A baby is born every eight seconds in the U.S. And with each of these eight-second miracles, a new mother is also born.
Ninety-eight percent of American mothers birth in a hospital, so this is the fertile ground where we can begin nurturing our new mothers.
During my 25-year career as a massage therapist and educator, it has been a privilege to help innovative hospitals embrace postnatal massage therapy as an integral part of maternity care.
The Postpartum Timeline
By medical definition, the postpartum period is the six weeks following the birth of a baby or completion of pregnancy through uterine involution–contractions that reduce the remarkable watermelon-size abdominal organ back to a pear-size pelvic organ.
However, many professionals also recognize that the postpartum period, or “fourth trimester,” is not only physical; it’s also emotional, intellectual, relational and spiritual, and lasts well into the first year or beyond.
After all, new mothers hold and carry their babies outside the womb until the babies begin crawling, and ultimately walking, between nine and 17 months of age.
Mothers and massage therapists often ask me how soon after birth a new mother can enjoy a postnatal massage. In the hands of a skilled postnatal massage therapist, the answer is right after birth, whether in the hospital 48 or 72 hours before returning home, in a birth center or at home, and continuing into the early weeks, months and years of motherhood.
Cultural Perspectives
Many cultures around the world practice massage rituals for new mothers to nourish, nurture and revitalize the mother after pregnancy and birth and to help her adjust to the new work of caring for a baby.
Malaysians practice mengurut badan, massaging from head to toe with an herbal oil and a focus on abdominal care, which they believe helps circulation and prevents muscle cramps.
In the Ayurvedic tradition from India, mothers receive daily warm-oil massages from a specially trained woman to soothe mothers’ nerves by calming the excess vata (wind) after birth.
On Africa’s Ivory Coast, female relatives arrive at the new mother’s home, where she is bathed and massaged in a healing shea butter by her own mother.
In Shanghai and Hong Kong, luxury confinement hotels offer affluent women the zuo yuezi experience with medicinal soups from gourmet chefs and on-site spa services with moxibustion and acupressure massages as often as they wish.
In Latin America, a new mother enjoys a 40-day la cuarentena with her belly massaged and wrapped in a faja (cloth sash) to warm the womb, while household responsibilities are delegated to others to guard against future exhaustion-related conditions and illnesses.
One reason these traditions are disappearing is that many new mothers around the world return to work as soon as possible after birth because they have no access to paid maternity leave. Lack of paid maternity leave is an issue in the developing world, but it is also a problem in the U.S. The U.S. is one of the only developed countries that does not provide paid maternity leave for new mothers.
For comparison, in Sweden new mothers and fathers are eligible for 48 weeks paid leave after the birth of a baby. The United Kingdom offers 39 weeks of paid maternity leave, Russia offers 28 weeks, and India and Malaysia both offer new mothers 12 weeks of paid leave.
Also, many of these postnatal massage traditions were lost when births moved from home to hospital. For perspective, in 1900, over 95 percent of U.S. births occurred at home, where the postnatal care rituals of immigrants from around the world were woven into new mothers’ lives.
It is time to bring the benefits of postnatal massage back to our new mothers in the hospital setting, where the majority of U.S. mothers give birth. In my experience, even one 30-minute massage in the hospital following birth has the potential to have a significant, positive impact on the mother’s body, mind and spirit, which can translate positively into her care of her new baby.
Early Postpartum Changes
As mothers care for their new, little human beings, it is normal for them to feel a full spectrum of emotions. While the stereotype is of the euphoric, smiling mother cuddling a quiet, cute newborn, women may also honestly express some ambivalence, doubts, regrets and sadness as they explore the gaps between the new realities of motherhood and their expectations.
New mothers also think about how they will navigate changes in relationship and intimacy with partners, if they have one, as well as changes in self-identity, and new lifestyle.
Bonding with a new baby is an evolving process that usually unfolds over weeks and months, not in a split second immediately after the birth. After a difficult birth or with complications for her baby, women can also feel overwhelm, confusion, sadness, worry and anger.
New mothers experience significant hormonal changes in progesterone, estrogen, prolactin, cortisol, oxytocin, thyroid and vasopressin, shifting all body systems from pregnancy toward mothering and lactation.
Blood-clotting activity remains high, especially after Cesarean birth, tubal ligation or hysterectomy, for up to eight or 10 weeks. This reduces the risk of postpartum hemorrhage, as the placenta’s prior attachment site inside the uterus heals during involution.
