The focus in conventional postnatal care is primarily on the health of the newborn and less so on the mother, especially if she has no obvious health issues. Postnatal care for the mother has often been described as the ‘Cinderella’ of the maternity services (Clift-Matthews 2007, Fraser & Cullen 2006), yet it is at this time the foundations of the future health of both mother and baby are laid. A traditional Japanese view was that if the baby was ill the mother should first be treated, because it is the mother who gives support to the baby. Naturally this would not apply in cases where the newborn was experiencing severe illness. Modern cultures are now beginning to value the importance of good support in the postpartum period and the phrase ‘Mothering the mother’ helps describe this emphasis (Kennell et al 1993). Bodywork provides a wonderful way of ‘mothering’.

Both physically and emotionally the postpartum is a time of great change. In many traditional cultures the new mother would get support and there was the ‘lying in’ or ‘confinement’ period of usually a month. Examples of this can still be seen, particularly among Asian families in the West. While family support can sometimes be overbearing, particularly if there are tensions, aspects of this idea of resting for a few weeks are useful to consider. Indeed, at the Birth Centre in south London, new mothers are advised by their midwives to stay at home for a month to rest and get to know their baby.

One client of mine decided not to have any visitors for a week or so, even close family, to support this process and called it her ‘baby moon’. I thought this was a nice way of creating intimate family bonding space.

(Suzanne Yates)

This is a welcome antidote to a current cultural trend of the ‘yummy mummy’ where celebrities parade their slim bodies in front of cameras days after giving birth. Many women feel under pressure to recover as quickly as possible and bounce back to ‘normal’, whatever ‘normal’ means. New mothers need to be encouraged to recognise that it takes time to recover, even from an ‘easy’ birth. It is unrealistic to expect the body to bounce back within days. The body is recovering not only from labour, but from the whole 9 months of being pregnant. At the same time, new demands are placed on it with all the physical and emotional adaptations of being a mother. It is common in the first few days, with the euphoria of birth, for the mother to do too much. Bodywork provides an excellent tool in this first week to help her rest and encourage her to stay in tune with her body. The bodyworker needs to liaise with the primary care provider as the risk of infection and complication is high and referral may be needed, but appropriate bodywork can offer support for the recovery process.

The mother’s living situation will be a major factor in this recovery. Factors such as whether she has a good support network; whether she has a supportive or unsupportive partner, or is on her own; the number of other children she has; her financial and housing situation, will all affect her experience of the postpartum.

In the weeks following birth, without the emphasis on the 1 month recovery time, many women tend to get caught up in the demands of adapting to a new baby and changing relationships in their family, so that they often neglect their own needs.

As well as the living situation, the mother’s experience of the early postnatal period (first 6 weeks) will depend greatly on the type of pregnancy and birth that she has experienced. For the bodyworker, knowing a woman’s pregnancy and birth history is important and having worked with a client throughout their pregnancy and even during their labour may help to facilitate optimal support being offered. The early postnatal period is a sensitive time and many mothers may benefit from this continuity of care, or certainly a therapist who knows the issues of this time.

Work in this early period, as indeed the whole postnatal period, will also be affected by the needs of the baby. If the baby is premature or spending some time in hospital this will impact significantly on the mother and the rest of the family. However, throughout the first year, and indeed beyond, how the baby feeds, sleeps and settles will hugely affect the emotional and physical state of both the mother and family. The therapist needs to be sensitive to these issues and include the baby, or not, as appropriate during the sessions. Infant work may help address some of the issues for the newborn and if the therapist is trained in infant massage, this can be a useful additional skill to be able to offer.

In some European countries the mother has 2–3 years’ maternity leave. However, in many other countries, particularly in the UK and USA, there is increased pressure for women to go back to work within 6 months or even earlier. In some cases women are working again at 6 weeks. This places additional strains on having to recover quickly while also getting the most out of the few precious weeks or months the mother has with her baby.

After 6 weeks the initial ‘recovery’ period is over, but the body still needs to recover from the many changes of pregnancy, birth and being a new mother. Many mothers experience health issues in this period, especially musculoskeletal or digestive issues, and even if they feel well physically, they are usually tired and need support and time out and need to be encouraged to continue looking after themselves. Bodywork can play a key part in this process, especially in establishing long-term patterns of good self-care – it is not simply a luxury. For many women having children signals a period of focusing on the needs of others and may lead to self-neglect. They may not begin to focus on their own needs until many years later when their children leave home.

