EducatingTouchProfessionals,StudentsandthePublic

PregnancyMassage:PositioningandDraping
ByCindyMcNeely,RMT(Trimesters.ca)
WithHelpfromLisaIvanyandCandaceGerriorGilmore
(AtlanticCollegeofTherapeuticMassage)
PhotographybySherriKuehlein(BabiesandBrides.ca)

CEUAttribution


TableofContents

GainingCredit................................................................................................................................................................... 3
ResponsibilityDisclaimerandRelease ................................................................................................................... 3
LearningObjectives........................................................................................................................................................ 4
PositioningOptions ........................................................................................................................................................ 4
FactorsAffectingPositioningChoices...................................................................................................................... 5
StageofPregnancyandPositioningChoices ......................................................................................................... 5
ThePronePosition ......................................................................................................................................................... 5
ProneintheSecondandThirdTrimesters?.......................................................................................................... 6
TheSupinePosition........................................................................................................................................................ 6
AvoidingSupieHypotensiveSyndrome ................................................................................................................... 7
SidelyingPosition............................................................................................................................................................ 7
SemiReclining ................................................................................................................................................................. 8
ForwardLeaning ............................................................................................................................................................. 9
DrapingthePregnantClientinSideLying............................................................................................................. 9
TemperatureRegulation ...........................................................................................................................................10
Summary ..........................................................................................................................................................................11
Biography.........................................................................................................................................................................11
References .......................................................................................................................................................................11
References .......................................................................................................................................................................12

GainingCredit

Successful completion of this course is demonstrated by a certificate that is awarded when a passing
gradeisobtainedonthequiz.Youmustscore80%orhighertopassthequiz.

Thiscoursehasbeenattributedfor2CategoryAContinuingEducationUnitsorCreditsbytheMassage
TherapistAssociationofAlberta,MassageTherapistAssociationofSaskatchewan,andtheManitoba
MassageTherapistAssociation.

TheCollegeofMassageTherapistsofOntariohasassigned1.0CategoryACEUsforthiscourse.

Application is being made for credit with the Colleges of Massage Therapists of British Columbia and
Newfoundland&Labrador.

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Much effort has been taken to ensure the safety and advisability of the information contained in this
course; however, it is possible to injure people by performing almost any type of intervention. This is
morelikelywhenaprocedureisperformedwithoutjudiciousprecautions,orwhentherecipientofthe
interventionhasuniquebiologicalorotherfactorsthatmakethemmorevulnerabletonegativereactions.

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regulatedand/orlicensedhealthcareprofessional.

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You further attest that you practice in an evidence based way. This means incorporating the best
available scientific evidence and blending that with your clients unique biological factors and
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If you do not agree with this release, do not study this course and do not practice the interventions
described.

LearningObjectives PositioningOptions
Every Massage Therapy client needs to be
Afterstudyingthisarticleyoushouldbeableto:
positioned in a way that supports their needs
Identify your client's trimester according to andthegoalsofthetreatment.Thefollowingare
gestationalage. common(andnotsocommon!)positions.

State the advantages of each positioning 1. Prone: most often used for back and neck,
choice. andposteriorlegmassage.

Position a client optimally for her stage of
pregnancy, comfort level(s) and objective
signs.
Understand that the therapist must position
for client wellbeing & that clients may not
always be able to clearly identify issues
regarding maximal comfort or the issues
relatedtoSupinehypotension.
Reposition a client to alleviate position
induceddiscomfort.
Negotiate draping for a pregnant client
securely and in a boundary conscious way
whentreatingherlegs,backandabdomenin
sidelyingandsemirecliningpositions.
2. Supine: used when massaging arms, legs,
abdomen,andhead,neckandshoulders.
3. Sidelying: used to massage the back, arms,
legs,head,neck&shoulders,andabdomenif
theclientispregnant.
4. Semilying/or semireclining: used to
massage the entire anterior body and
beneficial for the client who is pregnant,
hypertensive,hasvestibular(balance)issues,
oranytimetheclientisnotcomfortableina
supineposition.
5. Forwardleaning: using a massage chair
with special adaptation for the pregnant
abdomen or using pillowing designed to
support the anterior torso and head, neck,
andshouldersofthepregnantwoman.

