CHAPTER 14. Working with higher-risk maternity clients
Chapter contents
References and further reading 390
Introduction
From the 20th century onwards many countries throughout the developed world have witnessed a major decline in maternal and infant death rates. For women and babies in these countries, pregnancy and birth, are now relatively ‘safe’ events. Few women and babies die (e.g. 64 deaths per 1 054 828 in Canada). However, therapists working in these countries should not lose sight of the fact that
More than half a million women die from the complications of pregnancy and childbirth each year and 15 million women suffer injuries, infections and disabilities in pregnancy or childbirth. 10.6 million children under 5 die each year, 40% of them in the first month after birth. 98% of these occur in developing countries.
(WHO 2005)
The World Health Organization (WHO) chose World Health Day 7 April 2005 to focus on mothers and children. Their slogan was: ‘Make every mother and child count’. Other global initiatives such as ‘The Millennium Development Goals’, ratified by more than 189 nations, have set targets to reduce maternal deaths by 75% and child deaths by two-thirds by 2015 (WHO 2005). The goal of such initiatives is not only to reduce mortality, but also to ensure access to appropriate health care services during pregnancy and childbirth (WHO 2004).
The decline of mortality rates in developed countries is due to improved sanitation, nutrition, standards of living, and level of education along with advances in medicine, improved access to health care, and better surveillance and monitoring of disease (Center for Disease Control and Prevention 1999, Detels et al 2002). Because of the low incidence of death, an additional indicator, ‘severe maternal illness/morbidity’, has been established which ‘places a woman at serious risk of death but is not fatal’ (Public Health Agency of Canada 2006).
The reasons that women die vary from country to country. Canada has one of the lowest maternal mortality rates and one of the best early childhood survival rates in the world. The European fetal death rate ranges from 3.7 to 7.3 per 10000 births (Zeitlin et al 2003). In Canada, the leading causes of direct maternal death are pulmonary embolism and pre-eclampsia/pregnancy-induced hypertension, amniotic fluid embolism, and intracranial haemorrhage. The leading cause of indirect maternal death is cardiovascular disease (Gilbert & Harmon 1993, Health Canada 2004).
In 1997 the leading causes of direct maternal death globally were haemorrhage, infection and unsafe abortion. The leading causes of indirect maternal death were anaemia, malaria and cardiovascular disease (WHO 2005).
For information on mortality and morbidity rates in specific countries, check websites for the World Health Organization and for governing bodies related to maternity healthcare within the therapist’s location (e.g. SOGC, ACOG, RCOG, CDC).
The realities for therapists working in developing countries are different. In these countries, women are often younger, have many more children and may live in difficult conditions. They may not have access to basic facilities such as water, let alone healthcare or bodywork.
For therapists working in developed countries, the focus is not working with high mortality and morbidity rates since the majority of their clients will be healthy women. However, there will be a number of clients who have some kind of risk. It is important to identify those types of clients, understand the kinds of conditions they present with and how much or how little bodywork can support them.
14.1. Definition of ‘higher-risk’ pregnancy
A healthy pregnancy with no predictable risk is defined as:
• No pregnancy complications now or in the past.
• No significant maternal medical disease.
• No prior maternity morbidity or mortality.
• Adequate fetal growth.
(Ontario Medical Association 2005)
A pregnancy becomes ‘at risk’ when ‘Closer observation of the pregnancy may be necessary.’ These patients may be managed by continuing collaborative care and birth in an obstetrical unit with intermediate level of nursing facilities or they may be returned to the care of the referring provider with a suggested plan of management for the remainder of the pregnancy.
A pregnancy becomes high risk when ‘the fetus and/or mother are obviously in danger’. These patients should be transferred to a regional maternity centre (level III) for intensive care and birth. Clearly, there are patients who deserve to be placed in this risk category (with problems such as excessive antepartum bleeding, cord prolapse, or advanced uncontrolled premature labour) who cannot be transferred safely or in time to benefit the fetus or mother.
Risk factors can be divided into three main categories: (i) general health status and predisposing risk factors including systemic issues, (ii) obstetrical issues and (iii) socioeconomic-behavioural factors including psychological and emotional issues.
General health status and predisposing risk factors
• Current health issues, e.g. cardiac disease, hypertension, thyroid issues, anaemia, chronic lung disease, diabetes, seizure disorders.
• Past medical history: illnesses, surgeries.
