Positive Health Online

Abstract

Many complementary practitioners treat pregnant clients, although others lack the confidence to do so competently. Acquiring a deeper understanding of pregnancy physiology and potential pathology can increase professional confidence and ensure that treatment is safe and appropriate for each individual. This paper explains some of the possible complications which may occur during pregnancy and the implications for complementary therapy practice.

Key words: pregnancy, physiology, complications, safe practice

Introduction

Pregnancy is a natural life event which, for most women, is completely normal, with few complications. However, pregnancy is also a period of immense change, encompassing numerous physical discomforts and emotional and social adaptations. Whilst most changes are normal, women often find them difficult to cope with, especially if they have to deal with the demands of work or young children. Increasingly, pregnant women turn to complementary therapies (CTs) for relaxation, stress relief and treatment of specific pregnancy discomforts.

The role and responsibilities of therapists treating pregnant women have been discussed earlier, including legal obligations, record keeping, inter-professional communication and educational requirements (Positive Health PH Online Issue 165, December 2009).  For appropriately trained practitioners who fully understand pregnancy physiology, and can adequately relate this to their particular therapy, working with expectant mothers can be wonderfully fulfilling. Gaining additional training and appropriate experience, perhaps with the support of a midwifery mentor (see www.expectancy.co.uk), enables practitioners to extend their practice beyond basic pscyho-emotional relaxation, to using CTs as a set of additional tools to help women cope with the physical adaptations. However, it is important to distinguish between those symptoms which are a normal physiological part of a particular stage of pregnancy, albeit distressing for the mother, and those which are developing into pathological conditions for which medical management may be required. Of course, the principle rule must be that, if there is any doubt in the practitioner's mind about the justification for a treatment on any given day, therapy should be withheld until midwifery advice has been sought.

General Assessment of the Mother

If the expectant mother is well, there is usually no reason why she should not receive CTs, although pregnant women with epilepsy, cardiac conditions or blood-clotting problems should not be treated at all, since these conditions become very unstable during pregnancy and may adversely affect either the mother or baby. Women with conditions which are affected by, or which impact on, the pregnancy, such as diabetes, thyroid problems, renal disease or major respiratory conditions should only be treated with permission from the mother's midwife. This also applies to women with specific obstetric conditions, for example, women carrying more than one baby or who are in their fifth or subsequent pregnancy (because of the increased risk of miscarriage or premature labour), as well as those with a history of vaginal bleeding, premature labour or hypertension in previous pregnancies.

At each appointment, the practitioner should assess the mother's condition to ensure that it is appropriate to treat her on this occasion. If the mother has had any vaginal bleeding since the last appointment, treatment should be postponed until the cause has been established and the bleeding has subsided. Indeed, if the mother has not sought midwifery advice, she should be urged to do so at the earliest opportunity. Any unusual symptoms, such as abdominal pain, headache, or other discomforts of unknown cause, should alert the therapist to possible complications.

There is, in most therapists, an innate desire to do something for their clients, but it is important to remember that this sometimes means doing nothing, at least in terms of the CTs treatment. However, simply by 'being there', perhaps having a chat over a cup of tea, or performing a basic hand massage with carrier oil only,  so that the mother can discuss her worries, may be as effective a relaxation strategy as receiving more dynamic manual therapies. The practitioner might wish to agree a contract with the mother at the start of a course of treatment, to account for the possibility that she may be unable to attend on some occasions. Will the mother be expected to pay a cancellation fee, or will the therapist absorb the lost income in some way other than charging the mother? Non-attendance at appointments during pregnancy (for any reason) can be a real issue, not least because many pregnant women become very forgetful!         

Sickness

'Morning sickness' is the earliest and most common physiological symptom of pregnancy, affecting up to 90% of women, usually, but not exclusively in the first trimester. The cause is primarily hormonal, but tiredness, anxiety, infections, musculoskeletal misalignments and a lowered immune system may contribute to the problem (see Tiran 2004). It is usually the constant nausea, rather than the vomiting, which is the most depressing and wearing aspect, but associated symptoms such as headache, constipation, excessive salivation and heartburn can exacerbate the condition, as will multiple pregnancy.

