Common Ailments of Pregnancy & The
Post Natal Period Their Possible
Implications For Activities of Daily Life
& Massage Therapy
The conditions listed represent some of the most common ailments experienced by
mother’s during pregnancy and into the Post Natal period. As you no doubt
understand….. EVERY CLIENT IS UNIQUE. Some clients may present with many of
these conditions while some present with none. There is generally no strict time
frame for their onset or cessation. Always demonstrate caution regarding your
exercise prescription and whenever you feel out of your depth, ALWAYS REFER YOUR
CLIENT to a suitable Health Care Professional such as an Osteopath or Physiotherapist.
Carpal Tunnel Syndrome
Causes & Symptoms
 The main nerve to your hand is called the median nerve. It passes through the carpal
tunnel, a narrow space at the front of the wrist. The tendons that bend the fingers and
wrist pass through the carpal tunnel so space is limited. Any swelling (in the case of
pregnancy and post natal – caused by water retention) in the region will compress the
median nerve and interfere with nerve impulses.
 A loss of sensation or of pins and needles in the hands and/or wrists with sometimes
accompanying numbness and weakness.
 Occasionally the whole hand and forearm are affected and it can occur from
conception, throughout pregnancy and sometimes well into the post natal period.
ADL Considerations
 In an exercise scenario, clients can often complain of pain when bearing their weight
on their hands in a flexed position i.e., when on all-fours position.
 Painful positions should be avoided and good wrist alignment maintained monitored
throughout the exercise session.
 If your client’s ability to carry out Activities of Daily Life (ADLs) are hindered you
should refer her to a suitable health care professional.
 Dandelion tea has anti-water retention properties and can be safely taken during
pregnancy.
Symphysis Pubis Dysfunction & Diastasis Symphysis
Pubis
Causes & Symptoms
 The Symphysis Pubis is the fibrocartilaginous tissue reinforced by several ligaments
that forms the joint of the pelvic girdle at the pubis (front of the pelvic girdle).
During the pregnancy period the pregnancy hormone Relaxin causes ligamental
laxity which eventually aids the delivery of the baby, allowing the pelvis to open
sufficiently to allow the passage of the newborn.
 Diastasis Symphysis Pubis is the name for the problem in its most severe form –
where the Symphysis actually separates severely or tears.
 In some women, either because of excessive levels of hormones, extra sensitivity to
hormones, or a pelvis that is out of alignment, this area is extra lax or there is extra
pressure on the joint.
 When this increase becomes excessive there may be accompanying swelling and
severe pain over the joint – especially when walking, getting in and out of bed, and
climbing stairs. Pain may also be felt in and down the thighs and the back as the
whole pelvis is put under strain. Some women may also because totally
incapacitated by the pain and end up using wheelchairs or crutches during the later
stages of their pregnancy.
ADL Considerations
 Activities which take the legs apart and also which bring them together may cause
pain. Activities requiring abduction and adduction as well as squatting, lunging,
stepping, walking, yoga, breast stroke may also produce symptoms.
 Be considerate of this when the client is getting up onto the massage couch and
turning. Using a step to get onto the bed might be a good option in extreme cases.
Sacroiliac Pain
The Sacroiliac joint (SIJ) is one of the largest joints in the body. It is the point of connection
of the sacrum (base of the spine) and the Ilia (wings of the pelvic girdle). The SIJ is crossed
by very strong ligaments which hold the joint together. The joint is further stabilized by
Symphysis Pubis at the front of the pelvis.
Causes & Symptoms
 The theory associated with this joint as a generator of pain is that the bone on one
side of the joint can slide out of position with respect to the bone on the opposite
side of the joint.
 Joint laxity can be caused or exacerbated by pregnancy hormones causing
movement at one or both of the joints.
 Or conversely, pain can be caused by a lack of movement at the joints resulting in
the two joint surfaces becoming stuck and producing a “locked” joint reducing the
degree of mobility.
 Symptoms can vary, but generally consists of mild to severe pain in the sacrum and
lower (lumbar) back region. This pain can radiate out from that central point and
can travel through the buttocks and down either or both of the back of the thighs.
Referred pain may also be felt in the at the Symphysis pubis area.
 Sacroiliac pain can sometimes be misdiagnosed as Sciatica. A key difference to note
is that Sciatic pain usually travels down the leg as opposed to remaining in the pelvic
region.
ADL Considerations
 Restorative exercises for the TVA, multifidus and anterior pelvic floor muscles along
with strengthening the glutes especially glute medius, can be beneficial to aid the
stabilization of the pelvis.
 Activities where weight is distributed unevenly can often aggravate the condition.
Single leg work whether carried out standing or supine can cause aggravation.
 Lower body exercises requiring abduction or adduction may cause discomfort as may
breast stroke swimming.
 The “bend-to-extend” movement pattern may also cause a client discomfort.
 Assessing for tightness in the Piriformis (and relieving if present) can also be
beneficial to the client as the Piriformis attaches to the Sacrum and tension in the
Piriformis muscle can be additional factor in SIJ pain.
