A Midwife’s Touch

by Elaine Stillerman

© 2008 Midwifery Today, Inc. All rights reserved.

[Editor's note: This article first appeared in Midwifery Today Issue 84, Winter 2008. Portions of this article were taken from Prenatal Massage: a textbook of pregnancy, labor and postpartum bodywork, by Elaine Stillerman.]

“There is hardly a people, ancient or modern, that do not in some way resort to massage and expression in labor, even if it be a natural and easy one.”(1)

The statement above was made in 1884, but it stands the test of time. At the beginning of the following century, physician and anthropologist Ales Hrdlicka, who traveled extensively throughout North America, reported, “The assistance given is everywhere substantially the same, consisting of pressure or kneading with the hands or with a bandage about the abdomen, the object of which is to give direct aid in the expulsion of the child. The procedure, which is not always gentle, accomplishes very probably the same result as the kneading of the uterine fundus under similar conditions by the white physician, namely, more effective uterine contractions.”(2)

Midwives are in a unique position to carry the benefits of touch and massage with them into labor and childbirth. By doing so, they can help control pain, foster deeper relaxation and even hasten labor.

Studies on Touch in Labor

A study reported in Mental Health Update (3) demonstrated that physical and emotional support by a labor doula provided substantial benefits to women in labor. In the study, the women in a group that received physical touch (light massage and counter-pressure) and emotional support, as compared to controls, had 56% fewer c-sections; an 85% reduction in the use of epidural anesthesia; 70% fewer forceps deliveries; 61% decrease in the use of oxytocin; a 25% shorter duration of labor; and a 58% drop in neonatal hospitalization.

Another study demonstrated the power of partner massage during labor. The Touch Research Institute (Miami, Florida) reported that women whose partners massaged them felt less depressed, had less labor pain and had lower stress and anxiety levels.(4) The involvement of a partner correlated with less need for pain medication, shorter labors, fewer perinatal complications and a more positive attitude. In another study, massage provided by a partner was viewed by the mothers as having more therapeutic value than the touch of a nurse-midwife.(5)

Use of Touch in Labor

While in labor, a woman’s response to touch is unpredictable and variable. The midwife must understand that since there is no clear way to know how a mother will respond, she will need to use a number of different techniques and strategies.

Touch during labor is not massage, in the traditional sense of the word. Touch requires no prescribed routine; it has no beginning, middle or end and it doesn’t fit neatly into an hour. Instead, during a woman’s labor the source and type of touch has to change along with the progress of labor—if it is welcomed at all.

Rather than stroking, the midwife will need to use more support and counter-pressure. Generally, during the rest between contractions, elongated strokes—predominately effleurage (a massage technique used to warm up muscle prior to deep tissue work)—are used to relax muscles, reduce lactic acid build-up and control pain. She can also effectively employ stretching exercises at this time, to increase circulation and reduce muscle tensions. Moving around and/or changing birthing positions often provides pain relief.

Other techniques to give pain relief are the application of counter-pressure, sacral lifts, pelvic tilts, hip squeezes and stimulation to specific labor-enhancing acupuncture points for the duration of the contraction. A birthing mom also can sway her hips in a rhythmic figure-eight pattern while standing, leaning or bending.

Various birthing positions and tools can facilitate labor and ease labor pain, especially back labor. For instance, a midwife can firmly press a tennis ball(s) into the mother’s lower back or hips, at the location of the pain, during a contraction. The mother also may position her back against the ball(s) and let her own body weight provide the pressure. Another technique is to use a hollow rolling pin filled with ice or cool water to relieve sore back muscles.

The pressure you use depends upon the woman’s comfort level, which can be expected to change as labor progresses. The kind of touch that soothed her earlier may now irritate her. You can determine this by asking her for feedback, or just getting a sense of how she feels by how much she tenses or relaxes from your touch. When a woman cannot articulate her needs, she will express them through body language. Being cognizant of subtle changes and reactions is essential.