• Reproductive issues, e.g. pap smear anomaly, sexually transmitted infections.
• Older or younger pregnant woman.
• Pre-pregnancy obesity.
• History of genetic disease or congenital anomalies: family history or self.
• History of infections, e.g. cytomegalovirus, rubella, toxoplasmosis.
• Current symptoms, e.g. nausea, vomiting, headache, musculoskeletal discomfort or pain, varicosities.
• Significant family history, e.g. DVT, phlebitis, pre-eclampsia.
Obstetrical issues
• Previous obstetrical history: gravida/para/previous pregnancy losses.
• Previous history of pregnancy loss or termination including therapeutic abortion, spontaneous abortion (miscarriage), intrauterine death (IUD), or stillbirth.
• Fetal anomalies.
• History of pre-term labour (< 36 weeks).
• History of placental issues, e.g. placenta praevia, abruptiae.
• History of high-risk pregnancy, e.g. gestational diabetes, gestational hypertension, pre-eclampsia, antepartum haemorrhage, cervical incompetence, premature rupture of membranes, poly- or oligohydramnios.
• History of fetal/infant weight issues, e.g. SGA (small for gestational age), LGA (large for gestational age), IUGR (intrauterine growth restriction).
• Multiple birth.
• History of issues related to previous or current births, e.g. fetal malposition, breech presentation, labour dystocia, length of labour, medical interventions (induction, epidural, forceps, vacuum, operative delivery), outcome of labour.
Socioeconomic and behavioural factors
• Demographic factors.
• Socioeconomic status.
• Lack of prenatal care.
• Maternal substance abuse, e.g. smoking, alcohol, drug usage both prescription and non-prescription.
• History of sexually transmitted infection.
• Exposure to teratogens such as heavy metals, solvents, pollutants, radiation.
• Cultural practices, e.g. immunisation, nutrition.
• Occupation risks, e.g. exposure to adverse substances, heavy lifting.
• Nutritional status and supplementation, e.g. eating disorders, food restrictions.
• Exercise patterns and limitations if any.
• Sleep patterns.
• Teenage pregnancy.
• Stress issues.
• History of abuse or violence.
Some of the pregnancy outcomes related to these factors are low gestational weight gain, pre-term birth, small for gestational age births, intrauterine growth restriction, pregnancy-induced hypertension, gestational diabetes, higher risk of maternal death, as well as a range of adverse infant health outcomes including congenital anomalies (Public Health Agency of Canada 2006).
There are wide-ranging implications for pregnancy and birth outcomes related to the severity of the risk issue and how it is managed or treated. In some cases, for example with a multiple pregnancy, or with age as the ‘risk factor’, thorough monitoring is the outcome as opposed to a specific treatment and there may be no actual complication. It is important to remember that: ‘Only 10 to 30 percent of women who are labelled high risk actually end up having the outcome for which they are at increased risk’ (Pearson 1997).
One of the most important components for a healthy pregnancy outcome is adequate prenatal care. Many tests and observations are available to help assess risk factors, prevent complications from developing and assist with diagnosis and treatment.
Goals for bodyworkers when treating higher-risk population groups
Working with the higher-risk population requires additional skills, training and experience compared to working with the low-risk population. The therapist needs to know the specific adaptations and precautions including those on home or hospital bedrest.
Prior to undertaking bodywork, there needs to be a solid understanding of the circumstances which result in a woman being considered ‘higher risk’. This includes: the woman’s general and maternity health history, knowledge of the type of primary care she is receiving, liaising with primary caregivers if relevant, the specifics of the health issue and an evaluation of the type of bodywork which would be safest and most beneficial. Complete contraindications to bodywork are rare, except in the obvious case of medical emergency or an unstable health situation. Once the situation has stabilised, bodywork can be a useful adjunct to the recovery process.
Some bodywork texts suggest that higher-risk clients should not receive any therapy, or advocate modifications that are not based on clinically researched documentation. These recommendations are often based on fear or concern for litigation rather than clear evidence-based practice. There are no existing collected data to suggest that bodywork is harmful in higher-risk situations, particularly if it is done according to sound training and careful clinical application. On the other hand, there have been numerous clinical programmes within antenatal hospital settings, some for over a decade, with wide-ranging positive effects for patients, hospital staff, and the professional and student massage therapists who have participated in the sessions.