There is a great client information PDF that you can download here:
www.pelvicpartnership.com
Knee Pain
Causes and Symptoms
 Relaxin and other pregnancy hormones can cause a softening in the cartilage of the
knee.
 The already naturally wider “Q” angle of the woman’s pelvis may be further
exacerbated by pregnancy hormones which can have an effect on Anterior Cruciate
Ligaments (ACL) causing instability in the knee.
 Weight gain and altered posture will also increase the stress to the knee joint and
changes in the tension of the Illiotibial Band (IT Band) and the TFL. Pain or aching
will be felt in the front or side of the knee when the knee is flexed (sitting, squatting,
standing up) and is accentuated when walking downstairs.
 Remember when working on the IT Band, to work at both origin and insertion,
lateral knee to glute max and of course then onto TFL.
ADL Considerations
 Obviously, all knee flexion activities cannot be ruled out of a training programme but
proceed with caution and care and adapt exercises where possible to alleviate any
discomfort for your client.
 A well-planned, functional programme that includes work for the core and hip
stabilizers should improve stability for the client.
 As always, if you feel out of depth dealing with your client’s problem – ALWAYS
REFER YOUR CLIENT ON TO A SUITABLE OTHER HEALTH CARE PROFESSIONAL.
 Check out the Burrell Education YouTube Channell ‘BURRELLEDUCATION’
and you can see me perform Soft Tissue Releases on the ITB Band & TFL.
Back Pain
Causes and Symptoms
 Probably the most common pregnancy complaint experienced by many women.
 Postural adaptations and changes in biomechanics associated with pregnancy i.e.,
Lower and Upper Crossed Syndrome also contribute to back pain in both the upper
(Trapezius) mid (Rhomboids) and lower back areas.
 Sleep deprivation and general tiredness associated with pregnancy should also be
considered as a contributing factor as often good posture is often neglected when
tired.
ADL Considerations
 During pregnancy exercise and going forward into the post natal period, reinforcing
excellent postural alignment is ESSENTIAL for laying a strong foundation on which to
build true strength and stamina. Incorporating posture work with Inner Unit work
during 1-1 sessions and the consequent carry over in the clients’ Activities of Daily
Life (ADL) will make her stronger, more stable and more able to manage her
demanding lifestyle.
 Always check for Piriformis tightness and relieve if you find it as it can be the cause
of Sacrum Pain and also check for tight QL’s, a consequence of ongoing anterior
pelvic tilt during pregnancy.
 Freeing the deep hip flexors, especially Psoas can also be a beneficial component of
reducing low back pain.
There are 2 films of me performing a side-lying STR Piriformis Release and a standing QL
Release on the BURRELLEDUCATION YouTube Channel.
Rectus Diastasis
Causes and Symptoms
 Facilitated by the increasing size of the uterus and the pregnancy hormones, most
notably Relaxin, the Abdominal Wall undergoes increasing expansion resulting in
midline tissue stretching. At the outermost layer, the midline –Linea Alba – attaches
to the two bellies of the Rectus Abdomins and although a completely normal event
during Pregnancy especially during the later stages, a lack of integrity, strength and
function in this midline tissues in the Post Natal period, compromises core strength
and function which can lead to episodes of pain and discomfort in the entire core.
 This stretching of the midline is seen to a greater degree in those women who
develop especially protruding abdomen during their pregnancy, especially in the
case of multiple births. It can also be caused during the labour period as intraabdominal pressure is increased when the mother is pushing. Exercise habits,
weight gain and number of pregnancies, age, closeness of pregnancies can also be a
factor.
 Dysfunction in the abdominal wall is a major cause of back pain as it leads to
instability of the entire core (Inner Unit). If the strength of the core is compromised
it can only follow that any movement at the extremities (Outer Unit) will have a poor
foundation and could possibly lead to pain and/or injury.
ADL Considerations
 The factor that has to be constantly re-emphasized is “good posture” and “freeing
what’s tight/strengthening what’s weak” alongside re-educating the client of the
huge importance of regaining and ‘good abdominal care’ in her everyday life.
 Emphasizing optimal lifting strategies – EXHALE ON EXERTION – are also invaluable
in offsetting the intra-abdominal pressure creating when the system/core is loaded.
 Strengthening other musculature that reduce anterior tilt is also important, such as
the Glutes.
Pelvis Instability & Pelvic Floor Weakening/Dysfunction
Causes and Symptoms
 During your client’s pregnancy, the pelvic floor muscles work very hard to support
the loosening pelvic bones and the ever increasing weight of the uterus and
consequently become stretched, weakened and lose function through a loss of
innervation.
ADL Considerations
 Maintaining the neurological links with these muscles/tissues in alliance with the rest
of the Inner Unit is a vital part of your client’s Lumbopelvic Stability Exercise
Progamme. Once these muscles have been identified and connected with,
integrating their use via a functional, whole-body focussed exercise programme and
indeed daily life should be always emphasised.