Many women mistakenly believe that ginger is an effective remedy for pregnancy sickness. However, ginger is not always appropriate or safe, since it may increase nausea and heartburn and thin the blood, increasing the risk of bleeding (see Tiran 2004). Other self-help remedies include acupressure wrist bands, which have been shown to be very effective when used correctly (Can Gürklan and Arslan 2008), a DVD programme which applies unheard pulsations to rebalance the balancing mechanism in the ear, and homeopathic remedies, although these are best prescribed individually by a qualified homeopath.

Some women do not wish to be touched at this time, so massage, reflexology and aromatherapy may need to be adapted. The sense of smell changes dramatically in many women, so essential oils may not be appropriate and should, in any case, be used with caution especially in the first trimester. If the mother opts to consult an acupuncturist, nutrition therapist, homeopath or osteopath, she should be advised to check whether it is acceptable to receive relaxation therapies concurrently, since there is a possibility of interactions between therapies, which may complicate the symptom picture.

Nausea and vomiting usually subside to manageable levels by the second trimester, once the hormones have settled, but in some cases, symptoms persist beyond this, occasionally only being relieved once the baby is born. It is important not to give false hope that everything will miraculously resolve at 12 weeks' gestation, but rather to support the woman through the worst of the problem.  In practice, it is unlikely that the mother will attend for CTs if she feels seriously unwell, but therapists should be alert to any significant deterioration in the mother's condition and advise her to seek early medical treatment via her midwife. Approximately 2% of women progress to a more serious condition, hyperemesis gravidarum – excessive vomiting of pregnancy – in which dehydration and ketosis require hospitalization and intravenous fluid replacement.

Vaginal Bleeding

Bleeding from the vagina should be considered abnormal at any time during pregnancy. Bleeding in early pregnancy is classed as a threatened miscarriage, which may progress to an actual miscarriage. However, some women experience a very small amount of bleeding at the time when they would have had a period if they had not become pregnant - this is called implantation bleeding and can occur at monthly intervals for the first few months. It should not last for more than about half a day and is not normally bright red, but rather brownish in colour.

In the second half of pregnancy, vaginal bleeding most commonly occurs as a result of two problems with the placenta. First, if the placenta is situated high in the uterus (normal), partial separation due to high blood pressure, or as a result of trauma such as a car accident, will cause painful vaginal bleeding. The amount of visible blood may be minimal and may not reflect the degree of shock or pain which the mother exhibits. The second type of bleeding occurs when the placenta is situated low down in the uterus (placenta praevia), possibly even across the cervix. In late pregnancy, when the cervix softens in preparation for labour, a small amount of the placenta may separate; this causes a bright red, painless haemorrhage which can be fatal to both mother and baby and which requires immediate medical attention.  In either case, the mother should seek help from her midwife and CTs should be withheld until the bleeding has completely stopped.

Other causes of bleeding include cervical polyps which can become 'angry' during pregnancy and lead to frequent vaginal losses of red-tinged discharge, or prolapsed haemorrhoids (piles) which bleed after defecation and which the mother can sometimes mistake for vaginal bleeding. Generally, it is acceptable to treat the mother if she has either of these conditions, but if there is any exacerbation of symptoms, she should consult her midwife.

Backache

Backache, sciatica and groin or symphysis pubis pain are normal during late pregnancy, because the hormones relax the joints, ligaments and muscles of the bony pelvis in readiness for the birth. In severe cases the mother may have difficulty in walking, sitting, lying and moving; this seriously affects her daily life. Many women are referred for physiotherapy in the maternity unit, but shortage of staff often means the mother has a long wait for treatment; it may therefore be useful to refer her for osteopathy, chiropractic or acupuncture, which are some of the most effective therapies for dealing with these problems (Khorsan et al 2009).

Massage, aromatherapy and reflexology may aid relaxation, indirectly facilitating the mother's coping abilities. Care should be taken with massage around the sacrum and in the 'dimples' either side of the spine, where there are acupuncture points which can prematurely stimulate contractions; deep massage of these areas should be avoided in women who have a history of threatened premature labour. Massage is only a temporary relief of muscular pain and will not treat the hormonal or skeletal causes of the problem. Reflex zone therapy can be a more effective treatment, but general reflexology practitioners should take care with very dynamic manipulative techniques on the feet, unless they are experienced in treating pregnant women with these symptoms (see Tiran 2010).