As time goes by the mother may become pregnant again and then the therapist would be working with a woman who has both postnatal and pregnancy needs simultaneously. Some mothers may even conceive during the first 6 weeks. This places additional demands on the body which ideally needs at least 1–2 years to recover from a pregnancy/birth.

After having a baby, a mother’s life and her body are changed forever. Bodyworkers can support these changes and help lay the foundations for long-term emotional and physical health for both mother and baby. Indeed one of the best ways of supporting the long-term health of society would be to give mothers and babies regular bodywork during the first year, especially weekly for the first 6 weeks. It can make a huge difference in helping mothers come to terms with their changing bodies and emotions, which in turn affects their relationships with their whole family.

11.1. Benefits of postnatal work

For mother and partner

• Helps promote postnatal recovery, facilitating the restoration of pre-pregnancy physiology, for example by supporting abdominal and pelvic floor toning, relieving back and shoulder aches, improving circulation and lymphatic flow, supporting energy flows.

• May help prevent and provide support in cases of postnatal depression.

• Touch may help in the birthing recovery process by helping relieve stress and trauma, especially if the birth experience differed from the woman’s expectations. It may also help promote physical recovery and support healing from the effects of any strains or medical interventions experienced during birth.

• Helps promote a positive relationship with her partner and baby: the partner can be involved in providing bodywork for mother and baby. The partner could also receive bodywork to support them in their adjustment to parenthood.

• Provides support for the emotional demands of early mothering.

• Provides a relaxed environment.

• Helps promote sleep, giving space for rest, easing fatigue.

• Offers support for breastfeeding.

For baby

• Can offer a space for the mother to be with the baby without other demands.

• Offers support for bonding and feeding.

• Can include direct work for the baby, to support baby’s physical and emotional development.

Long-term implications

• Supports the family unit in making the transitions.

• Helps lays foundations to support the long-term emotional and physical health of mother, father and baby.

11.2. Overview of practical postnatal bodywork themes

The impact of birth

Postnatal bodywork includes being aware of the effects of birth including the effects of different types of instrumental delivery, working with awareness of scar tissue and the effects of different drugs and interventions.

Whatever kind of birth the mother has experienced she needs time to ‘recover’ – even from an uncomplicated vaginal birth. Emotionally and physically, birth is a major life event for women. However, if there has been medical intervention, especially if the mother had not anticipated it, there may be additional physical and emotional effects to process.

It is important to gather appropriate information about the mother’s personal emotional and physical response to her birth as each woman has different expectations and responses to her birth. Do not assume that a fast vaginal birth was ‘easy’ or that the mother is disappointed because she had to have an elective caesarean. Consider each mother’s needs on an individual basis.

Many women have some form of medical intervention during the birthing process. The therapist needs to understand the physical and emotional implications of different interventions, both in the short and long term, and the most appropriate form of work along with any relevant aftercare issues.

Space for the emotional processing of birth and being a mother

As it is a key time of change for the mother, the therapist needs to create an environment for the woman to describe or discuss her experiences within the context of the bodywork session. Bodywork sessions can provide a valuable space to debrief after the birth, especially if the therapist had been supporting the mother in the antenatal period. It can also provide an opportunity for the mother to air issues about how she is feeling about herself and her baby, how breastfeeding is going, sleeping issues, partner relationships and so on.

Working with awareness of the baby

This includes bonding with and feeding the baby and postural demands on the mother.

The mother and baby are very much a unit and it can be good to encourage the mother to bring the baby to the bodywork sessions, if she wants to. Work can be done while the mother is breastfeeding or while the baby is sleeping. In this way the baby is less likely to be fussy and distract from the work. Work on the floor may provide a slightly roomier space for the baby to lie down next to the mother. If the therapist is appropriately trained, bodywork can also be included for the baby. Once the baby starts becoming more physically active, especially crawling, they usually become too ‘disruptive’ to remain present.

