How does pregnancy change a female client’s body?

Kate Jordan responds:

Many therapists see clients who have recently given birth, or who have developed significant musculoskeletal dysfunction from childbearing in the past. When working with postpartum clients, massage therapists should be aware of the physiologic and structural stresses pregnancy, labor and delivery create and how they might manifest.
The hormonal, weight and postural changes of pregnancy can be a cause of permanent postural dysfunction and muscular pain. Your postpartum client may have adapted a kyphotic thoracic spine and a lordotic lumbar spine with an anterior rotation of her pelvis and an increased angulation at the lumbosacral angle.

This can lead to hypertonicity and shortening in the upper abdominals, the lower lumbar extensors, the iliopsoas, piriformus, rectus femoris and hamstrings, with weakening in the scapular adductors, the lower abdominal muscles, the pelvic floor and the gluteals. There is a tendency for these tissues to remain in their new, shortened or stretched states after childbirth, potentially leading to permanent pelvic asymmetry and pubic, lumbar or thoracic problems.

In addition, the pregnancy hormone relaxin leads to laxity in the joint capsules and ligaments that support the joints of the lumbar spine, pelvis and hips. For example, a normal joint space in the pubis symphysis is 4 millimeters. With pregnancy, this increases to 9 millimeters by birth, leading to a less stable joint and greater possibility of injury over time. This ligamentous laxity lasts for six to 12 weeks after birth.

In as many as one out of 600 pregnancies, postpartum dysfunction in the pubis symphysis leads to pain performing simple activities, such as walking, turning over in bed or twisting to get in and out of a car.

Women who spend time on partial or total bed rest for significant portions of their pregnancies may develop neck and shoulder girdle dysfunction as well as lower back and pelvic discomfort, especially resulting from pressure on the subdeltoid bursa in the shoulder or the subtrochanteric bursa of the hip.

The circumstances of a woman’s labor can greatly affect her subsequent quality of life. The positions she assumes during her labor, the length and difficulty of labor, the delivery of a large baby, the use of an epidural anesthetic, vacuum extraction, forceps or gynecologic stirrups can all increase the chances a woman will experience back and pelvic pain afterward.

The pelvic floor musculature is strained during pregnancy in supporting the ever-increasing weight of the enlarging uterus. Additionally, the distension of the perineum at birth can lead to ligamentous and muscular strain around the coccyx and ischium.

If your client recently gave birth by cesarean section (31 percent of all births in the U.S. in 2006), then she will be recovering not just from pregnancy and, perhaps, a trial of labor, but also from a major surgical procedure. She may have developed a spinal headache, and will have a slower recovery from her pregnancy than a vaginal birth mom. If your client had one or more cesarean births in the past, she may have developed significant fascial restrictions in the pelvis and lumbar spine that are currently contributing to low-back or pelvic pain.

The physical demands of caring for a newborn—feeding, diapering, changing, walking and transferring to and from car seats, strollers and beds—can provoke neck, upper back and lumbar muscle and joint strain.

Just as a skilled massage therapist can provide appropriate therapy and emotional support to a pregnant client, in the postpartum period, professional massage therapy can give a new mother the kinds of physical support many traditional societies provide as a matter of course, where daily massage of the new mother’s abdomen, back and legs is common in the first month after childbirth.

If a woman has had no maternal complications, she may receive a postpartum massage as soon after birth as she wishes. Because the veins in the legs don’t return to their pre-pregnancy state for six to eight weeks postpartum, all leg massage should be directed toward the heart, with no deep thumb or finger pressure, especially on the medial side of the leg, to prevent dislodging blood clots (risk for embolism is highest postpartum).

If your client had a cesarean section, unless you’re working in a hospital setting, you probably won’t see her for one to two weeks after her baby is born. Concentrate on gentle, Swedish massage and reflexive strokes that will facilitate her recovery from surgery. Avoid massage of her abdomen until she’s been released by her physician.
Be aware your client may not be comfortable in the prone position on your table because of breast engorgement or incision pain. However, prone positioning will encourage her uterus to reposition itself in the pelvis.

Neuromuscular therapy, focusing on trigger points in affected muscles, and myofascial release directed to areas of fascial restriction are particularly useful for the postpartum client.

If your client reports low-back pain, it may be derived from:
1. The iliopsoas muscle (pain just lateral to the spine, from the lower thoracic to the lumbar and into the pelvis)
2. Quadratus lumborum (pain lateral to the sacroiliac joint, along the crest of the ilium anteriorly to the lower quadrant of the abdomen, into the groin and greater trochantor)

If she has posterior pelvic pain, it may be coming from:
1. Piriformis (pain in the posterior pelvis toward the greater trochantor, which may radiate down the leg)
2. Coccygeous (which can provoke pain in her coccyx, hip or lower back)
3. Obturator internus (which can cause pain deep to the coccyx or in the perineum)

The abdominal muscles and superficial fascia are weakened and stretched immediately after birth. The band of fascia separating the two halves of the rectus abdominus (the linea alba) may have widened from 1 centimeter to as much as 8 centimeters, and should be palpated gently during massage. Tender trigger points in the rectus abdominus and pyramidalis muscles (just above the pubic bone and the lower internal obliques) can lead to bladder spasms of the detrusor muscle and urinary sphincters, causing urinary frequency or retention of urine, and even groin pain.

Your client may have developed neck and upper-back or scapular pain resulting from inappropriate patterns of sitting while nursing or walking her baby, especially if she carries a heavy infant car seat or stroller.
These most-common postpartum musculoskeletal dysfunctions can be treated with trigger point therapy, Strain Counterstrain, muscle energy technique and similar approaches.

When working with any new mother, take the time to hear her birth story; within it are clues to any discomfort or pain she may be experiencing. And whenever a female client presents with abdominal or lower-back or pelvic pain, don’t discount the possibility the dysfunction she is currently experiencing derives from a past pregnancy.

Kate Jordan, Expert Advice: Kate Jordan, MASSAGE MagazineKate Jordan is developer of the Bodywork for the Childbearing Year and SpaMassage for Pregnancy trainings. She is certified in Jones Strain Counterstrain and sees patients at La Jolla Clinic of Integrative Medicine in La Jolla, California.