Cindy McNeely
Massage therapy colleges in Ontario, Canada, have been pioneers in creating maternity hospital programmes. The first programme of its kind in Canada began in 1991 at Guelph General Hospital. Under the supervision of Kathy McDonald RMT, students from a Toronto massage therapy college provided treatments for antenatal patients as well as for women who were in the labour and delivery and postpartum setting. Students also provided direct hands-on care for hospitalised babies within the nursery setting.
In 1995 another maternity massage therapy programme was piloted within an urban level III, high-risk maternity hospital setting. This hospital delivers 4000 babies each year, with one quarter of the deliveries related to high-risk pregnancies. Cindy McNeely RMT designed and implemented this programme which served pregnant clients in the hospital due to their high-risk pregnancy. In addition, students worked within the labour and delivery and postpartum units. Infant massage instruction was provided for parents, both out-patients and within the level II nursery setting.
To date, the programme has trained students from four massage therapy colleges as well as providing postgraduate experience for Registered Massage Therapists (RMTs) seeking skill development in working with higher-risk pregnant clients. Student training in Ontario encompasses 2200 hours of training: this is the highest level of training worldwide.
Approximately 400 treatments are administered to patients in the maternity units each year which has resulted in over 5000 treatments given in the 13 years the programme has been running. Some patients receive a single session of treatment, while others may receive several massage therapy treatments per week and/or a series of treatments over the prolonged time they are in the hospital for observation and treatment of complications of their pregnancies. Women have been treated who have been in the hospital for up to 5 months of their pregnancies.
Although formalised statistics have not been gathered from these patients, whenever possible an evaluation form is given to the recipient of the treatment in order to receive voluntary feedback about the effectiveness of the programme.
Information requested relates to the effects of the massage treatments with respect to muscle discomfort and tension, effect on mobility and stiffness of joints, swelling, pain, feelings of stress and anxiety and sleep patterns. Of thousands of evaluations gathered, an overwhelming majority of positive feedback has been received about the efficacy of the treatments received in all units.
General points
In addition to knowing the specifics of each individual condition and client, there are some general points to consider.
Work in close collaboration with the primary care provider
Always ensure that the client is receiving appropriate medical care for their condition. Consult with the care provider if unsure of approach.
Stress reduction – a primary component of care
Regardless of the condition or issue, documentation of preventative and treatment practices within nursing care highlight the importance of stress reduction. Gilbert & Harmon, 1986, Gilbert & Harmon, 1993 and Gilbert & Harmon, 2002 repeatedly list anxiety, stress, fatigue, and over-activity in their list of contributing factors to some of the issues resulting in a higher-risk pregnancy. They suggest rest, stress reduction, relaxation techniques, problem solving and ‘back rubs’ as appropriate care strategies for the patient experiencing higher-risk pregnancy: ‘plan daily rest periods to increase blood flow to the uterus which decreases the risk of prostaglandin release’ (Gilbert & Harmon 1993: 281, 430).
Daily activity level
The bodyworker can be aided in assessing treatment approach by considering the daily activity level prescribed by the primary care providers and any modifications or limitations. If extra caution is desired, the level of intensity of bodywork should be slightly less in nature than the activities of daily living prescribed by the primary care provider.
Encourage listening to the body
The therapist can play a role in encouraging, nurturing, and supporting the client in listening to her body.
The client on bedrest
If the client is on bedrest, then bodywork should aim to provide comfort, increase relaxation and reduce stress, and help maintain tissue well-being. As these clients may be at higher risk of developing DVT they are usually prescribed dorsiflexion/plantarflexion exercises by the antenatal physiotherapist and advised to mobilise. Bodywork can support these protocols with gentle mobilisations and effleurage. Energy work can include LV to support blood flow.
Absolute contraindications to bodywork
When working with this client group, the therapist needs to be more alert to the times when not to use bodywork (refer to tables in assessment chapter).
Working in hospital
The therapist may need to visit the client in hospital, with agreement from the primary caregiver.
Specific needs groups
In addition to understanding specifics of medical conditions, therapists may need to educate themselves on the specific needs of specific client groups such as: teenagers, refugees, women with a history of abuse, women carrying twins, women who have conceived through assisted reproductive technologies.
