During pregnancy, several physiological changes in her circulatory system caution the use of deep massage work. As a way to prevent hemorrhaging during labor, her body increases her coagulating activity (the creation of fibrin) 4-5 times. The potential of developing blood clots is 5-6 times greater than when she is not pregnant. In some cases, these thrombi cause pain, heat, muscle spasms and are symptomatic. However, sometimes the presence of thrombi is asymptomatic: there is no over-riding pain or discomfort. These clots are generally found where the blood is most stagnant - the iliac, femoral and saphenous veins of the legs. Deep massage strokes, ischemic compression (i.e. acupressure, shiatsu), deep vibration, tapotement or friction could dislodge these clots are send them coursing through the circulatory system. The result could be a stroke, or coronary or pulmonary thrombosis.

Another equally important consideration is the increase in interstitial fluid. By the third trimester, the fluid within her tissues can increase as much as 40%. It is no wonder, then, that her legs are tired and sore. But the only way to effectively increase removal of the fluid is through lymphatic drainage technique. This massage technique is light to enhance the lymphatic drainage of the superficial lymph vessels. The direction of this light pressure is always towards the heart and the massage starts at the proximal portion of the leg (knee to hip) to open the channels and then continues from ankle to knee to hip and finally from the feet (distal) up the leg to the hip.

Traditional Swedish massage strokes, or any other deep technique, can actually inhibit lymphatic drainage. These strokes (i.e. deep effleurage) cause an increase in arterial blood flow. You can see this when the skin turns red after an area has been massaged (hyperemia). This increase of arterial blood flow causes an increase in blood capillary pressure and subsequent increase in ultra filtration of water. Therefore, more water accumulates within the tissues causing an increase in lymph load and lymphedema. Another reason to avoid deep Swedish massage strokes on pregnant women's legs is that the superficial lymphatics are vulnerable to external pressure and damage can be done to the anchoring filaments and endothelial lining of the lymph vessels.

As a spa director or massage practitioner, you want to do what is right and best for the client. When a pregnant client tells you her legs bother her, the best way to treat them is to address the cause of the problem: fatigue and soreness from swelling. Even if her legs aren't swollen, it is still important to massage them following lymphatic protocol to avoid dislodging potential blood clots: lightly. The fact that the lymph load is decreasing from this safe and appropriate care will provide her with much needed and welcomed relief."

Elaine Stillerman, LMT is the author of MotherMassage: A Handbook For Relieving the Discomforts of Pregnancy (Dell, 1992) and The Encyclopedia of Bodywork (Facts On File, 1996). She is the developer and instructor of the professional certificate program MotherMassage: Massage During Pregnancy, taught at massage schools and spas across the country.

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