Urinary Stress & Urge Incontinence
Symptoms and Causes
 The most common types of incontinence. As the foetus grows, it may reduce the
available space for full distension of the bladder which leads to the bladder having a
reduced capacity leading to urge incontinence. Also the weight of the growing
foetus may also weaken the pelvic floor musculature as the pregnancy progresses
leading to stress incontinence when intra-abdominal pressure is increased.
 Small amounts of urine leak out during physical activity such as running or jumping
and also when there are sudden changes in intra abdominal pressure in
circumstances such as sneezing, laughing, heavy lifting or sexual intercourse (usually
at penetration).
 Stress Incontinence caused by the loss of tone in the pelvic floor musculature
inability of the pelvic floor to contract with appropriate force to withstand the
applied pressure.
Exercise Considerations
 Pelvic Floor exercises should be performed daily with emphasis on both the Anterior
Pelvic Floor (APFM) and Posterior (PPFM).
 The PFM musculature consists of both fast and slow twitch muscles so a combination
of quicker, more powerful contractions and slower more sustained contractions
should be part of any client’s exercise routine.
 As you can imagine, activities which cause obvious impact to the pelvic floor should
be avoided as this will exacerbate the condition, e.g., jumping/running or changes to
pressure such as coughing and sneezing.
 Also the lifting of heavy weight, holding the breath or changes in pressure while
performing work which increased intra-abdominal pressure can cause leakage.
 Leakage can be avoided or at least minimized by applying the EXHALE ON EXERTION
PRINCIPLES to reduce and increase in intra-abdominal pressure.
Verbal Queues: “Exhale on Exertion” – when LOADING / LIFTING
Haemorrhoids (Piles) & Constipation
Symptoms & Causes
 Piles are enlarged and swollen blood vessels in or around the lower rectum and
anus. When the pressure of these blood vessels is increased, they swell and form
small lumps.
 Pregnancy hormones cause the relaxation of the intestinal tissue. This leads to a
slowing down of the passage of food through the gut, leading to constipation.
 The delivery process may also cause piles to appear due to the pressure of pushing
and birthing the baby.
Constipation
Two major factors of constipation are:
1. The pregnancy hormones Relaxin and Progesterone causing muscle relaxation so
that the muscular contractions of the bowel (PERISTALSIS) are less forceful and
effective at transporting bowel and eventually faecal matter.
2. The physical effects of the growing foetus compressing the large bowel in the
pelvis. The infrequent passage of hard stools can result in abdominal pains as a result
of the build-up of impacted faeces and so it is important to take measures to reduce
constipation such as increasing optimal hydration and fibre in the diet alongside
maintaining a regime of gentle exercise.
ADL Considerations
 Clients should be encouraged to stay well hydrated and increase their fibre intake to
help relieve constipation.
 Any exercise that promotes blood flow, especially abdominal work will be an aid to
relieving constipation
Braxton Hicks
Symptoms & Causes
Towards the end of her pregnancy the mother may experience the muscles of the uterus
wall contracting and hardening for short periods of time (a matter of seconds). These
contractions are called BRAXTON HICKS. They can sometimes feel so strong that the mother
may think labour is starting and it can be difficult to distinguish from true labour. Usually
labour is established when there are three to five good, regular strong contractions in 10
minutes, each contraction lasting 40 to 60 seconds.
Heartburn
Symptoms & Causes
This a common symptom of pregnancy, more frequent in late pregnancy as a result of
increasing levels of pregnancy hormones and the increasing size of the space take up by the
foetus delaying the emptying of your stomach. This leads to stomach acids refluxing
(overflowing) into the lower part of the oesophagus. The symptom is a feeling of burning in
the lower central chest area.
ADL Considerations
Certain foods are more commonly associated and should be avoided, especially fatty, spicy
and highly acidic foods. Small, frequent meals are advised rather than larger ones.
When sitting or standing, the acids naturally drain from the stomach. Bending over and
lying down can both increase the incidence of reflux so exercising in those positions should
be avoided. If symptoms persist, ANTACIDS (under the direction of your medical
professional) will usually help reduce or eliminate the symptoms.
Nausea & Vomiting
Most women experience nausea in early pregnancy and in some its combined with
vomiting. It does not usually last beyond the first Trimester of pregnancy. Rarely, episodes
may be prolonged with excessive vomiting – HYPEREMESIS - when admission to hospital is
required.
Swelling of Hands, Feet & Face (Odema)
During the last Trimester of pregnancy there is a tendency to retain water and this can be
more noticeable in the hands and feet. Although uncomfortable, swelling and puffiness in
these areas is fairly normal, compared with overall fluid retention in the whole body and
face. But be aware that an extreme version of this may be an early sign of pre-eclampsia
(see later notes).