Having the baby present may help the therapist observe how the mother holds and carries the baby and the postural effects of this. However, it is also important to recognise that, for some mothers, the bodywork session is providing time and space away from the baby, where her own needs can be focused on.

Bodywork can support the establishment of breastfeeding, help prevent mastitis and support changes in the ribs and breasts.

11.3. Specific considerations for supporting different postnatal periods

Energetically, the woman starts from a state of relative ‘weakness’ and ‘depletion’ immediately after birth and gradually her emotional and physical strength start to build. There is considerable variation in terms of length of time of recovery. Recovery tends to be longer after instrumental and surgical deliveries, longer labours and for multiparous women. Recovery tends to be quicker for fit and healthy women who have had natural deliveries.

The first 6 weeks

In many traditions the first 4–6 weeks was the period of ‘lying in’. In contrast, in modern cultures many women tend to be up and about too quickly and resuming their normal life patterns. Often, in the excitement of wanting to ‘show off’ a new baby, families invite too many visitors round. This can be tiring for both mother and baby and place additional strains on the family.

The early postnatal period is a sensitive time where the mother is recovering from the experience of pregnancy and the effects of birth and is getting to know her baby. She needs good nutrition and adequate rest to support this process. Inadequate nutrition may result in slower recovery, difficulties breastfeeding and conditions such as anaemia.

The uterus is contracting and only goes back into the true pelvis by around day 10, resuming its pre-pregnant size around week 6. The lochial discharge has usually become colourless by 3–4 weeks, indicating that healing is nearing completion. However, if there is still red lochia present at 6–8 weeks this may indicate problems, so it is important to refer the mother back to her primary caregiver. If there is odour this is especially important as it indicates the possibility of infection. How long the mother will be monitored by the primary caregiver differs from country to country.

Until recently the mother would spend most of the first week in hospital after birth, but currently there is an emphasis on early discharge in many countries, primarily as a cost-saving measure. With an uncomplicated vaginal birth, discharge can be as early as within 6–24 hours. After an instrumental delivery or a caesarean, discharge typically ranges from 3–5 days, if there are no complications. Some women prefer to return home as soon as possible as they find their own space more restful, while others find the support and observation of the hospital setting to be more reassuring both physically and emotionally. Both possibilities have advantages and disadvantages. In the hospital the mother may not be able to sleep that well and is potentially exposed to infection. However, she can be monitored closely and given appropriate treatment and support. At home the mother may get back too quickly into her normal routine and may miss out on appropriate breastfeeding and exercise/self-care support. Bodyworkers may find it useful to have some basic training in these fields so they can at least give some support and know when and where to refer. It is important to work in collaboration with the primary care provider.

The end of this period coincides with the 6 week medical check which is offered in most countries. From the western point of view the mother is considered to be ‘back to normal’. The gross physical (hormonal, cardiovascular, reproductive) changes have occurred by this time. By 2–3 weeks the perineum is usually healed, even after an episiotomy. However, in reality it is only the beginning of the body’s recovery. Some of the organ changes take longer (for example the intestines) and the musculoskeletal changes will impact on the mother for the rest of her life. There will always be a tendency to weakness in the abdominal and pelvic floor. Some women feel quite well by the end of 6 weeks, some may still be recovering from the effects of surgery, and some may be feeling exhausted or overwhelmed. Some women may still be experiencing ligamentous or musculoskeletal problems such as pelvic girdle instability or diastasis recti. Others may be dealing with more serious health issues such as scar tissue healing, infection or fever. Bodywork will need to reflect the individual reality of each mother but work in this period is important as it sets the foundation for the rest of the postnatal period and therefore for the rest of life.

The baby might not be sleeping much during the night or the mother might not be able to sleep as she might be preoccupied by her baby. The mother may start to suffer effects of sleepless nights. If she gets overly tired then this may trigger depression. This is a time when it is ideal for the bodyworker to be able to visit the mother where she is, whether it is home or hospital, so that she can rest as much as possible and not have to worry about getting her baby ready to go out or be looked after.