Testimonial
C.B. (client of Suzanne Yates)
I had kidney disease before becoming pregnant and knew some of the risks. However, when I saw the consultant I was informed I had stage 4 renal failure and a60–90% chance of a successful pregnancy (i.e. live birth) and a 10% chance of needing dialysis during the pregnancy. The outlook seemed bleak. It was hard to find a complementary practitioner who would support me but eventually I found Suzanne and had shiatsu regularly during the rest of the pregnancy, during my birth and in the immediate postpartum.
Possibly the most important benefit was that it gave me a space where I could come back to myself and be doing something that other pregnant women were doing. I think it had an impact on my blood pressure; I remember feeling the ground under my feet after my shiatsu and I felt a lot less stressed. It gave me time to be aware of my baby daughter; it was very reassuring to feel her kick. Suzanne showed me points to work on myself between sessions, which really helped calm me down. She encouraged me to continue with my meditation practice.
My whole pregnancy was quite stressful and I was continually being monitored. Suzanne helped me get things in perspective and be calm about all the tests. If I had gone along with all the worries I would have been a basket case. Suzanne gave me space to express my fears, without denying the situation and giving false reassurance. I also appreciated that she was not afraid of working with me.
The main risks were that I would miscarry, have a premature baby or develop PET and need an emergency caesarean section.
When I was in hospital towards the end with suspected PET, the hospital staff were more than happy for Suzanne to come in and provided us with a space where I could have my shiatsu. This helped me continue to stay calm and connected.
At 36 weeks, after some weeks in hospital, a decision was taken to induce me. It felt like it was a bit of a long shot, but there was not much choice as my creatinine levels were creeping up. Suzanne worked the labour focus points with me for about a week before. I was given prostaglandin gel but after 24 hours nothing much had happened and my waters were broken. By this time my partner and I were both exhausted and feeling very negative. Suzanne came and gave me about an hour of shiatsu and I was able to reconnect once more with the calm meditative space and be more aware of my body. When Suzanne worked the labour focus points I could feel that I was beginning to contract. My partner also managed to have a rest.
No one believed I was having contractions and so I was put on a drip which made the contractions even stronger. I managed to get them to check my blood pressure before giving me drugs to lower it and to everyone’s astonishment it had gone down after the shiatsu. As the contractions got more intense I felt scared but Suzanne helped me to focus and kept reminding me of my body. I managed to avoid having an epidural and things progressed quickly and I wanted to bear down. The midwife wanted to catheterise me as my bladder was full and give me drugs for third stage, but I did not want any more intervention. Suzanne explained the reasons so I did not resist. My daughter was born soon after with no other interventions.
I am sure I would have ended up with an emergency caesarean if Suzanne had not been there. I felt supported by her calm presence. She helped me stay with myself but also encouraged me to work with the medical team who were supporting me. It felt good that there was no conflict between those who were caring for me.
Suzanne
My main focus in pregnancy was to:
• Support Kidney function with energy work.
• Help C. stay connected with her feelings.
• Support the positive aspects of the pregnancy, especially her connection to her baby.
• Give C. support while she was going through tests.
• Create a supportive space in the hospital environment.
In labour:
I worked to keep her in tune with what she needed to do and support the positive aspects of birth and her connection with her body.
I see my main focus of work in labour to support someone to be in the moment with their body and not worry about what might happen. That is a luxury of being a bodyworker rather than a primary care provider. They have to try to predict what may happen and also deal with complications. I have immense respect for that. It was an amazing process to support C. through many months of stress and uncertainty to reach 36 weeks of gestation and deliver her baby vaginally. Sadly now her kidney function has degenerated more and she is on the list for a kidney transplant. She has found the first year of being a mum with a serious medical condition quite draining but has appreciated the support of her medical carers and bodywork therapy.
14.2. Medical conditions existing prior to pregnancy
• Pre-existing hypertension, gestational hypertension and pre-eclampsia.
• Pre-existing heart or kidney disease.
• Diabetes.
• Thyroid problems.
• Endometriosis.
• Immune system disease: e.g. fibromyalgia, lupus.
• Reproductive tract anomalies.
• Sexually transmitted diseases.
• Genetic factors.
• Other diseases.
The conditions listed above may or may not cause additional complications.
Heart or kidney conditions
These two systems are significantly challenged by the increased demands of pregnancy and, depending on the type and severity of the condition, there is an increased risk of complications. Bodywork may be completely contraindicated, or reduced with respect to the length of time of the treatment, the intensity or vigour of the work, and the position of the client.