Varicose Veins
Each leg has two large veins on the surface, just under the skin. Once is in the inner aspect
of the leg (LONG SAPHENOUS VEIN). The other is on the outside aspect of the lower leg
(SHORT SAPHENOUS VEIN). When standing, the blood in these veins is under increased
pressure as a result of the force of gravity acting on the blood in the circulation. During
pregnancy, the pressure is greater due to increased weight acting to increase the pressure in
the veins and there is also reduced flow of blood back to the heart from the legs. This leads
to the veins in the legs becoming distended. Sometimes this extends to involve the veins on
your vulva and these are seen as vulval varicosities. There may be a sensation of heaviness,
throbbing or tingling.
The treatment is to avoid standing for long periods. If standing cannot be avoided, it is
helpful to keep moving the legs to avoid blood pooling. Compression stocking or tights give
support and reduce the distension in your veins. Resting with elevated legs will also be of
help.
Night Leg Cramps
Cramps are involuntary contractions of the muscle causing pain. During late pregnancy,
these usually occur during the night and are thought to be caused by depletion of minerals
especially Sodium and Magnesium but may also have other causes. A banana (high in
Potassium/Magnesium) before bed has been shown to improve the symptoms as has a
pinch of Himalayan Mountain Salt (high in trace minerals) in a small glass of water before
bed too can be helpful.
Placenta Previa/Low Lying Placenta
Placenta previa occurs when the placenta lies low in the uterus below the presenting part –
head or buttocks. This means that the birth canal is obstructed to a varying degree by the
placenta. If the placenta starts to peel off the uterus, there will be painless bleeding. There
are various degrees of placenta praevia and the use of ultrasound scanning helps to make
this diagnosis.
Major placenta praevia is the most serious problem in that it is associated with recurring,
painless bleeding and, ultimately, the foetus will have to be delivered by C-Section. This is
usually preceeded by an extended hospital stay in the first instance as the mother is
immobilized and kept under observation.
Current statistics show that the majority of mis-placed placentas viewed at the 20 week
scan move to a ‘normal’ position without intervention as the pregnancy progresses to term.
Gestational Diabetes (GD)
Gestational diabetes is a type of diabetes that occurs ONLY during pregnancy.
Diabetes is a condition in which the body is not able to utilize and process the sugar
(glucose) in the bloodstream as efficiently as it should, so the level of sugar in the blood
becomes higher than normal.
Gestational diabetes affects between 1% to 3% of all pregnant women (is this figure
growing?)
It usually develops in the second trimester (sometimes as early as the 20th week of
pregnancy). In most cases, the symptoms of GD resolve after the baby is born but they
can/may linger into the early post natal period. High blood sugar levels can have negative
consequences for both the mother and the baby as follows:
The baby may have a low blood sugar level, jaundice and weight much more than normal.
This increased size and weight of the baby may mean that vaginal delivery may be
troublesome and need to be assisted or the mother may need a C-Section.
GD also increases the risk of developing PRE-ECLAMPSIA (see below).
Signs of GD are the same as for general Diabetes, and symptoms usually include an
increase in thirst and desire to consume water and fluids and consequently, an increase in
urination. Dizziness, faintness and changes in state after eating and also during long gaps
between eating food may also be present. The above indicators also need to be
addressed as part of your PARQ for the pregnant client more so than for the post natal
client.
As well as offering medication to control the condition, the clients’ HCP will suggest
alterations in diet and exercise as a means of combating the condition. Exercise will help to
normalise blood sugar levels and walking is usually the easiest type of exercise during
pregnancy, but swimming or other exercises deemed low risk exercises can also be
beneficial.
Pre/Eclampsia & Eclampsia
Pre-eclampsia is a condition that affects some pregnant women usually during the second
half of pregnancy (from around 20 weeks) or immediately after delivery of their baby.
Women with pre-eclampsia have high blood pressure, fluid retention (oedema) and protein
in the urine (proteinuria). If untreated, it can lead to serious complications.
In the unborn baby, pre-eclampsia can cause growth problems.
Although the exact cause of pre-eclampsia is not known, it is thought to occur when there is
a problem with the placenta (the organ that links the baby’s blood supply to the mother’s).
Pregnant women with pre-eclampsia may not realise they have it. Pre-eclampsia is usually
diagnosed during routine antenatal appointments.
Mild pre-eclampsia can be monitored with blood pressure and urine tests at regular
antenatal appointments and usually disappears soon after the birth. Severe pre-eclampsia
may need to be monitored in hospital.
Who is affected
Mild pre-eclampsia affects up to 10% of first-time pregnancies. More severe pre-eclampsia
affects 1-2% of pregnancies. If you have pre-eclampsia during your first pregnancy, you will
be more likely to have it again in subsequent pregnancies.
Treating pre-eclampsia
Treatment for pre-eclampsia focuses on lowering blood pressure and managing the other
symptoms, sometimes with medication.
The only way to cure pre-eclampsia is to deliver the baby. In some cases this may mean
inducing labour (starting labour artificially), although this depends on how far along the
pregnancy is. Being born prematurely (before the 37th week of pregnancy) can be
dangerous for the baby, but delivery may sometimes be necessary to relieve the mother's
symptoms.