The tactile stimulation of stroking increases the input on the large diameter nerve fibers and helps block pain impulses. This action of the “gate control theory” is also enhanced by the dynamic activity of the mother’s cerebral cortex, which is engaged in attention-focusing or other mental activities for relaxation. The more proactive the laboring woman is regarding breathing or relaxation strategies, the more her descending nerve fibers will take priority within the central nervous system and override pain signals.(6)

Touch in Early Labor

Midwives or other support providers can easily provide massage in a variety of positions and in familiar surroundings for women who are home during the latent phase of stage one or who stay home during their entire labor. They have to be ready to assist and support women in various positions without compromising their own bodies. (See sidebar)

Relaxation is essential to promoting the progress of labor; many comfort measures and coping strategies throughout labor will insure that the birthing woman stays calm and controlled.(7) The midwife can use light touch to make a mother aware of any tense areas throughout her body that she needs to release. She can also encourage the mother to breathe into those areas and exhale with a loud sigh. Breathing with her will encourage a patterned rhythm.

During stage one of labor, pain impulses are transmitted along the lower thoracic spine, between T11 and T12 and through the accessory lower thoracic and upper lumbar sympathetic nerves. (These nerves originate in the uterus and cervix.[8]) Women feel most of the pain and discomfort brought on by cervical changes in the lower abdomen. They also may experience referred pain, which radiates from the uterus and is felt in the lumbosacral region, iliac crests, gluteals and down the thighs. (9) Generally, the pain is present only during a contraction, although some women may feel residual discomfort between contractions.(10)

Nearly 25–65% of women experience lower back pain, which may slow down the progress of labor.(11) This pain can be ascribed to uterine changes, uterine ischemia and distention of the fetal occiput posterior position in which the fetal head stretches the ligaments of the sacroiliac joints. Most babies will rotate during birth and relieve the pressure on the lower back. Another possible reason lumbosacral pain occurs is cephalo-pelvic disproportion, which exerts pressure on the sacral nerves and other pelvic structures. As the contractions of early labor begin, the mother should take a deep cleansing breath, in through the nose and out through the mouth. This breathing pattern should be repeated after the contraction ends, as well.

Massage Techniques for Early Labor

1. Start your massage between contractions with an effleurage (long, gliding stroke) in her mid-back down to her sacrum, in the direction of the muscle fibers. The pressure should be as deep or light as she prefers. She can be sitting on a stool, leaning over a bed or pile of pillows, or side-lying. Gradually work deeper into the lower erector spinae muscles from T11 to the sacrum using your fingertips, thumbs, knuckles or elbows across the muscles fibers from the lateral borders of the erector spinae to the transverse processes of the spine and down to the lumbosacral joint.
2. Stroke up her entire back from the sacrum, up the spine and over her shoulders. Massage around and over her shoulders and up her neck.
3. When a contraction starts, apply counter-pressure at the site of any pain or discomfort. Keep your wrist neutral and alternate between using your wrists, knuckles, elbows or knees (on her sacrum). Hold this counter-pressure throughout the contraction—and remember to breathe.
4. Use the sacral lift during a contraction to reduce the pressure of the fetal head on the spinal nerves, relieve lower abdominal pressure, ease engorgement of hemorrhoids and support the bulging pelvic floor. Place your hand low on her sacrum and lift upwards and slightly towards her umbilicus. (This stroke cannot be performed on anyone with coccyx pain or subluxation.) Use your knuckles, forearms, shoulder, knee and foot as alternatives to your hands. Hold this for the entire contraction. This is best performed when the mother is sitting down, but can be very effective in a side-lying position using only your neutral fist. Fold a small hand towel or dry wash cloth over your knuckles to prevent bone-on-bone discomfort.
5. During a contraction, use the pelvic tilt, done with your client on her side. This elongates the lumbar spine, stretches the compressed muscles and reduces lower back pain. Use your fleshy forearm on her top hip and gently pull toward her head while your lower hand is on her sacrum gently pulling toward her feet. A variation of the pelvic tilt is the knee press, also performed with your client on her side. Sit behind her and secure your hip directly next to her sacrum. Lean over and clasp your hands around her top knee. Position her hip at a right angle and pull her knee toward your hip. For additional support, press your body onto her hip, thereby providing a pelvic squeeze at the same time.
6. If she has backaches, try the pelvic press or hip squeeze (locate the center of her buttocks and using your fists with your wrists neutral, squeeze in and slightly up—forming an X—and hold for contraction). An acupuncture point can release a lot of back tension during labor: Gall bladder 34 is found in the depression anterior and inferior to the small head of the fibula on both legs. Hold both points at the same time for a count of 10, repeating a total of 10 times.
7. Another acupuncture point that minimizes pain is found posterior to the outside corner of the nail of both little toes. This point is Bladder 67. In China, this point is needled to stop the pain of labor. (It is also needled or treated with moxibustion [heated herbs] in the 37th or 38th week of pregnancy to turn a breech presentation.) A recent study of this ancient Chinese technique has proven it to be effective in relieving labor pain. Large intestine 4 is found in the webbing of the thumb and index finger. Although contraindicated during pregnancy, when an ice massage is given to this point on the left hand for 20 minutes or until the 4th contraction, whichever came first, pain was cut in half. Icing the right hand reduced pain by 19%.(12)
8. To speed up labor at any stage, use pressure on certain acupuncture points, especially when used during a contraction. Hold each point bilaterally for the duration of the contraction, releasing only to relieve your fingers. These points are: Large intestine 4, found in the webbing of the thumb and index finger; Liver 3, found on the top of both feet about 2 inches down from the first and second toes, where the foot bones meet; Spleen 6, the expression of Female Energy, found on both legs approximately 2–2½ inches from the top of the medial ankle bone, under the tibia.