Heart conditions
The primary care provider may prohibit the inclusion of any bodywork if there is any risk of overload to an already compromised cardiovascular system as in cases of unstable hypertension or thrombosis or imminent risk. Technique approach is soothing in nature. Energy approaches aim toward supporting the Conception Vessel, Heart, Heart Protector and Penetrating Vessel.
Kidney conditions
The woman is at increased risk of developing hypertension, including eclampsia and associated issues. Energy work, if appropriate, would focus on the Kidney and Extraordinary Vessels.
Effects on labour
Both the heart and kidney have extra demands placed on them during labour and a compromised heart or kidney may be especially challenged. Renal issues are associated with a risk of pre-term labour.
The type of delivery is determined by the primary care provider but vaginal delivery is generally considered preferable as it causes less haemodynamic fluctuation than a caesarean section (Gilbert & Harmon 1993). It is also advised that the second stage of labour be kept as short as possible to avoid excessive stress.
Implications for bodywork postnatally of heart conditions
Due to the strain of labour and early postnatal circulatory changes, heart failure may occur in the first few days postnatally. These clients are usually kept in the hospital after delivery for observation or treatment. They may be on orders for increased rest. Modified activity is usually advocated in order to prevent increased risk of onset of circulatory issues such as the formation of thromboembolic disorders.
There is no contraindication to breastfeeding; however, consultation would be made with the primary care provider in the event that the client is taking particular medications.
Bodywork, especially if it includes gentle leg work and mobilisation of the legs, may help to reduce the risk of thromboembolic disorders.
Postnatal kidney implications
The kidneys may be strained after the delivery, resulting in altered blood pressure (either higher or lower). Medications may be prescribed to normalise blood pressure. Energy work to GV, CV and KD may help support the normalisation of blood pressure and kidney function. Studies related to massage therapy and its effect on blood pressure are still preliminary.
Diabetes
The pregnant diabetic woman
Women who have diabetes and are considering becoming pregnant are advised to consult their primary care provider or specialist before becoming pregnant. Blood glucose levels should be stabilised before pregnancy as unstable levels during embryologic development may increase the risk of congenital anomalies.
Pregnant diabetic women experience an increase in insulin requirements by the end of pregnancy and may need up to four times their usual dose of insulin. Women with type II diabetes may require insulin during their pregnancy. Insulin requirements return to normal after delivery. During pregnancy, insulin levels become less stable and this may exacerbate some of the existing complications. There is an increased risk of pre-eclampsia, polyhydramnios, pre-term labour, fetal macrosomia (large baby) and fetal malformations, especially cardiac anomalies (Landon 1999). However, regular monitoring has proved successful in achieving good control.
Implications for bodywork
Refer to GDM (p. 381).
Thyroid issues
These may be exacerbated or improved by the changes in the endocrine system. Depending on the symptom presentation, therapists may need to adapt their bodywork or work. Energy work would include Extraordinary Vessel work.
Endometriosis
This is likely to be a cause of infertility, ectopic pregnancy and miscarriage, due to the presence of endometrial tissue outside the uterine cavity. Energy work can be done to support the Extraordinary Vessels and Spleen, Liver and Kidney.
Autoimmune disease
This may be related to the immune mechanism involved – if the disorder involves alterations in T h1 responses which decrease in pregnancy or T h2 responses which increase (Formby 1995).
Rheumatoid arthritis
Around 77% of women with rheumatoid arthritis (which is associated with increased T h1 mediators which are decreased in pregnancy) experience improvement, generally beginning in the first trimester; 90% relapse between 6 weeks and 6 months after delivery (Formby 1995, Buyon 1998).
Systemic lupus erythematosus (SLE/lupus)
Lupus may be related to an increased incidence of miscarriage. It is often exacerbated, especially in women with renal involvement or active SLE at the time of conception. SLE involves the production of auto-antibodies of the IgC class and increases in T h2 mediators which are increased in pregnancy. Women with SLE who have anticardiolipin antibodies or lupus anticoagulant antibodies have an increased risk of thrombosis, fetal loss and thrombocytopenia (Tseng & Buyon 1997).
Fibromyalgia
Fibromyalgia is a chronic condition which can affect the autoimmune and musculoskeletal system. It may improve or worsen during pregnancy. Massage therapy can be an effective treatment for easing symptoms of pain and chronic fatigue. Depth of pressure can vary significantly and relates to the client’s previous experience with massage therapy. Feedback from the client is crucial to ensure improvement rather than exacerbation of musculoskeletal symptoms.