Treating the pregnant client safely and comfortably is very rewarding!


FactorsAffectingPositioning
Choices
Of the 5 options mentioned above, specific
consideration must be made to adapt the
positioningofthepregnantclientrelativetothe
specific trimester of their pregnancy and their
physicalcondition.
Factors affecting what position is chosen
include:
Casehistoryinformation
Generalhealthstatus
Trimesterofthepregnancy.
Health Status related to this pregnancy as
wellaspreviouspregnancies.
o Including general health & obstetrical
history.
History of musculoskeletal wellbeing, areas of
stress, tension, injury, pain, muscle strain, &/or
anyoveruseorrepetitivestrainissues.
StageofPregnancyand
PositioningChoices
The majority of pregnant women in their 1st
trimester(upto13weeksgestationalage(GA)),
can lie in prone or supine with comfort and
safety. In the 1st trimester breast
sensitivity/tenderness or nausea/vomiting may
interfere with the client finding comfort in the
proneposition.
As the pregnancy progresses into the 2nd
trimester (14 to 26 weeks GA), and the gravid
(pregnant) uterus expands, alterations to
positioningmustbemadeforsafetyandcomfort
reasons. The third trimester extends from 27
weeksGAtodelivery.
The downward weight of the pregnant
womancanincreasechallengestotheutero
sacral ligament which helps to stabilize the
uterusinrelationtothesacruminthepelvis.
This could also potentially manifest as
increasedsacraldiscomfort.
Challenges to SI joint stability may also
occur in this position. This may increase
aggravationtoanalreadyirritatedSIjoint.
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
orloadonmusculaturewhichmayalreadybe
challengedbythegrowingpregnantbelly.
ProneintheSecondandThird
Trimesters?
Many massage therapists adjust their prone
pregnancyworkbyutilizingcushioningsystems
or tables which allow the pregnant abdomen to
restproneinahollowedstructureduringthe2nd
and3rdtrimesters.Thesedevicesprovideasling
like type of support for the pregnant prone
client.
The individual therapist who wishes to treat a
AvoidingSupieHypotensive
Syndrome
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
instinctivelyneedingtochangepositionie.tosit
uporrollontotheirside.
Atwhatstageofpregnancydoessupine
hypotensionoccurwiththepregnant
client?
Thereisnoabsoluteanswertothisquestionand
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
beavoidedthroughouttheentiretyofthe2ndand
3rd trimester. Myles textbook edited by Fraser
andCooper(2003)however,suggestsavoidance
of the supine position only late in the 2nd
trimester.
The Society of Obstetricians & Gynecologists of
Canada has guidelines for pregnant women and
the supine position that are midway between
MayesandMyles.Somewomenmayexperience
symptomatic hypotension from compression of
thevenacavabythepregnantuterusandshould
modify these (strengthening and weight
training) exercises to avoid the supine position
afterapproximately16weeksgestation.(SOGC
Clinical Practice Guidelines. Exercise in
Pregnancy & the Postpartum Period. No. 129.
June2003.p.4)
Patientcomfort,thesizeofthebellyandwhether
she sleeps in a supine position need to be
integratedwiththeseguidelinestohelpyouand
the client make an informed decision about her
treatmentposition.
Thereisalsoasimpleadaptationtominimizethe
risk of supine hypotension during pregnancy.
Two to three (or more) pillows between the
legs or under the superior leg if the inferior
legisextended.
Apillowinthemidtorsomightalsoserveto
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 sidelying is also often
wellreceivedbyclients.
Aswell,atowelorparticularlyababywedge
iswonderfulforincreasingthesupportofthe
side lying abdomen and minimizes lateral
twist on the trunk as the baby in 3rd
trimester can create torque due to its
growingweight.
Women who have difficulty getting comfortable
inbedoronthemassagetablemayfindanegg
carton mattress very helpful for alleviating
discomfort.Thisisutilizedinsomehospitalsfor
clients on prolonged bed rest. Side lying should
presentnoincreasedriskofharminthemajority
of pregnant clients unless they disclose
particularissuesrelatedtolyinginthisposition.