Occasionally backache develops for reasons other than physiological musculoskeletal factors. Low spasmodic backache can be a symptom of early labour, but before 37 weeks this would be premature. The therapist can enquire about other symptoms such as diarrhoea, breaking of the waters, usually resulting in leaking of fluid from the vagina, or a 'show' (a thick heavy vaginal loss tinged with blood, which occurs when the mucus plus in the cervix is passed out). Backache can also indicate a urinary tract infection, which if left untreated can lead to serious kidney infection and/or premature birth. Cystitis and urinary infections are common in pregnancy because the hormone progesterone relaxes the ureters, resulting in pooling of urine along the tubes. If the mother complains of a burning sensation on passing urine, an increased need to urinate (different from normal pregnancy frequency of micturition) or reports an unusual odour or appearance of the urine, she should see her midwife. Antibiotics can be prescribed and the infection usually resolves quickly. Backache can also sometimes accompany constipation, which although not a medical problem, can be very uncomfortable. Enquiring about her bowel habits, encouraging her to drink as much water as possible and to eat a high fibre diet can stimulate the intestines to work more efficiently, and the backache should ease spontaneously.

Headaches

Headaches in early pregnancy are normal, and are caused by the relaxation of the cerebral blood vessels by progesterone. Anxiety, tiredness or other symptoms such as nausea increase the severity and frequency of headaches. Although drugs are generally contraindicated, an occasional dose of paracetamol (maximum two tablets, four hourly) is acceptable. However if the mother is requiring medication over a prolonged period of time she should seek medical help. Osteopathy, chiropractic, acupuncture and reflexology can keep the discomfort at a manageable level, and aspects of other therapies can ease current symptoms, for example homeopathic remedies, shiatsu, head massage and aromatherapy (using oils which are acceptable in pregnancy such as peppermint or citrus oils).

Headaches which occur in later pregnancy are more likely to herald a complication - notably hypertension. Some women have high blood pressure before conceiving, others develop it during pregnancy, which may progress to pre-eclampsia, a condition characterized by hypertension, oedema and protein in the urine in the early stages. As it worsens, the mother begins to feel unwell, mostly as a result of internal oedema - headaches, visual disturbance and nausea from swelling around the brain, and epigastric pain and reduced urinary output from abdominal oedema. If left untreated, epileptic-type fits occur, which can be fatal to mother and baby. If a mother arrives in your treatment room and feel significantly more unwell than she has done previously, you should be alerted to pre-eclampsia, especially if she shows signs of excessive swelling - legs, face, fingers, sacrum etc. She should be transferred to the maternity unit for assessment without fail. 

Multiple Pregnancy

Expecting twins is not, in itself, a medical problem, but a multiple pregnancy places extra strain on the mother's body and there is an increased risk of complications developing. If the mother is expecting triplets or quadruplets (or even more!) pregnancy is deemed to be medically complicated and it is unlikely that the mother will attend for CTs in your private practice.

Women with twins experience all the pregnancy symptoms more significantly than with pregnancies where there is only one foetus, and they can more easily progress to medical complications. Nausea, headache, backache, sciatica, symphysis pubis pain, carpal tunnel syndrome, constipation, varicose veins, haemorrhoids, heartburn and other symptoms can become a real problem, and the therapist may be in an invaluable position to help reduce these physiological symptoms. It is not the purpose of this paper to discuss how women can be treated with each of the different therapies, and it is the responsibility of each practitioner to obtain adequate training to understand how multiple pregnancy can exacerbate these conditions so that they can work effectively and safely.

Diabetes Mellitus

As with many medical problems, pregnancy can affect the stability of diabetes, or the condition may have an adverse effect on the progress of the pregnancy or on the health of the mother or baby. Women with pre-existing diabetes are at risk of complications in pregnancy, including increased chance of miscarriage, premature labour and Caesarean section, whilst the babies may develop abnormally or be very large and prone to sugar imbalances after birth. Women may already have diabetes when they become pregnant, or they may develop a temporary pregnancy-induced diabetes. Some women with diabetes in pregnancy may be able to control their sugar levels with dietary measures, whilst others will require insulin injections. Women who do not require insulin to control the disease may receive CTs with caution. It may be wise to advise them to have a carbohydrate snack before their treatment, or for you to have dry biscuits available in case the mother becomes hypoglycaemic during the appointment.  Therapies such as reflexology may precipitate hypoglycaemia if there is over-zealous stimulation of the abdominal reflex zones overlying the zone for the pancreas, whilst treatments which are prolonged may inadvertently adversely affect the mother who needs to eat regularly to maintain her energy / sugar balance.