Overexertion can exacerbate symptoms, so good communication is important. Prenatal preparation taking into consideration the pregnant woman’s stamina will help ensure an appropriate labouring process.
In the postnatal period, the mother may experience a worsening of her symptoms, and with increased demands postnatally, she may feel additionally tired.
Energy work will include Extraordinary Vessel and Spleen work.
Reproductive tract abnormalities
Approximately 3% of women have a developmental anomaly of the genital tract (Llewellyn-Jones 1990). Examples of such conditions are: double uterus (with or without a double cervix and vagina), bicornuate uterus or septate uterus and/or abnormalities of genital tract, cervix, vagina, malformation of the kidney and ureters (Rabinerson et al 1992, Tindall 1987).
A uterine malformation increases the risk of fetal malpresentation, spontaneous abortion and pre-term labour by four times (Llewellyn-Jones 1990). Some malformations may cause complications in labour.
Cervical incompetence is also common. The use of ultrasound scanning will usually reveal a uterine abnormality. However, if the cervix and vagina are structurally normal, the woman is usually fertile.
Women may also have displacements of the uterus, such as retroverted uterus or prolapsed uterus, which may cause complications. These may be indicated by severe abdominal pain.
Implications for bodywork
• Clients who have a history of miscarriage or pre-term labour may have structural abnormalities of the uterus.
• A less optimal position of a fetus may be due to a malformation of the uterus. Bodywork by a therapist with a goal to encourage optimal fetal positioning would not only be ineffective in changing fetal position but could cause increased risk of harm.
• Fetal positioning at term may affect the progress of labour and determine mode of delivery.
• The therapist needs to be cautious with abdominal work as there is an increased risk of other complications.
• Energy work may include supporting the Extraordinary Vessel energy, especially CV, GV and PV.
Fibroids and cysts
About 5 per 2000 Caucasian women have fibroids (Lewis & Chamberlain 1990), although the number varies among population groups and the incidence is higher in older women. Most fibroids cause little problem apart from pain and tenderness but sometimes they may prevent the descent of the fetus into the pelvis or obstruct labour. With the changes to the endocrine system during pregnancy, fibroids may either increase or decrease in size.
Cysts are less common (1 in 1000). They may obstruct labour if left untreated.
Cysts and fibroids are considered a result of Liver Qi stagnation which could be addressed from the second trimester once the pregnancy has become established.
Cervical incompetence
Cervical incompetence is loss of sphincter control resulting in dilatation or opening of the cervix. Rechberger describes an incompetent cervix as containing more smooth muscle than a normal cervix (Gilbert & Harmon 1993). ‘It is usually caused by one of three factors a congenital defect, cervical trauma, or hormonal factors.’ (Parisi 1988). It may cause miscarriage, usually in the second trimester, and is the cause of 15–20% of pregnancy losses as well as premature labour. There may be no warning signs of early dilatation in the second trimester and the diagnosis and treatment is given for subsequent pregnancies.
Treatment is to surgically insert a stitch or suture around the cervix – ‘cervical cerclage’. Timing varies according to clinical practice with some clinicians believing that early insertion may prevent the miscarriage of an abnormal pregnancy. Risks include increased infection, rupture of the membranes, or onset of premature labour at the time of insertion. Research on the benefits is inconclusive and its use varies; it is not commonly performed in the UK, but is quite common in Canada, France and other European countries. The stitch may be removed in the last few weeks of pregnancy so that spontaneous labour can occur, or may be left in and a caesarean section performed.
Bodywork implications
Pregnancy
• Be alert to any signs of premature labour and refer immediately.
• Techniques utilising deep abdominal strokes, especially downward strokes, should be avoided.
• The woman may be placed on bedrest to diminish activity levels and prevent the weight of the gravid uterus from increasing downward pressure on the cervix. This may occur temporarily in the event of the insertion of a cerclage, or longer term depending on the client’s history.
• Exercises such as squats which increase intra-abdominal pressure or downward pressure which could affect the cervix are contraindicated. This may include modifications to pelvic floor exercises.
• Visualisations to focus on drawing up and holding in may be appropriate.
