Many massage therapists are confused and uncertain about the appropriateness of accepting pregnant clients who are in high-risk pregnancies. Who can be harmed? Can massage therapy and bodywork be useful and beneficial in a high-risk pregnancy? Are there techniques to avoid?

A high-risk pregnancy is one in which the mother or baby has a greater chance of injury or death. About 5-10% of all pregnancies in the U.S. fit in this category.

Prenatal care for women in this situation may include more extensive testing, more frequent prenatal visits, medications, and bed rest.

A woman may be identified as high risk because of her age (under 15 or over 35), family history, medical condition, or complications that develop in her pregnancy. Therapists should include a question about risk status in intake forms for pregnant clients, or in initial phone contacts. If a client indicates that she is considered to be high risk, it is essential to communicate with, and secure a release from, her prenatal health care provider, who will be a doctor, nurse-midwife, or lay midwife. Such a release asks the health care provider to approve massage therapy, and also list any precautions or limitations in massage procedures. I find it easiest to fax a release form to the doctor's office, or ask my client to hand-deliver it on her next prenatal visit.

When working with a high-risk pregnant client, it becomes even more important to observe basic precautions and contraindications for bodywork in pregnancy. Some clients may have been restricted by their health care providers in the positions they are allowed to take. This can include no sitting or prone or supine positioning, or lying on either the left or right sides. When no specific restrictions have been given, side-lying positioning is the safest, offers the greatest comfort, and increases blood flow to the heart. Side-lying is also the most common position a high-risk client on bed rest will be asked to assume.

Therapists should also modify bodywork modalities used on the legs in pregnancy. Fibrinolytic changes in pregnant women's blood makes blood clots more likely to develop. These clots can develop in both superficial and deep veins in the legs, and are not always detected by common tests. Therapists should avoid using techniques that involve deep pressure and friction on the legs. This includes, but is not limited to, deep acupressure, shiatsu, cross-fiber friction, deep tissue massage, and all percussive movement. In addition, all techniques on the legs, except for the lightest effleurage, should be directed toward the heart, since hormonal changes in pregnancy weaken the valves in veins.

Therapists should restrict abdominal massage with high-risk pregnancies to light touch, and should avoid touching the abdomen entirely in the first trimester. Since 80% of miscarriages occur in the first trimester (1-13 weeks), it is wise for a therapist to avoid even the appearance of possible contribution to the loss of a baby.

When a mother knows that her pregnancy is high risk, or develops a complication that puts her in that category, she may experience anxiety, fear, and guilt. This increased stress can further endanger the successful outcome of her pregnancy.

Massage therapy is especially appropriate for the high-risk mother, since it promotes relaxation, reduces anxiety, supports the physiology of the pregnancy, and can relieve the discomfort and muscle strain that develop when a mother is placed on bed rest. Recent research has shown that massage in pregnancy decreases the incidence of prematurity or other complications in labor.

When in doubt about the appropriateness of specific techniques for a high-risk pregnancy, therapists should consult experts in that modality, or err on the side of caution. Observing guidelines on client positioning and use of modalities will enable the therapist to provide the high-risk pregnancy client with a safe, enjoyable, and therapeutic bodywork experience.

There is a need to understand and address the unique health concerns of women. This column will continue to explore issues of particular interest in massage therapy and bodywork for women, including reproductive health, sexuality, body image and eating disorders, pain syndromes, osteoporosis, and aging.