Lochia is the normal vaginal discharge that gradually tapers off, ending several weeks after both vaginal and Cesarean births. Diuresis (increased urine output) and diaphoresis (sweating) are normal as the body eliminates pregnancy’s higher fluids levels necessary during pregnancy to grow a baby. Mothers’ abdominal and pelvic organs quickly “go back home” after being slowly displaced by the growing uterus during pregnancy.
Her core, including pelvic floor strength, may feel weak, uncoordinated and uncomfortable from the imbalance between hypertonic back and hip muscles, hypotonic abdominal muscles, including diastasis recti (midline separation of rectus abdominus), pelvic floor tissue inflammation, perineal tears or episiotomy.
Constipation and hemorrhoids are also common.
Breast tenderness and fullness is common as colostrum — baby’s first milk — transitions to more voluminous mature breast milk in the first week. New mothers also often have upper body muscle strain from newborn care.
Listen to What Mothers Want
In hospital-based postnatal massage, mothers often request attention to relieving their muscle tension and pelvic pain lingering from pregnancy, labor and birth. This tension and pain are found most commonly in their jaw, neck, shoulders, arms, back, pelvis and legs.
Trigger points in the abdominal muscles, iliopsoas, quadratus lumborum, spinal erectors, and other pelvic movers require sensitivity with release techniques that promote deep relaxation. Postnatal massage techniques that address pain emanating from sacroiliac, sacrotuberous, sacrospinous ligaments and the pubic symphysis provide additional comfort, especially after vaginal birth, with an attunement to the hormone relaxin’s effects on the new mother’s joints’ connective tissue.
Secondarily, mothers also tend to request focus on relieving the strains of early newborn care on stretched, weak or imbalanced joints and muscles, especially in the neck and pectoral girdle.
In the U.S., approximately 30 percent of women give birth by Cesarean. These mothers often request post-surgical pain reduction and edema relief from administered IV fluids during their births. Swollen hands can make caring for a newborn uncomfortable and difficult, while swollen feet can make walking quite painful.
Benefits to Mother
Recent research on postnatal massage focused on its benefits in reducing postpartum depression. Research also shows us that massage is beneficial for many of the conditions that postpartum women experience, including carpal tunnel syndrome, back pain and post-surgical pain.
Postnatal massage has many other benefits yet to be studied, but women and therapists anecdotally report the following additional postnatal massage benefits:
• Relieves muscle strain from labor and birth and promotes recovery from vaginal and Cesarean birth, including healing of the incision after the skin is healed closed.
• Reduces musculoskeletal, visceral and pelvic pain and promotes structural integrity and reorganization of functional movement patterns.
• Reduces uterine involution after-pains and expedites uterine involution.
• Reduces pain resulting from repetitive newborn care activities and feeding, including carpal tunnel and DeQuervain’s syndrome (radial wrist and thumb pain related to inflammation of abductor pollicis and extensor pollicis brevis tendons).
• Facilitates postpartum emotional, physiological and family adjustment.
• Provides nurturing touch, which can translate into the same nurturing touch and care of the newborn. This may have lasting implications for children’s health and builds a more caring, touch-oriented culture: A new study—the first of its kind in humans—suggests that early postnatal contact has lasting impacts for a child’s biology by changing their DNA.
Using a scientific process called DNA methylation, the researchers were able to see significant differences between children who received high-contact and low-contact at five specific DNA sites.
The children who experienced less physical contact had cells that were less developed than they should have been for a child of that age. (“Epigenetic correlates of neonatal contact in humans,” was published inDevelopment and Psychopathology, Volume 29, Issue 5 (Biological and Behavioral Effects of Early Adversity on Multiple Levels of Development), December 2017, pp. 1517-1538.)
6 Essential Skills for MTs Providing Postpartum Care
When consulting with a hospital that is hiring postnatal massage therapists, I recommend the following competency standards. Therapists must:
1. Understand and articulate the benefits of postpartum massage therapy and the common anatomical, physiological and psychological changes of the early postpartum period using both medical and layman terminology.
2. Offer safe and effective patient positioning protocols immediately after vaginal and Cesarean births in the hospital setting.
3. Offer safe and effective massage therapy techniques that address common concerns of postpartum women immediately after birth while observing precautions and contraindications.
4. Know how to adapt techniques with postpartum medications, including the residual effects of spinal or epidural medication, and IV and oral pain medications.
5. Think critically in developing appropriate plans of care for a spectrum of early postpartum patients that improve patient satisfaction and clinical outcomes.
6. Communicate effectively with patients and medical staff to improve patient care and promote interdisciplinary teamwork.