Feeding patterns are being established. Many women experience the discomfort of ‘after pains’ in the first couple of weeks, especially after more than one pregnancy or if they have had medication for third stage labour. The mother may develop sore nipples, especially if the baby is not attaching properly. Milk comes in around days 3–5 and engorgement may be a problem with the breasts becoming full, hard, hot and painful. Engorgement can be relieved by removing some of the excess milk by hand or expressing with a pump, or through massage. It is important to develop good patterns as otherwise issues may become more severe. Sore or sensitive nipples or blocked milk ducts could lead to infection and mastitis. If the bodyworker cannot give sufficient support then refer to experienced care providers to create success and confidence in establishing breastfeeding.

If the mother is not breastfeeding, then she and the baby are still getting used to feeding patterns and she may experience breast tenderness as the milk supply dries up. For all women there are hormonal changes and the mother is getting used to feeding her new baby. This means she may feel quite emotional as well as concerned about whether her baby is putting on enough weight.

It is an important family bonding time. If the mother already has a child, s/he will be getting used to the new baby and this may raise some issues and possibly cause some stress for the mother. If the mother is in a relationship there are big adaptations for the partner to make and feelings of jealousy may arise as the mother focuses attention intently on her newborn. Resuming sex may become an issue. Often the partner will be at home for the first couple of weeks, depending on the paternity leave of the country.

Emotionally this can be an intense period. Hormones are adjusting at a rapid rate. There is often, especially after an ‘easy’ birth, an initial elation, the surge of oxytocin bonding, followed by a ‘down’ around days 3–5 as the hormones settle back to their pre-pregnancy levels. These days are known as the ‘baby blues’. It is normal for the woman to feel emotional and important for the therapist to reassure and validate these feelings. However, for some women, these huge emotional changes may trigger longer-term feelings of depression and it is important for the therapist to be alert to that possibility.

Bodywork

Due to the focus on the baby, mothers usually need to be encouraged by the therapist to book appointments. It can be a good idea to book a postnatal appointment at the last antenatal appointment. The therapist may want to offer a home visit at the clinic price for clients who have come regularly through their pregnancies, to encourage them to continue looking after themselves once they have their baby. The first 6 weeks is a good time to give mothers regular, ideally at least weekly, bodywork sessions. In some cultural traditions women would have massage daily for the first week (Japan, India, Asia; Davis-Floyd 1992, Priya 1992) and some women would benefit from that. However, the reality is that most women tend to only manage one or two sessions a week. During weeks 2–6 it is still of great benefit to have a session once a week.

Whatever kind of birth she has had, the woman’s body has had to open up and deliver a baby, whether vaginally or abdominally. In some respects the approach is similar to that of the first trimester, with a focus on gathering in energies and structures with the goal of supporting the uterus to contract and the pelvis to become strong.

In the early part of this period especially, be careful not to over-stimulate the body. Although the mother’s pre-pregnancy and pregnancy fitness will influence the type of work done, work tends to be gentle and often involves the use of energy and holding techniques to help the body recover. It is unlikely that the mother will want any vigorous physical work. The levels of relaxin remain high for the first 6–8 weeks and even longer. This means that caution still needs to be taken in terms of softness of the tissue and laxity of joints and ligaments, especially in the pelvic and lumbar areas.

If the mother has had a vaginal birth, she may have given birth squatting, which will have placed demands on the pelvis to expand and the joints to move, especially the sacroiliac (SIJ) and symphysis pubis and the hips. If the mother had a forceps or ventouse delivery, or delivered lying on her back, she may have displaced or even fractured the pubic bone, or had damage to the coccyx. There may be sensitivity around the epidural site in the lumbar region. Issues of pelvic girdle instability may therefore be aggravated.

It is vital to include work which can help strengthen the abdominal muscles, pelvic floor muscles and muscles of the lower back to support pelvic strengthening. The abdominal muscles need to be encouraged both to contract and the rectus abdominis muscles to draw back together. If the mother feels comfortable, the recti can be checked for separation and appropriate work given. If there is no scar tissue, abdominal work can be done to help encourage involution of the uterus. In many cultures this is done quite vigorously and it often results in an initial increase in bleeding. This style of deeper work needs to be done by the primary caregiver rather than the bodyworker. The bodyworker can, however, work with more of an energy focus and through encouraging the mother to massage her own abdomen.