ForwardLeaning
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 thechair (provided
nosymphysispubisdysfunctionexists!)andlean
their arms onto a well pillowed massage table.
Thisprovidesfullaccesstothebackareaaswell
as partial access to the gluteal and hip region.
Sitting in this position also gives the client
thekinaesthetic sense of opening the pelvis,
somethingsheneedstopracticeinordertobirth
herbaby.Theclientcanalsopracticethiswithin
the massage therapist's office or at home with
the use of a physio or birthing ball as we refer
toit.
DrapingthePregnantClientin
SideLying
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.
SideLyingDrapingProtocol (Courtesy of
Lisa Ivany, Atlantic College of Therapeutic
Massage)
Securepillowsunderclient'shead
Place another pillow under her arm for
comfortandstability
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TemperatureRegulation
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 nonpregnant M.T.
treatments,mayfindtheyarejusttoowarmfor
theseadditions.Alongwithensuringthatwedo
not increase the systemic temperature of the
pregnant client, focusing on client comfort may
demand that sheets are the primary covering
duringthesession.
Summary
With these options for effective positioning and
draping,therereallyisnoneedforaclienttobe professionals.
in an uncomfortable situation! Positional and
draping comfort is crucial to a satisfactory
pregnancy massage experience, and ensuring
these preliminary activities are wellperformed
will add much to a pleasant and therapeutic
pregnancytreatment.
GoOnlineand
StudytheDrapingVideoClip
TaketheQuiz
PrinttheCertificate
&KeeptheseDocumentsinYourCEUFolder!
References
Byrne H: Supine Hypotensive Disorder during
Pregnancy. BeFitMom.
at:http://www.befitmom.com/supine.html
accessedMay12,2008.
College of Massage Therapists of Ontario.
Draping Standard available at
http://www.cmto.com/pdfs/CPH
12.pdfaccessedMay12,2008
EngebretsonJC,LittletonLY:Maternal,Neonatal,
and Womens Health Nursing.Thomson Delmar
Learning.2002.
Fraser DM, Cooper MA Editors:Myles Textbook
forMidwives,14thEdition.ChurchillLivingstone.
U.K.2003,192.
Henderson C, Macdonald S. Editors: Mayes
Midwifery: A Textbook for Midwives. 13th
ElsevierLtd.2004,386.
Knuppel R, Drukker J: HighRisk Pregnancy: A
TeamApproach,2ndEd.W.B.SaundersCo.USA..
page19
Society of Obstetricians & Gynecologists of
Canada/CSEP Clinical Practice Guideline:
Exercise in Pregnancy and the Postpartum
Period.June2003,No.129.
Watterson L: Aortocaval Compression. At
http://www.manbit.com/oa/oaindex.htm
accessedMay12,2008.
World Health Organization: Preoperative
Procedures. http://www.who.int/reproductive
health/impac/Clinical_Principles/Operative_care
_C47_C55.html
Lets explore the prosand cons of each position
relativetoyourclientstrimesterindetail.
ThePronePosition
The prone position generally has many
advantages,including:
Easy access to structures of the back and
posteriorlegs.
Allows maximum use of the therapists
weightforincreaseddepthofpressure.
With a face cradle the prone position helps
theclientmaintainsymmetricalalignmentof
upper back, shoulders, and neck which
provides more effective care in the event of
musculoskeletalissuesintheseareas.
Clientpreference
Clients who are stomach sleepers may have
difficulty resting in other positions due to their
preferenceinsleepingfacedown.
As the pregnancy progresses some
disadvantagesarisewiththepronepositionand
needtobeconsidered.Theyinclude:
As the uterus and baby expand during the
2nd and 3rd trimesters, downward pressure
fromlyingpronecreatesaddedstressonthe
clientsbody.
Theincreasedlordoticcurveofthepregnant
clientalongwiththeanteriorshiftingravity
due to the expanding pregnant belly can
create musculoskeletal issues related to the
areas of the lower lumbar, gluteal, and leg
regions.Increasingthelordoticcurveviathe
prone position may aggravate preexisting
issues.
Relaxationoftheligamentousstructuresdue
to the hormonal influence of relaxin can
influencejointinstabilityandligamentlaxity.
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
theirinformedconsentwiththeclient.