• Cervical incompetence is a sign of weak Spleen energy and energy work would have a focus of drawing energy up and strengthening the cervix.
Postnatally
Depending on mode of delivery, bodywork to help strengthen the abdominal muscles and pelvic floor may be appropriate. The emphasis of energy work would be work with Spleen and the Extraordinary Vessels, especially Girdle Vessel.
Sexually transmitted infections
Women who are considering becoming pregnant, or who are pregnant, may have a range of optional or mandatory tests which indicate the presence of sexually transmitted infections. Choosing to have such tests done, and/or awaiting results, may create stress for women.
Positive test results may have an impact not only on the woman but on her baby as well. Treatment options and delivery choices may both be affected by the presence of sexually transmitted infections.
Bodywork should not be done in the presence of an active infection and/or fever.
The presence of HIV raises issues regarding treatment possibilities, the type of delivery most suitable for the woman and her baby, and whether breastfeeding is an appropriate form of feeding for the baby.
The therapist needs to be aware of the emotional impact on the client, as well as the possibility that they may have challenging decisions to make. Universal Standards of Infection Control must be applied, especially in the presence of bodily fluids during delivery or during breastfeeding.
Female genital circumcision
Circumcision is still relatively common among some groups of African women (especially women from Nigeria, Ethiopia, Sudan and Egypt). Because of the large immigrant populations in most western countries and the fact that some bodyworkers may be working on the African continent, it is wise to be aware of the implications of this procedure, both emotionally and physically.
There are three main types of circumcision:
1. Simple excision of the clitoral hood and suturing of the labia majora.
2. Removal of the clitoris (clitoridectomy).
3. Infibulation or pharonic circumcision.
The third type is the most extensive and similar to a vulvectomy. The clitoris, labia minora and most of the labia majora are removed and the labial remnants are closed together, leaving a small orifice near the fourchette which allows the escape of urine and menstrual blood.
Although these practices are illegal in many western countries, including the UK and Canada/USA, they are often carried out by a traditional birth attendant illegally or young girls may be sent back to their country of origin for the circumcision. Types 1 and 2 present fewer complications, particularly for the maternity period; however, type 3 may cause major issues. The procedure itself carries a high risk of mortality from haemorrhage and sepsis. Lifelong morbidity from urinary infection, pelvic inflammatory disease, endometriosis and renal damage is common. Cervical smears cannot be obtained and psychological trauma and marital disharmony are common (Jordan 1994).
In pregnancy urinary tract infection is more likely. During labour, progress cannot be assessed by vaginal examination and second stage labour may be prolonged because of the rigidity of the scar tissue. This may result in fetal hypoxia and brain damage (Thompson 1989). An episiotomy may be needed. If the perineum is not meticulously repaired then faecal incontinence may result, there is likely to be severe damage to the pelvic floor and uterine prolapse is not uncommon. The caregiver must not repair the labia to restore the infibulated state, which is illegal, although they may face pressure from relatives to do so.
14.3. Issues arising during pregnancy
• Hyperemesis gravidarum.
• Hypertensive disorders of pregnancy:
• Gestational hypertension.
• Pre-eclampsia.
• Haemolysis, elevated liver enzymes and low platelet count (HELLP).
• Issues with the placenta;
• Placenta praevia.
• Abruptio placentae.
• Coagulation disorders in pregnancy:
• Disseminated intravascular coagulation (DIC).
• Venous thromboembolism (VTE)/thromboembolic disorders (TED).
• Diabetes.
• Gestational diabetes mellitus (GDM).
• Poly-/oligohydramnios.
• Rho (D) isoimmunisation and ABO incompatibility.
• Infections during pregnancy.
• Renal and bladder conditions.
• Cholelithiasis (gallstones).
• Chromosomal and developmental abnormalities of the fetus.
Hyperemesis gravidarum
This is severe nausea and vomiting, which may be accompanied by ptyalism (excessive salivation) and is pathological. Its exact cause is unclear although it is thought to be related to the endocrine and hormonal changes of pregnancy. The client can become dehydrated and, more seriously, suffer electrolyte disturbances, ketosis and weight loss. Hospitalisation may be necessary if the woman is unable to retain fluids and nutrition and needs to receive them intravenously; otherwise, her condition could deteriorate resulting in liver and renal damage.
It is more likely to occur during the first trimester, although for some women it remains an issue throughout the pregnancy.
