibia.

Active Labor

As labor progresses into the active phase, a noticeable shift occurs in contraction pattern and mother’s emotional response. The midwife’s goal is to keep her calm, comfortable and focused and to encourage the normal progress of labor. Another important task is to meet her emotional needs with understanding, nurturing and respect. This will give her a greater sense of control over labor, which can lead to heightened self-esteem and a more satisfying, empowered experience.(13)

The bodywork techniques must now be adapted to the mother’s emotional and physical needs and changes. Her breathing pattern will be different and should be encouraged by breathing (or intoning, moaning, etc.) with her.

Techniques for Active Labor

  1. Encourage her to change positions whenever she needs to, but at least every 30 minutes to treat backaches and speed up labor.
  2. Hold pelvic tilting throughout a contraction.
  3. Use hot or cold compresses with or without rolling pressure on her lower back.
  4. Use knee press with mother sitting in a chair with her back supported by pillows. Press just inferior to her knees and sustain this pressure for the contraction. If your wrists tire from this exertion, sit on the floor and turn away from her, facing outward. Lean against her knees with your back, saving your hands.
  5. Use a pelvic squeeze to alleviate the pain of back labor, as it repositions the sacroiliac joints that are being stretched by the back of the baby’s head against mother’s sacrum.
  6. Do gentle lymphatic drainage, stroking towards her heart, if her legs shake or feel tired and heavy.

Transition

 As labor progresses into the transition phase of stage one, most women are no longer comfortable with long, gliding strokes. Some women may actually pull away from touch altogether as they focus on the task at hand. Hot or cold packs, or ice chips (perhaps imbued with an herbal remedy such as black cohosh, if her blood pressure is low and stable) may be welcome. Holding, rocking or swaying with her may be all the support she needs. Placing your hand on an area of tension or firmly applying pressure on her sacrum during a contraction can relieve back pain. (Don’t forget to keep her face and jaw relaxed, since a lot of women in late labor grimace in pain and lock their jaws.)

 Quiet encouragement and reassurance are paramount during transition. Keeping her relaxed and calm lets her natural rhythm of labor proceed smoothly and on course.

Stage Two

After the short resting phase of stage two where she may enjoy a few gliding strokes on her back or belly, strong contractions resume and the urge to push becomes involuntary and compelling. Relaxation is vital to the conservation of her energy and smooth passage, particularly her pelvic floor and adductors, as any physical tension could increase pain and slow labor. Gently and quietly remind her to release tension and allow her body to open.

Helpful ways to support her include encouragement, staying calm and helping her follow patterned breathing and chosen relaxation strategies. Help her change positions and rub any tense areas—if she wants the touch. The strokes of abdominal effleurage during the active phase begin at the fundus and move toward the pubic bone in tandem with uterine contractions. Between contractions, try effleurage of the lower back, or she might prefer gentle pelvic rocking. Leg cramps or muscle spasms can be treated with active or passive stretching or appropriate light leg massage. She will most likely need assistance straightening her legs after squatting to either stand erect or sit down.

Birth

Most of the support during the baby’s birth helps to calmly remind mother to stay relaxed and conserve her energy. You can offer some physical support such as counter-pressure or perineal support and help her find a comfortable birthing position.

Expulsion of the Placenta

In the tribal world, placental birth was usually very fast because women were in good physical shape and they used efficient birthing positions. Standing and stretching can expedite placental delivery.(14) Massage was used almost exclusively to encourage expulsion of the placenta in tribal societies. Other procedures included contracting the abdominal muscle, having the woman sneeze, having the new mother bite on something very hard or having her blow into her hands or an empty bottle.(15) Heat applications were also used to effectively expel the afterbirth.