Complications
In some cases further complications can develop, such as eclampsia. This is a type of seizure
that can be life-threatening for the mother and the baby. However, this is rare and less than
1% of women with pre-eclampsia develop eclampsia.
Complications of pre-eclampsia are responsible for the deaths of around six women every
year in the UK. Several hundred babies also die each year following complications from
severe pre-eclampsia, often as a result of premature birth. Therefore, the earlier that preeclampsia is diagnosed and monitored, the better the outlook for mother and baby.
What are the key symptoms of pre-eclampsia?
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Headaches.
Blurring of vision, or other visual problems.
Vomiting.
Swelling or puffiness of your feet, face, or hands (oedema) is also a feature of preeclampsia. However, this is common in normal pregnancy. Most women with this
symptom do not have pre-eclampsia, but it can become worse in pre-eclampsia.
Therefore, any sudden worsening of swelling of the hands, face or feet need to be
promptly to your doctor or midwife.
For further information contact - APEC (Action on Pre-Eclampsia)
Web: www.apec.org.uk
Obstetric Cholestasis (OC)
Obstetric Cholestasis is a condition of the liver which occurs in some pregnant women. OC
means there is a reduced flow of bile down the bile ducts in the liver. Some bile then 'leaks'
out into the bloodstream, in particular the bile salts. These circulate in the bloodstream and
can cause symptoms.
OC occurs in about 1 in 100 pregnancies in the UK. It is more common in women carrying
twins, triplets, or more. Mothers, daughters and sisters of affected women have a higher
than average risk of also being affected when pregnant.
The exact cause is not clear, although hormonal and genetic factors have a part to play.

Hormonal factors. Pregnancy causes an increase in oestrogen and progesterone
hormones. These can affect the liver in a way which slows down the rate of bile
passing out along the tiny bile ducts. Some pregnant women may be more sensitive
to these hormone effects.
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Genetic factors. OC seems to run in some families (although it may skip some
generations). One theory is that women who develop OC may inherit a slight
problem with the way bile is made and passes down the bile ducts. This does not
matter when not pregnant. However, the high level of hormones made during
pregnancy may 'tip the balance' to cause a much reduced flow of bile.
There may be other environmental factors which contribute. However, whatever the
underlying cause, the pregnancy 'triggers' the problem. Within a week or so after giving
birth the symptoms clear and there is no long term problem with the liver.
What are the symptoms of OC?
Typically, symptoms occur in the last third of pregnancy when the hormone levels are at
their highest. However, it sometimes develops earlier in pregnancy.
Itching
This is the most common and typical symptom. The itching can be 'all over', but it is often
worst on the hands and feet. Commonly, itching is the only symptom. It tends to get worse
until you have the baby. The itching can become severe and affect sleep, concentration,
mood, and can become distressing.
Note: mild itching from time to time is normal in pregnancy. However, if woman develops
a constant and global itch that gets worse, advise her to seek advice from her HCP. A
simple blood test will confirm whether she has OC.
The symptoms can be unpleasant for the mother - in particular the itch. But, whether OC
causes an increased risk of harm to mother or baby is still being debated. If there is a risk, it
is thought to be small, but the concerns are as follows.
For the unborn baby
Until recently it had been thought that OC caused a small increased risk of stillbirth. The risk
of stillbirth in a normal pregnancy is about 1 in 100. The risk if the mother has OC was
thought to be only a little more than this.
For the mother
There is possibly an increased risk of serious bleeding from the womb just after giving birth.
However, again the studies are not conclusive and there may be no increased risk of this.
How is OC diagnosed?
The diagnosis is suspected if you develop itch during pregnancy. A blood test can detect the
raised level of bile acids and liver enzymes (chemicals) in the blood. Other blood tests may
be taken to measure other liver functions and to rule out other causes of liver problems
such as viral hepatitis. In some cases the itch develops a week or more before the blood test
becomes abnormal. Therefore, if the first blood test is normal then another may be done a
week or so later if the itch continues.
Obstetric Cholestasis Support Website: www.ocsupport.org.uk
The diagnosis is confirmed if you have:
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Itching that is not due to any other known cause (such as a skin disorder), and
High levels of liver enzymes and/or bile salts in your blood that cannot be
explained by any other liver disease such as viral hepatitis.
Both the itch and high level of liver enzymes and bile salts go away after the birth of the
baby. A blood test done sometime after the baby is born can confirm this. This sometimes
helps to confirm that the diagnosis was, in fact OC if there had been any doubt.
Bleeding During Pregnancy
Some light bleeding during pregnancy although alarming for the woman is actually fairly
common and doesn’t necessarily mean the worse. There are several reasons why it might
happen. In the first three months, 25% of women will experience some bleeding and of
these over half will go on to have a healthy baby. There are obviously acceptable and nonacceptable levels of bleeding during pregnancy and as a general rule, a client reporting
consistent, heavy and painful bleeding should mean an IMMEDIATE REFERRAL BACK TO
HER HCP.