Be Prepared
Massage therapists working with new mothers in a hospital setting need to be prepared to nonjudgmentally and compassionately serve all their patients, including those who relinquish their babies to social services or adoption agencies; those who identify as LGBTQIA; those who terminate their pregnancies, and those who have unexpected outcomes, as these women also experience a postpartum period.
Pregnancy loss, stillbirth and neonatal deaths are sad, sobering realities. Skilled postnatal massage coupled with a therapist’s active listening go a long way to healing a new mother’s grief and nurture her healing process.
Models of Success
One hospital partnered with a local massage school that offered a postnatal massage elective in their core curriculum. Student interns who completed this elective, as well as requisite health screening and orientation, offered postnatal massage to patients in their hospital beds under the supervision of an on-site instructor supervisor.
There was no cost to patients, and the hospital and massage school shared the cost of instructor supervision. Postnatal massage services were limited to the days that student interns were scheduled.
Another hospital hired massage therapists as independent contractors who completed requisite postnatal massage therapy training, medical screening and hospital orientation. Patients received postnatal massage in their hospital beds and paid out of pocket at the time of the massage.
A third hospital surveyed previous patients, asking them to rate the value of several amenities including postnatal massage, take-home dinner, diaper bag or baby book scrapbooking pages. Participants said they would prefer services that bring value to their lives and would prefer to not have material gifts.
They hired massage therapists as employees who completed requisite postnatal massage therapy training, medical screening and hospital orientation, and the postnatal massage program is in its fifth successful year.
A fourth hospital pioneered postnatal massage for its patients by replacing plastic lawn storks, a steak dinner and package of disposable baby wipes with a complimentary 30-minute postnatal massage for every patient available 365 days every year. In the 1998 three-month pilot program, pre- and post-massage patient surveys showed 100 percent patient satisfaction with their experience, with 70 percent of new mothers having never received a professional massage before.
In the two decades of this successful program, approximately 15,000 new mothers were served. Today, the postnatal massage therapy program has evolved to a collaboration with hospital OB-GYNs who offer their patients a three-pack of both prenatal and postpartum massages, as well as a full menu of services including classes for expectant couples, infant massage and pelvic floor wellness.
For hospitals that provide outpatient massage therapy services, mothers can continue to enjoy postnatal massages after their hospital discharge. Simple additions and flexibility make it easy for mother and baby to continue enjoying the experience together.
In fact, the American College of Obstetrics and Gynecologists’ May 2018 recommendations for Optimizing Postpartum Care include more postpartum contact for new mothers with the physicians — within the first three weeks postpartum followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks with a full assessment of physical, social and psychological well-being.
Physicians have an exquisite opportunity to integrate postnatal massage by a well-trained postnatal massage therapist in these office visits, which can improve visit attendance as well as improve their patients’ postpartum care experience.
Semi-reclined or side lying positions where baby can be held or breastfeed in mother’s arms during the massage, a nearby baby bassinet or baby swing, extra seating for family or friends who may accompany the mother and provide baby care while mom receives her massage nearby, and a diaper-changing area make it a welcoming, family friendly experience.
Benefits to Hospitals
The most compelling reason for hospitals to consider including postnatal massage in their maternity care is their patients’ satisfaction. Also, when birthing women have a positive care experience in a hospital, it positively influences their future health care decisions when choosing a hospital for themselves or their family members.
Each year, hospitals budget for promotional amenities for their obstetric patients as a marketing strategy. Because women of childbearing age make most of the health care decisions for their families, innovative hospitals are looking for evidence-based, value- added amenities that attract new patients and keep their current patients returning.
By offering postnatal massage, hospitals are also meeting Joint Commission (JCAHO) required standards for offering their patients non-pharmacological pain relief options.
Postpartum massage has potential benefits to enhance healing, decrease perception of pain and decrease the amount of pain medication used by mothers during their postpartum hospitalization. This not only enhances more effective patient pain management; it also improves patient clinical outcomes.
Lastly, integrating postnatal massage into the hospital’s care follows patient-centered healthcare trends in offering more evidence-based wellness and preventive therapies as an option for patients.
Michele Kolakowski is passionate about improving maternity care, one pregnancy, birth and new family at a time. She taught maternity and infant massage therapy at Boulder College of Massage Therapy and Cortiva Education for 17 years before joining Carole Osborne’s Pre & Perinatal Massage Therapy instructor team in 2011. Kolakowski owns Sanctuary Healing Arts. She also wrote “This is How to Start a Hospital-Based Massage Program” for MASSAGE Magazine.