Implications for bodywork
• Energy-based techniques could be utilised, especially those that affect PV, SP, ST and LV, or reflex zones.
• A small study of 10 hospitalised women considered the effect of tactile massage for severe nausea and vomiting during pregnancy. After treatments were administered, an open interview was done with subjects commenting that the massage ‘helped women obtain a relieving moment of rest access to the whole body when nausea rules life, promoted relaxation, and gave the subject an opportunity to regain access to her body’ (Agren & Berg 2006).
Hypertensive disorders of pregnancy
The hypotensive client
Some women have reduced blood pressure, in the region of 110 over 60, throughout their pregnancy. There are no specific bodywork precautions for women with lower blood pressure except to ensure that they get off the table slowly in order to prevent light-headedness or dizziness from occurring. However, extremely low blood pressure may be linked with issues of placental abruption.
Energetic work to the Governing Vessel can be done with focus to GV 20 and an aim to draw energy upwards.
The hypertensive client
Terminology describing hypertensive orders varies within the medical community. The guidelines of the Journal of Gynaecologists of Canada are used in this text (Magee et al 2008).
Hypertension can be classified as chronic or existing prior to pregnancy, or may develop within pregnancy or the postpartum.
Gestational hypertension
Gestational hypertension is a diastolic blood pressure (dBP) equal to or greater than 90 mmHg based on at least two measurements, taken using the same arm. Above this level perinatal morbidity is increased in non-proteinuric hypertension.
While dBP is considered a better predictor of adverse pregnancy outcomes than systolic blood pressure (sBP), women with a systolic BP greater than or equal to 140 mmHg ‘should be followed closely for development of diastolic hypertension’.
The onset of gestational hypertension usually occurs at or after 20 weeks.
Pregnancy-induced hypertension (PIH) is frequently referred to in the literature. However, the SOGC guidelines advise against using this term because ‘its meaning in clinical practice is unclear’ (Magee et al 2008).
Women with gestational hypertension of onset before 34 weeks are more likely to develop pre-eclampsia, with rates of about 35%, and the associated risks of serious maternal (2%) and perinatal complications (16%) are high.
Pre-eclampsia
Pre-eclampsia is a multi-system disorder that complicates 3–5% of all pregnancies. It usually arises after 32 weeks but may occur as early as 20–24 weeks (Dietl 2000, Higgins & de Swiet 2001).
The SOGC guidelines define pre-eclampsia as ‘a hypertensive disorder most commonly defined by new-onset proteinuria, and potentially, other end-organ dysfunction’.
Oedema used to be included as one sign of pre-eclampsia but now is considered a feature of normal pregnancy, although it is a different type of oedema when linked with pre-eclampsia. Weight gain is also not included in the definition of pre-eclampsia.
Pre-eclampsia may develop into eclampsia. However, with adequate monitoring and treatment it rarely reaches this level of severity. Once an initial assessment has been made, through elevated blood pressure and proteinuria, further tests are undertaken to assess renal function, thrombocytopenia and liver enzymes.
Eclampsia is assessed with extreme oedema occurring throughout the body including the face, eyelids and neck and onset of headaches, visual disturbances, followed by seizures. The onset of convulsions (although in 38% cases there were no signs of pre-eclampsia) in the UK occurs about once in every 2000 births and represents severe risks to mother and fetus. Of these, 1 in 50 women died and 1 in 14 babies also died (Douglas & Redman 1994).
Eclampsia is characterised by decreased perfusion to all organ systems secondary to vasospasm (narrowing of the blood vessels). There is arteriolar vasoconstriction and disseminated intravascular coagulation (DIC). The effects are seen in the kidney, liver and placental bed. Other features of PET may include central nervous system irritability and at times coagulation or liver function abnormalities.
Past medical history
• Previous pre-eclampsia.
• Pre-existing medical conditions such as hypertension, diabetes, or renal disease.
• Family history of pre-eclampsia (mother, sister, grandmother).
• Obesity (30% body mass index (BMI)).
• History of autoimmune disorders such as lupus, rheumatoid arthritis or multiple sclerosis.
Current pregnancy
• Multiple pregnancy.
• First pregnancy.
• Inter-pregnancy interval greater than or equal to 10 years.
• Booking sBP greater than or equal to 130 mmHg.
• Booking dBP greater than or equal to 80 mmHg.
• Polycystic ovarian syndrome.
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