‘Spotting’ – light bleeding is common in the first three months. It may be due to the
fertilized egg implanting itself the wall of the uterus or may happen around the time that
the woman previously had her period. Spotting may also occur if there are issue with the
cervix.
Bleeding in the last three months is less common. It could be a sign of issues with the
placenta (sometimes separating from the wall of the uterus), Placenta Praevia – where the
placenta is covering part or all of the cervix or premature labour. This is usually picked up at
the 2nd Trimester scan at around 20 weeks gestation.
At the end of the pregnancy, the first signs that the body is starting to prepare for birthing
is called a ‘show’. It usually presents as a blood tinged blob of mucus and is one of the
first signs of labour process beginning.
Post Partum Haemorrhage
In some women, severe haemorrhage (loss of blood) can occur after delivery. It is termed
postpartum haemorrhage (PPH) when the blood loss is more than 500ml and can occur
unexpectedly without any risk factors. This is one of the main reasons why obstetricians
advise against home delivery. PPH can occur when the uterus relaxes after delivery of the
baby, rather than continuing to contract and so putting pressure on the interior of the
uterus. PPH may also occur is the birth passages are injured or the placenta is not fully
delivered (retained placenta).
In 1-2% of deliveries, the placenta does not separate from the uterus because it is intricately
interwoven within the walls of the uterus. The retained placenta has to be removed by an
operation under spinal or general anaesthesia. This is term a ‘manual removal of the
placenta’.
Ultrasound Scans
An ultrasound within the first three months of pregnancy (the first Trimester) is performed
by a SONOGRAPHER. Its main purpose is to establish the viability of the pregnancy,
gestational age and the number of foetuses. Further scans will be carried out during the
pregnancy but the quantity/frequency of further scans relate directly to the age and level of
pregnancy risk. Generally, there is always a further scan at roughly 20 weeks gestation.
Blood Tests and Other Investigations
Several blood tests/laboratory investigations may be performed to monitor the progress of
a pregnancy and to check that both the mother and foetus are in good health. Some of the
tests may be repeated during pregnancy at specific intervals.
Some Tests That May Be Carried Out
Full blood count
Haemoglobin electrophoresis for genetic disorders
Blood Group
Blood Group Antibodies
Rubella
Hepatitis B & C
HIV Status
Syphilis Testing
Glucose and Protein In Urine
Blood Glucose
Urine Specimen for Culture
Blood Screeening for Down Syndrome
Blood Screening for Spina Bifida
Cervical Smear
Pre-Screening Health Questionnaires &
Referring Your Client Sample Letters
Please note, the following forms are duplicated (two copies) one for use during this course
and a fresh set for your own use afterwards.
Pregnancy Pre-Therapy Health & Lifestyle Questionnaire
You are advised to ALWAYS carry out a full INITIAL CONSULTATION before commencing any
therapy. In the case of ‘high risk’ pregnancies, it is also valuable to ensure that your client has
been given permission to seek and take part in the therapy you are offering.
Client Name:
Due Date/No. Of Weeks Pregnant:
Client Address:
Health Care Provider Details:
Client Phone No:
Client Email:
First Impressions/Visual Assessment
Pregnancy Therapy Open-Ended Questions for
Cautions/Contraindications to Massage
Reason for seeking therapy today? Where do you have
pain/discomfort? (Use Body Map Diagram).
Any excessive or sudden swelling and water
retention?
Any skin rashes, open or unhealed cuts or bruises?
Any history or blood clots or Thrombosis?
Any extreme calf pain, swelling or redness?
Any severe and chronic itching?
Last visit to Primary Health Provider and outcome?
Scan results?
Extreme high blood pressure – current and previous
history?
Any excessive thirst and urination?
Any rapid or large weight gain while Pregnant?
Any varicose veins or haemorrhoids?
Any extreme itchiness?
Current multiple pregnancy?
History of miscarriages?
Currently, or during previous pregnancies have you suffered any of the following
conditions?
Symphysis Pubis Dysfunction
(SPD)
Carpal Tunnel Syndrome
Sacrum or SIJ Pain
Bleeding during pregnancy
Knee Pain
Low Back Pain
Upper Back Pain
Neck Pain
Coccyx Damage or Pain
Separation of your abdominal
muscles
Varicose Veins
Gestational Diabetes
High Risk Pregnancy Indicators
The term "high-risk pregnancy" describes a case where a pregnant woman has one or
more factors that could put her or the fetus at risk for health problems.
In general, a pregnancy may be considered HIGH RISK if the pregnant woman:
1.
2.
3.
4.
5.
6.
7.
8.
Is 35 years or older.
Is 15 year old or younger.
Is either extremely under or overweight during pregnancy.