Women who are insulin dependent should not be treated with CTs unless the practitioner is very experienced at treating pregnant women with diabetes. The very fact of requiring insulin indicates that the diabetic state is unstable, and unknown factors could precipitate a major diabetic crisis in some women. It is vital to understand both the disease process of diabetes in general and in pregnancy in particular, as well as the impact of individual therapies on the condition.

Onset of Labour

Normal labour occurs any time after 37 completed weeks of pregnancy, up to about 42 or even 43 weeks; before 37 weeks labour is premature and the baby may not be capable of living independently from the mother. Labour is a combination of uterine contractions, cervical dilatation and descent of the baby, and may be preceded by breaking of the bag of waters which surrounds the baby, a 'show' of mucus, slightly reduced foetal movements, diarrhoea or a mad desire to clean everything in preparation for the baby's arrival. Therapists intending to specialize in treating pregnant women would be wise to undertake training which equips them to deliver a baby in an emergency.

Giving birth is a spontaneous and natural event, and labour is dependent on a variety of factors, including maternal hormones, foetal hormones and neurological effects. It is therefore inappropriate to interfere in this process. Many women become fed up towards the end of pregnancy and want to have their baby as soon as possible, but induction is a medical procedure undertaken for specific medical reasons. Using CTs to try to stimulate contractions is as much an intervention as a medical induction, and should only be done if the mother is past her due date and is being advised to have the labour induced in hospital. Interfering inappropriately can, in some cases, lead to a cascade of complications which can be traumatic and life-threatening. However, massage, aromatherapy, reflexology, acupuncture etc can be useful in relaxing the mother whilst she waits to start labour. Relaxation reduces the stress hormone, cortisol, thus enabling the labour hormone, oxytocin, to increase to facilitate normal progress of labour.

Conclusion

This paper can, of necessity, provide only a brief overview of some of the many physiological and pathological conditions which occur in pregnancy. The message for therapists is the need for comprehensive ongoing education to ensure that they understand the symptoms and conditions and how their therapies relate to normal pregnancy and antenatal complications. In any situation where the therapist is unsure, treatment should be withheld until there has been discussion with the mother's midwife. The health and wellbeing of the mother and baby are paramount; being cautious is a far more professional way of ensuring long-term wellbeing, rather than attempting to please the mother in the short term by providing treatment when it is inappropriate.

References

Can Gürkan O, Arslan H.  Effect of acupressure on nausea and vomiting during pregnancy Complement Ther Clin Pract. 14(1): 46-52. 2008.
Khorsan R, Hawk C, Lisi AJ and Kizhakkeveettil A.  Manipulative therapy for pregnancy and related conditions: a systematic review. Obstet Gynecol Surv. 64(6): 416-27. 2009.
Tiran D. Nausea and vomiting in pregnancy: an integrated approach to care. Elsevier Edinburgh. 2004.
Tiran D. Reflexology for Pregnancy Elsevier Edinburgh. 2010.

Further Reading

Medforth J et al 2006 Oxford Handbook of Midwifery Oxford University Press Oxford
Tiran D 2007 Bailliere's Midwives' Dictionary Elsevier Edinburgh  
Tiran D 2010 Teach Yourself: Have a happy pregnancy Hodder Headline London

Further Information

Further references, research abstracts and information about complementary therapies in pregnancy and an online mentoring system for therapists treating pregnant clients is available via www.expectancy.co.uk  

Expectancy provides accredited education for therapists on pregnancy, childbirth, infertility and the safety of complementary therapies in maternity care. The Caring for Pregnant Clients course, Maternity Support Therapist programme and the Certificate in Maternity Complementary Therapies offer possible career pathway options for those wishing to specialize in maternity work. There are also therapy-specific pregnancy courses shared with midwives, e.g. Aromatherapy, Reflexology, Hypnosis, Herbal Medicines etc. See  www.expectancy.co.uk