Since sidelying and semireclining are very
comfortable positions for the pregnant client,
and create no additional challenges to her
pregnantbody,Irecommendthesetwopositions
as the safest and most effective positions to
utilizewhenprovidingmassagetherapyduringa
pregnancywithoutcomplications.
TheSupinePosition
While most clients are comfortable in supine
when they arent pregnant, they become
increasingly uncomfortable as the pregnant
abdomengrows.Themostcommonissuewhich
impairs client comfort is Supine Hypotension
Syndrome.
While most clients are comfortable in supine
when they arent pregnant, they become
increasingly uncomfortable as the pregnant
abdomengrows.Themostcommonissuewhich
impairs client comfort is Supine Hypotension
Syndrome.
General consensus in obstetrical and midwifery
textssuggestthatapillow,rolledtowel,orbaby
wedgepillowcanbeplacedundertherighthip.
This tilts the gravid uterus off of the inferior
vena cava and reduces the possibility of supine
hypotensionoccurring(Henderson2004).
Positioningtheentireclientinsidelyingalsohas
thesameeffect.Mostresourcesstatethatleftor
right side lying are equally effective at relieving
posturalhypotension(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
minimizingaddedstressonthebody.
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
SidelyingPosition
Sidelyingisanaturalpositionformostwomen
during their pregnancy. Sometimes, discomfort
can occur on the weight bearing joints
particularlytheshouldersandhipsasaresultof
lying on the side and with the increased weight
gainduringpregnancy.
Adequate pillowing should, however, alleviate
discomfortinthispositionduringmassage.
Irecommendaminimumof5pillowsaswellasa
babywedgeforsupport.
One to two pillows placed under the head
serve to increase the distance between the
earandshoulder.
SemiReclining
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 semiupright
position.
MayesMidwiferydemonstratesutilizationofthe
45 degree wedge as valuable for both exercise
andrelaxationpractices(p.388).
For massage clients care should be taken to
ensuretheyarenotslumpingastheysettleinto
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
needtobewellsupported.
Forsomeclientswithpaininthisarea,Iwillalso
add a rolled up towel for lumbar support. The
clientsneckandheadshouldalsobesupported
so that they are not in a hyperextended neck
position.
Straightentophipandknee
Flexbottomhipandknee
Securethetopsheetatthehiplevel
Take the back corner of the top sheet and
bring it over the top leg, making sure the
sheetundrapestoabovetheknee
Bringthesamecornerunderneaththetopleg
tocreateafanwhichwillbeusedtocoverthe
gluteals
Bring the top sheet upwards to undrape the
greater trochanter and posterior superior
iliacspine
Movethefanunderthetopsheetandpullthe
topsheetsecurelyagainstthegluteals
Holdingthesheetsinplace,askclienttoflex
their top hip and knee andextend the lower
hipandknee
Readjust the draping and securely tuck the
topsheetunderthelowerglutealarea
Place two pillows under the flexed knee for
clientcomfort
UndrapingProtocol
Removepillowsfromunderknee
Askclienttoextendtophipandkneeandflex
lowerhipandknee
Untuck top part of sheet and pull it and the
fansectiondownoverthegluteals
Takethebottompartofthesheetandbringit
backovertheleg.
Biography
Cindy McNeely, R.M.T. has been practicing in
Ontariosince1985andteachingsince1988.
Trimesters: Massage Therapy Education was
created by Cindy and Allison Hines, R.M.T. in
1995toraisethestandardsofPerinatalMassage
TherapythroughoutNorthAmerica.
In1995theycreatedthefirstCanadianLevelIII
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 inservice trainings about Massage
Therapy for other Perinatal healthcare
In 2001 Trimesters collaborated with the
Atlantic College of Massage Therapy
(http://www.actmonline.com) to create the
most comprehensive Collegebased Perinatal
Training available in Canada a 125 hour
program devoted entirely to M.T. during
Pregnancy, Birth, Postpartum, and Infants &
Children.
For2008trainingdatesorformoreinformation
about their trainings, visit their website at
http://www.trimesters.on.ca.
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