Is pregnant with one or more fetuses
Has Gestational Diabetes
Has high blood pressure
Has heart or lung disease
Has diabetes, lupus, asthma
*Although deemed factors that contribute to a HIGH RISK pregnancy are not
necessarily TOTAL CONTRAINDICATIONS to massage but PERMISSION must be
sought from the clients’ HCP before commencing therapy.
Post Natal Pre-Therapy Health & Lifestyle Questionnaire
You are advised to ALWAYS carry out a full INITIAL CONSULTATION before commencing any
therapy.
Client Name:
No. Of Weeks Post Natal:
Client Address:
6 Week Check Carried Out? & Results:
Health Care Provider Details:
Client Phone No:
Client Email:
First Impressions/Visual Assessment
Open-Ended Questions
Reason for seeking Therapy today? Where do
you have pain/discomfort? (Use Body Map
Diagram)
Last visit to Primary Health Provider and
outcome?
6 week check-up carried out?
Have you or are you currently suffering from any of the following conditions?
Symphysis Pubis
Dysfunction
Carpal Tunnel Syndrome
Sacrum or SIJ Pain
Low Back Pain
Knee Pain
Coccyx Damage or Pain
Upper Back Pain
Neck Pain
After-effects of Gestational
Diabetes
Separation of your
abdominal muscles
Varicose Veins
Piles/Haemorrhoids
Post Natal Therapy
Contra-Indications Biased Open-Ended Questions
Are you currently or have you experienced any problems in the following areas in your
post natal period?
Fever?
Prolonged post natal bleeding (more than 8
weeks)?
Burning while urinating?
Passage of clots or heavy bleeding?
Difficulty urinating?
Resumed bleeding after cessation?
Swollen, red, painful area(s) on calves or
lower legs?
Increase pain/discomfort/poor healing at
Episiotomy site?
Painful breasts?
Increased pain/discomfort/poor healing at
the C-Section site?
Sore, itchy vagina and discharge?
Rationale for Post Natal Contraindications - Referral to HCP
The following are all TOTAL CONTRAINDICATIONS TO THERAPY. They are potential Post
Natal emergency situations and as such, IMMEDIATE REFERRAL to primary HCP is strongly
advised.
Fever
It may indicate uterine infection, bladder or
kidney infection, breast infection (mastitis) or
other illness.
Burning with urination or blood in
urine
Inability to urinate
This could indicate a bladder infection
Swollen, red painful area on leg
(especially calf) which is hot to touch
Thrombophlebitis – development of blood clot in
blood vessel. However, remember that DVT’s are
not always symptomatic!
Sore reddened painful area on the
breast in addition to fever and flulike symptoms
Breast infection, probably Mastitis.
Passage of large red clots, pieces of
tissue or return of bright red vaginal
bleeding after flow has decreased
and changed to brownish pink or
yellow
Foul odour to vaginal discharge,
vaginal soreness or itchiness
Possibly:
Retained fragment of Placenta
Uterine infection
Over Exertion
Increase in pain in Episiotomy site,
may be accompanied by bleeding or
foul-smelling discharge
Infection of Episiotomy, reopening of incision or
tear, stitches given way.
Slight opening or c-section incision
wound, maybe accompanied by foulsmelling discharge and blood
Infection of c-section incision
Slow healing/over-sore c-section
wound
If cause for concern, wise always to seek advice.
This could indicate a bladder infection
Uterine or vaginal infection
2nd COPY!!!!!!
Pregnancy Pre-Therapy Health & Lifestyle Questionnaire
You are advised to ALWAYS carry out a full INITIAL CONSULTATION before commencing any
therapy. In the case of ‘high risk’ pregnancies, it is also valuable to ensure that your client has
been given permission to seek and take part in the therapy you are offering.
Client Name:
Due Date/No. Of Weeks Pregnant:
Client Address:
Health Care Provider Details:
Client Phone No:
Client Email:
First Impressions/Visual Assessment
Pregnancy Therapy Open-Ended Questions for
Cautions/Contraindications to Massage
Reason for seeking therapy today? Where do you have
pain/discomfort? (Use Body Map Diagram).
Any excessive or sudden swelling and water
retention?
Any skin rashes, open or unhealed cuts or bruises?
Any history or blood clots or Thrombosis?
Any extreme calf pain, swelling or redness?
Any severe and chronic itching?
Last visit to Primary Health Provider and outcome?
Scan results?
Extreme high blood pressure – current and previous
history?
Any excessive thirst and urination?
Any rapid or large weight gain while Pregnant?
Any varicose veins or haemorrhoids?
Any extreme itchiness?
Current multiple pregnancy?
History of miscarriages?
Currently, or during previous pregnancies have you suffered any of the following
conditions?
Symphysis Pubis Dysfunction
(SPD)
Carpal Tunnel Syndrome
Sacrum or SIJ Pain
Bleeding during pregnancy
Knee Pain
Low Back Pain
Upper Back Pain
Neck Pain
Coccyx Damage or Pain
Separation of your abdominal
muscles
Varicose Veins
Gestational Diabetes
High Risk Pregnancy Indicators
The term "high-risk pregnancy" describes a case where a pregnant woman has one or
more factors that could put her or the fetus at risk for health problems.