Active labor

As labor progresses into the active phase, a noticeable shift occurs in contraction pattern and mother’s emotional response. The midwife’s goal is to keep her calm, comfortable and focused and to encourage the normal progress of labor. Another important task is to meet her emotional needs with understanding, nurturing and respect. This will give her a greater sense of control over labor, which can lead to heightened self-esteem and a more satisfying, empowered experience.(13)

The bodywork techniques must now be adapted to the mother’s emotional and physical needs and changes. Her breathing pattern will be different and should be encouraged by breathing (or intoning, moaning, etc.) with her.

Techniques for Active Labor

1. Encourage her to change positions whenever she needs to, but at least every 30 minutes to treat backaches and speed up labor.
2. Hold pelvic tilting throughout a contraction.
3. Use hot or cold compresses with or without rolling pressure on her lower back.
4. Use knee press with mother sitting in a chair with her back supported by pillows. Press just inferior to her knees and sustain this pressure for the contraction. If your wrists tire from this exertion, sit on the floor and turn away from her, facing outward. Lean against her knees with your back, saving your hands.
5. Use a pelvic squeeze to alleviate the pain of back labor, as it repositions the sacroiliac joints that are being stretched by the back of the baby’s head against mother’s sacrum.
6. Do gentle lymphatic drainage, stroking towards her heart, if her legs shake or feel tired and heavy.

Transition

As labor progresses into the transition phase of stage one, most women are no longer comfortable with long, gliding strokes. Some women may actually pull away from touch altogether as they focus on the task at hand. Hot or cold packs, or ice chips (perhaps imbued with an herbal remedy such as black cohosh, if her blood pressure is low and stable) may be welcome. Holding, rocking or swaying with her may be all the support she needs. Placing your hand on an area of tension or firmly applying pressure on her sacrum during a contraction can relieve back pain. (Don’t forget to keep her face and jaw relaxed, since a lot of women in late labor grimace in pain and lock their jaws.)

Quiet encouragement and reassurance are paramount during transition. Keeping her relaxed and calm lets her natural rhythm of labor proceed smoothly and on course.

Stage Two

After the short resting phase of stage two where she may enjoy a few gliding strokes on her back or belly, strong contractions resume and the urge to push becomes involuntary and compelling. Relaxation is vital to the conservation of her energy and smooth passage, particularly her pelvic floor and adductors, as any physical tension could increase pain and slow labor. Gently and quietly remind her to release tension and allow her body to open.

Helpful ways to support her include encouragement, staying calm and helping her follow patterned breathing and chosen relaxation strategies. Help her change positions and rub any tense areas—if she wants the touch. The strokes of abdominal effleurage during the active phase begin at the fundus and move toward the pubic bone in tandem with uterine contractions. Between contractions, try effleurage of the lower back, or she might prefer gentle pelvic rocking. Leg cramps or muscle spasms can be treated with active or passive stretching or appropriate light leg massage. She will most likely need assistance straightening her legs after squatting to either stand erect or sit down.

Birth

Most of the support during the baby’s birth helps to calmly remind mother to stay relaxed and conserve her energy. You can offer some physical support such as counter-pressure or perineal support and help her find a comfortable birthing position.

Expulsion of the Placenta

In the tribal world, placental birth was usually very fast because women were in good physical shape and they used efficient birthing positions. Standing and stretching can expedite placental delivery.(14) Massage was used almost exclusively to encourage expulsion of the placenta in tribal societies. Other procedures included contracting the abdominal muscle, having the woman sneeze, having the new mother bite on something very hard or having her blow into her hands or an empty bottle.(15) Heat applications were also used to effectively expel the afterbirth.

