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When working in a spa (or in private practice), what does a prenatal massage therapist do when she is told that the client's baby is breech?
A sensible policy is to anticipate this issue ahead of time and educate your therapists and clients with the facts about breech presentation. Follow this with a handout for the clients explaining non-invasive ways she can help enhance spontaneous version. Most spas and resorts today are interested in more than offering sublime treatments - you are interested in educating and effecting your clients' overall health and well-being.
The word presentation is used to describe how the fetus is lying within the uterus. Position refers to the direction toward which the baby lies within the uterus - anterior, posterior or transverse. Most babies, about 95% in fact, are born in the vertex, or head down presentation (Bilodeau and Marier, 1978). Yet as many as 40% of all pregnancies are labeled "breech" before 28 weeks. In actuality, it is a non-vertex presentation, since there is plenty of time for the fetus to assume it's preferred placement for birth. However, you can well imagine how distressing this can be for the pregnant woman who is told that her baby is breech. Informing them about the facts can assuage much of this fear and stress, which after all, is your goal.
Between weeks 28-38, that number declines to 17% and at 40 weeks, or full gestation, only 3-5% of babies are in breech presentation. That's quite a drop from the initial number of "breech" presentations.
In the vertex presentation, 75% are born with occiput anterior, meaning that the back of the fetus' head is pointing forwards. This is the most favorable and common presentation. Occiput posterior, or the back of the fetus' head against the mother's sacrum, often slows down labor and causes backaches as the head presses against the sacroiliac joints.
Any presentation other than vertex is considered breech. Frank breech, the most common form of breech, is buttocks first with the legs straight up. A footling refers to one or both feet first, while a complete breech has the fetus crossed-leg, bottom first. About 4% of fetuses are born in like this, some vaginally, others by C-section (Bolane, 1999). Another type of breech is kneeling, or knees first.
By re-examining the statistics, it is fair to say that most of your guests who say that their fetus is breech will have babies born in the vertex position.
For those few whose babies are still breech, it would be supportive of you to provide them with information about manual version, or external cephalic version. This viable alternative to breech is performed by your client's doctor or midwife. Manual version should never be attempted by a massage therapist. Success rates vary according to the reports. Savon-Ventura (1986) reported success rates from 8-97% while other studies averaged the success rate at 70% (Stine et al, 1985; Ferguson et al. 1987).
Prior to the version, an ultrasound is performed to confirm the breech presentation and to assess the site of placental attachment. A non-stress test is also performed to make sure the fetus is in good health.
Women are given tocolytic drugs, such as terbutaline, to relax the uterus and minimize preterm labor contractions. The ultrasound is used throughout the procedure to monitor fetal heart rate and for guidance. The doctor then presses and pushes the fetus , trying to turn the baby into a vertex position. The procedure is immediately stopped if there are any signs of fetal distress.
The fact remains, however, that most fetuses will turn prior to labor. Here are some non-invasive suggestions your spa might offer those clients whose fetuses are still breech or occiput posterior by 36-37 weeks:
1. Crawl on all fours. This allows gravity to bring the head down. It also provides room for the occiput posterior position to turn.
2. Pelvic rocking, particularly when used in conjunction with crawling. The mother gets on all fours - keeping her wrists and feet in neutral positions to avoid wrist pain and/or calf cramps - and gently pulls her belly towards her spine. On an inhalation, she arches her back. Her belly remains pulled in towards her spine. She then exhales and slowly returns to a neutral spine. Do this 3 times a day for a count of 10 each time.
3. Stair climbing can help turn an occiput posterior position by widening the pelvic outlet.
4. Gentle lateral lunges to widen the pelvic outlet also helps an occiput posterior fetus turn.
5. The breech tilt should be done 3 times daily for 10-15 minutes each time on an empty stomach. Her hips are raised about one foot off a firm surface with pillows tucked her her hips. She should concentrate on relaxing all her muscles, particularly her abdomen.
6. Place an ironing board or slant board on a secure surface at a 45 degree angle. She lies on it, head down, with her knees bent. The breech tilt and ironing board exercises work on the same principle: by placing her head lower than her hips, gravity encourages the fetus' head to move towards the fundus of the uterus, flex his chin and turn under. The fetus slowly rotates first into a transverse position and finally vertex.
7. Place an ice pack on the top of the uterus and a warm pack at the bottom of the uterus. The baby will move towards the heat.
8. Make a tape of mother talking or singing. Place the earphones near her pubic bone so the fetus can hear her voice. The principle is that the fetus, who hears well, will gradually move towards the pleasant sounds.
9. Visualizing the fetus turning adds mental powers while performing any of the above procedures.
10. Stimulating the acupuncture point Bladder 67, found on the outside of both little toe nails, with moxibustion (mugwort), has proven very effective in turning the fetus. These points should not be used prior to 37 weeks, however. You might not want to try this at your spa, but you can certainly make the recommendation to her. If she does not have access to an acupuncturist who does moxibustion, she can have her partner press on both points, hold for a count of 6-10 and repeat 6-10 times. These points must not be stimulated before 37 weeks.
11. There are some very effective bodywork techniques which have been helpful in turning breech presentation. You could suggest myofascial release or craniosacral therapy which you may already offer at your facillity. Sacral-occipital blocking is done by a chiropractor or osteopath and helps realign and balance the pelvis. The theory behind these gentle techniques is that certain myofascial restrictions make it diffcult or impossible for the fetus who wants to be vertex, to turn. By removing these restrictions and aligning the pelvis, the fetus has room to turn.
It is glorious working with pregnant and postpartum women and all spas and resorts should have certified prenatal massage therapists on staff. Your spa can also easily improve and augment your services by providing information about a number of pregnancy-related issues. Your guests will appreciate your treatments as well as the extra effort you make in addressing their needs and concerns.
Elaine
Stillerman, LMT
MotherMassage (R): Massage During Pregnancy
www.MotherMassage.net
About the author: Elaine Stillerman, LMT, a New York State licensed massage therapist since 1978, has been working with pregnant women since 1980. She is the author of MotherMassage: A Handbook For Relieving the Discomforts of Pregnancy (Dell, 1992) and The Encyclopedia of Bodywork (Facts On File, 1996) as well as numerous articles on prenatal and postpartum massage therapy. She is the developer and instructor of the professional certification course, "MotherMassage (R): Massage During Pregnancy" taught at prestigious massage schools, spa and resorts across the country.
Bibliography:
Bilodeau,
R. and R, Marier, "Breech Presentation at Term", Am Journal Obstet
Gynecol, 130:555, 1978
Bolane, Jamie Eloise, B.F.A., With
Child, Childbirth Graphics, Waco, TX, 1995
Cox, Janice P., "Delivery Alternatives In the Term Breech Pregnancy",
ICEA Review, Vol. 12 No.4, ICEA, Minneapolis, MN 1988
Ferguson, J.M. et al, "Maternal and Fetal Factors Affecting Success of Antepartum External
Cephalic Version", Obstet Gynecol 70:722, 1987
Savona-Venutra C., "The Role of External Cephalic Version in Modern
Obstetrics", Obstet Gynecol Survey 41:393, 1986
Simkin, Penny, PT et al, Pregnancy,
Childbirth and the Newborn, Meadowbrook Press, New York, NY 1979
Simkin, Penny, "Turning Breech to Vertex", ICEA, Minneapolis, MN
1987
Stine, L., et al, "Update on External Cephalic Version Performed at
Term", Obstet Gynecol 65:642, 1985
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