In general, a pregnancy may be considered HIGH RISK if the pregnant woman:
1.
2.
3.
4.
5.
6.
7.
8.
Is 35 years or older.
Is 15 year old or younger.
Is either extremely under or overweight during pregnancy.
Is pregnant with one or more fetuses
Has Gestational Diabetes
Has high blood pressure
Has heart or lung disease
Has diabetes, lupus, asthma
*Although deemed factors that contribute to a HIGH RISK pregnancy are not
necessarily TOTAL CONTRAINDICATIONS to massage but PERMISSION must be
sought from the clients’ HCP before commencing therapy.
Post Natal Pre-Therapy Health & Lifestyle Questionnaire
You are advised to ALWAYS carry out a full INITIAL CONSULTATION before commencing any
therapy.
Client Name:
No. Of Weeks Post Natal:
Client Address:
6 Week Check Carried Out? & Results:
Health Care Provider Details:
Client Phone No:
Client Email:
First Impressions/Visual Assessment
Open-Ended Questions
Reason for seeking Therapy today? Where do
you have pain/discomfort? (Use Body Map
Diagram)
Last visit to Primary Health Provider and
outcome?
6 week check-up carried out?
Have you or are you currently suffering from any of the following conditions?
Symphysis Pubis
Dysfunction
Carpal Tunnel Syndrome
Sacrum or SIJ Pain
Low Back Pain
Knee Pain
Coccyx Damage or Pain
Upper Back Pain
Neck Pain
After-effects of Gestational
Diabetes
Separation of your
abdominal muscles
Varicose Veins
Piles/Haemorrhoids
Post Natal Therapy
Contra-Indications Biased Open-Ended Questions
Are you currently or have you experienced any problems in the following areas in your
post natal period?
Fever?
Prolonged post natal bleeding (more than 8
weeks)?
Burning while urinating?
Passage of clots or heavy bleeding?
Difficulty urinating?
Resumed bleeding after cessation?
Swollen, red, painful area(s) on calves or
lower legs?
Increase pain/discomfort/poor healing at
Episiotomy site?
Painful breasts?
Increased pain/discomfort/poor healing at
the C-Section site?
Sore, itchy vagina and discharge?
Rationale for Post Natal Contraindications - Referral to HCP
The following are all TOTAL CONTRAINDICATIONS TO THERAPY. They are potential Post
Natal emergency situations and as such, IMMEDIATE REFERRAL to primary HCP is strongly
advised.
Fever
It may indicate uterine infection, bladder or
kidney infection, breast infection (mastitis) or
other illness.
Burning with urination or blood in
urine
Inability to urinate
This could indicate a bladder infection
Swollen, red painful area on leg
(especially calf) which is hot to touch
Thrombophlebitis – development of blood clot in
blood vessel. However, remember that DVT’s are
not always symptomatic!
Sore reddened painful area on the
breast in addition to fever and flulike symptoms
Breast infection, probably Mastitis.
Passage of large red clots, pieces of
tissue or return of bright red vaginal
bleeding after flow has decreased
and changed to brownish pink or
yellow
Foul odour to vaginal discharge,
vaginal soreness or itchiness
Possibly:
Retained fragment of Placenta
Uterine infection
Over Exertion
Increase in pain in Episiotomy site,
may be accompanied by bleeding or
foul-smelling discharge
Infection of Episiotomy, reopening of incision or
tear, stitches given way.
Slight opening or c-section incision
wound, maybe accompanied by foulsmelling discharge and blood
Infection of c-section incision
Slow healing/over-sore c-section
wound
If cause for concern, wise always to seek advice.
This could indicate a bladder infection
Uterine or vaginal infection
Seeking Permission from Clients’ GP for Therapy
10th March, 2006.
Dr. Parker,
Kensington Surgery,
Poole Road,
London,
W14 4JK.
Dear Dr. Parker
Re: Gemma Brown, 56 Target Road, Willesden, NW1.
DOB: 4.12.74 – 22 Weeks Pregnant
Gemma has attended my clinic requesting a session of massage and remedial therapy because of
various muscularskeletal issues relating to the postural changes of pregnancy.
I have asked Gemma to seek your permission for massage as she is expecting twins and multiple
births are a ‘reason to seek permission’ to receiving massage therapy and it is deemed good practice
to seek permission from the clients’ HCP.
Type of Therapy Proposed:
Your permission to proceed or advice regarding the treatment options for Gemma would be greatly
appreciated.
Yours Sincerely,
Jenny Burrell, BSc (Hons), ITEC, BTEC
Pregnancy & Post Natal Massage & Remedial Therapy Specialist
Planning Your Awesome Session
Welcome & Begin
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Elevated Supine
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Side Lying – Top Leg Exposed
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Side Lying - Bottom Leg Exposed
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Side Lying – Back 1
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Side Lying – Back 2
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Ending
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