The women of Morocco soak the end of the severed umbilical cord in oil heated over hot coals. Within a few minutes of the treatment, the new mother stands and the placenta falls out.(16) The Filipinos warm the handle of a wooden rice ladle and press it against the woman’s navel. In certain regions of Mexico, a hot tortilla is placed against the mother’s right side.(17) In India, the birth attendant oils her head and rubs it against the standing mother’s belly until all the blood comes out.(18) In Tahiti, the afterbirth is expelled as mother kneads her own abdomen while bathing in the sea. Her husband presses his foot against her to stimulate further expulsion of fetal detritus.(19)

Abdominal massage from the fundus to the pubic bone, skin-to-skin contact between mother and baby (kangaroo care, nursing), nipple stimulation or oral stimulation (by the partner) promote the release of endogenous oxytocin that encourages the uterus to contract and expel the placenta. Midwives can stimulate acupuncture point Spleen 10 to release the placenta. Place the heel of your hand at the top border of the mother’s knee. Your thumb should reach the belly of the vastus medialis muscle where the point is found. Hold for a count of 10, repeating until the uterus starts to contract.(20)

If mom starts to shake, squeeze the arches of her feet to control the trembling and guide her through gentle breathing.

Many helpful bodywork and massage techniques, along with numerous comfort measures and coping strategies, can have a positive impact on the way a woman perceives and experiences her labor. These techniques also provide midwives with additional ways to keep their clients calm, comfortable and relaxed.

Elaine Stillerman, LMT, has been a New York State licensed massage therapist since 1978. She began her pioneering prenatal practice in 1980. She is the developer and instructor of the professional certification workshop “MotherMassage: Massage during Pregnancy” (www.MotherMassage.net) and the author of MotherMassage: a handbook for relieving the discomforts of pregnancy (Dell, 1992); The encyclopedia of bodywork (Facts On File, 1996); Prenatal massage: a textbook of pregnancy, labor, and postpartum bodywork (Mosby, 2008); Modalities for massage and bodywork (Mosby, publication date to be announced). She is the researcher and writer for the PBS-TV show “Real Moms, Real Stories, Real Savvy” and is proud to have helped organize the March 2008 Midwifery Today conference in Philadelphia, Pennsylvania.

Sources:

1. Englemann, G.J. 1884. Labor among primitive peoples. St. Louis: JH Chambers.
2. Hrdlicka, A. 1908. Physiological and medical observations among the Indians of southwestern United States and northern Mexico. Washington, DC: Smithsonian Institute Bureau of American Ethnology, Bulletin 34.
3. Institute for the Study of Human Knowledge. 1993. The effect of continuous emotional support during labor. Los Altos, California: Mental Health Update, The Center for Health Sciences.
4. Field, T. et al. 1997. Labor pain is reduced by massage therapy. J Psychosom Obstet Gynecol 18(4): 286–91.
5. Birch E. 1986. The experience of touch received during labor. J Nurse Midwifery 31(6): 270–76.
6. Stillerman, E. 2007. Prenatal massage: a textbook of pregnancy, labor, and postpartum bodywork. St. Louis: Mosby; Lowdermilk, D.L., and S.E. Perry. 2004. Maternity & Women’s Health Care, 8th ed. St. Louis: Mosby.
7. Stillerman, 2007.
8. Lowdermilk and Perry.
9. Ibid.
10. Lowe, N. 2002. The nature of labor pain. Am J Obstet Gynecol 186(5): S16–24.
11. Cogan, R. 1976. Backache in prepared childbirth. Birth 3(2): 75–78.
12. Waters, B.L., and J. Raisler. 2003. Ice massage for the reduction of labor pain. J Midwifery Women’s Health 48(5): 317–21.
13. Olkin, SK. 1987. Positive Pregnancy Fitness. New York: Avery Publishing Group.
14. Sousa, M. 1976. Childbirth at home. New York: Bantam.
15. Ibid.
16. Boston Women’s Health Book Collective. 1971. Our Bodies, Ourselves. New York: Simon & Schuster.
17. Lacey, L. 1975. Lunaception. New York: Coward, McCann & Geoghegan.
18. Hart, DV. 1965. From “Pregnancy through birth in a Bisayan Filipino village.” In Southeast Asian Birth Customs. New Haven: Human Relations Area Files Press.
19. Ibid.
20. Stillerman, 2007.
21. Ibid.

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