The women of Morocco soak the end of the severed umbilical cord in oil heated over hot coals. Within a few minutes of the treatment, the new mother stands and the placenta falls out.(16) The Filipinos warm the handle of a wooden rice ladle and press it against the woman’s navel. In certain regions of Mexico, a hot tortilla is placed against the mother’s right side.(17) In India, the birth attendant oils her head and rubs it against the standing mother’s belly until all the blood comes out.(18) In Tahiti, the afterbirth is expelled as mother kneads her own abdomen while bathing in the sea. Her husband presses his foot against her to stimulate further expulsion of fetal detritus.(19)

Abdominal massage from the fundus to the pubic bone, skin-to-skin contact between mother and baby (kangaroo care, nursing), nipple stimulation or oral stimulation (by the partner) promote the release of endogenous oxytocin that encourages the uterus to contract and expel the placenta. Midwives can stimulate acupuncture point Spleen 10 to release the placenta. Place the heel of your hand at the top border of the mother’s knee. Your thumb should reach the belly of the vastus medialis muscle where the point is found. Hold for a count of 10, repeating until the uterus starts to contract.(20)

If mom starts to shake, squeeze the arches of her feet to control the trembling and guide her through gentle breathing.

Many helpful bodywork and massage techniques, along with numerous comfort measures and coping strategies, can have a positive impact on the way a woman perceives and experiences her labor. These techniques also provide midwives with additional ways to keep their clients calm, comfortable and relaxed.

Elaine Stillerman, LMT, has been a New York State licensed massage therapist since 1978. She began her pioneering prenatal practice in 1980. She is the developer and instructor of the professional certification workshop "MotherMassage: Massage during Pregnancy" (www.MotherMassage.net) and the author of MotherMassage: a handbook for relieving the discomforts of pregnancy (Dell, 1992); The encyclopedia of bodywork (Facts On File, 1996); Prenatal massage: a textbook of pregnancy, labor, and postpartum bodywork (Mosby, 2008); Modalities for massage and bodywork (Mosby, publication date to be announced). She is the researcher and writer for the PBS-TV show "Real Moms, Real Stories, Real Savvy" and is proud to have helped organize the March 2008 Midwifery Today conference in Philadelphia, Pennsylvania.

Sources:

  1. Englemann, G.J. 1884. Labor among primitive peoples. St. Louis: JH Chambers.
  2. Hrdlicka, A. 1908. Physiological and medical observations among the Indians of Southwestern United States and northern Mexico. Washington, DC: Smithsonian Institute Bureau of American Ethnology, Bulletin 34.
  3. Institute for the Study of Human Knowledge. 1993. The effect of continuous emotional support during labor. Los Altos, California: Mental Health Update, The Center for Health Sciences.
  4. Field, T. et al. 1997. Labor pain is reduced by massage therapy. J Psychosom Obstet Gynecol 18(4): 286–91.
  5. Birch E. 1986. The experience of touch received during labor. J Nurse Midwifery 31(6): 270–76.
  6. Stillerman, E. 2007. Prenatal massage: a textbook of pregnancy, labor, and postpartum bodywork. St. Louis: Mosby; Lowdermilk, D.L., and S.E. Perry. 2004. Maternity & Women’s Health Care, 8th ed. St. Louis: Mosby.
  7. Stillerman, 2007.
  8. Lowdermilk and Perry.
  9. Ibid.
  10. Lowe, N. 2002. The nature of labor pain. Am J Obstet Gynecol 186(5): S16–24.
  11. Cogan, R. 1976. Backache in prepared childbirth. Birth 3(2): 75–78.
  12. Waters, B.L., and J. Raisler. 2003. Ice massage for the reduction of labor pain. J Midwifery Women’s Health 48(5): 317–21.
  13. Olkin, SK. 1987. Positive Pregnancy Fitness. New York: Avery Publishing Group.
  14. Sousa, M. 1976. Childbirth at home. New York: Bantam.
  15. Ibid.
  16. Boston Women’s Health Book Collective. 1971. Our Bodies, Ourselves. New York: Simon & Schuster.
  17. Lacey, L. 1975. Lunaception. New York: Coward, McCann & Geoghegan.
  18. Hart, DV. 1965. From "Pregnancy through birth in a Bisayan Filipino village." In Southeast Asian Birth Customs. New Haven: Human Relations Area Files Press.
  19. Ibid.
  20. Stillerman, 2007.
  21. Ibid.
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