Hopefully all massage students are taught symptoms of DVT’s (Deep Vein Thrombosis or Blood Clots) and understand the importance of avoiding applying any pressure distal to a clot. Many may not realize, however, that the risk of developing clots increases dramatically during pregnancy and postpartum. Many prenatal bodyworkers are taught to avoid or use only light touch to the inner thighs/adductor region throughout this period of a woman’s life because of the generalized increased risk. I researched long and hard the realities of DVT’s during pregnancy and postpartum while writing the text Nurturing Massage for Pregnancy (2008); I came to the conclusion I would support these commonly taught precautions until I had enough information to debunk it. I am now revising my perspective!
By now, I have discussed DVT and pulmonary embolism concerns with vascular surgeons, obstetricians, and midwives, in the USA, and I have spoken to prenatal educators and doctors in other countries. Here is what I have learned:
Unless a client has specific risk factors for developing a clot, none of these professionals recommend bodywork restrictions. Their main concern is that therapists be more aware of the risks associated with blood thinners. If a woman actually Has a clot she will be treated with blood thinners. While on this medication, she will bruise and bleed easily, and only light touch should be used during this treatment, and for some time afterward. (Note: Contrary to popular belief, once a client is being treated for a blood clot, they can still receive bodywork with understanding of the precautions and contraindications.)
After 24 years of researching and teaching MotherTouch prenatal, birth, and postnatal bodywork, and working as a birth professional and labor & delivery nurse, I have come to the conclusion that
using a standard DVT precaution for all pregnant clients promotes unreasonable fear without enough evidence to support its implementation. Rather than broad contraindications, I prefer students to learn facts about specific conditions so that they can make educated decisions and respond appropriately with their individual clients. While this list may sound frightening if you are not well-educated about pregnancy conditions, it actually indicates that the vast majority of pregnant women will not develop a clot. Considering the high rate of cesarean sections in the USA (around 32% of deliveries), it’s the postpartum client who is of greatest concern for DVT.
Women do die from blood clot-embolisms around the world; it is a tragic and frightening reality. However, the likelihood of a massage therapist encountering this in the USA, and causing an undiagnosed clot to embolize––which is really what the fear is about––is extremely remote. Generalized contraindications applicable to all pregnant women because a few are at risk is unreasonable. Many people are at risk for blood clots, but we don’t restrict access to adductors and gastrocnemius/soleus on everyone just because some people might have a clot. Instead, as therapists, we learn who has the highest risk and observe for symptoms in those clients, such as older sedentary people, people with a history of clots, those who doing long distance air travel. The same is true for pregnant clients: the DVT risk increases during pregnancy and even more during postpartum, but this risk is mainly for those who have other specific risk factors related to birthing.
While the frequency of developing clots increases dramatically during pregnancy and postpartum, the risk that one of your clients will have one is still very low (though not impossible!). 1 out of 1000 woman or fewer may develop a clot that may be symptomatic, or non-symptomatic. I personally have worked with clients who have clots. It’s not unheard of in the massage community. However, the likelihood of a non-symptomatic client who has no other risk factors arriving on your doorstep wanting massage, is probably on par with Any client arriving at your doorstep with the same condition. Be aware, screen your clients, and then proceed accordingly. I’m not suggesting that everyone start to ream on perinatal women’s adductors. I’m merely suggesting that the precautions you apply to pregnant women should be based on an understanding of risks so that you can make judgments accordingly.
So what are the risk factors?
The primary risk for developing a clot is having had a cesarean section. This means that most women at risk have already given birth and are no longer pregnant! Other conditions that increase risk include the following: (Please note that most of these conditions are considered high-risk conditions; if you are not specialized in prenatal bodywork working with high-risk conditions already, you should refer these clients to someone who is!)
Postnatal Risk Factors:
1. Instrument-assisted births: The use of forceps or vacuum extractor, both lead to pelvic trauma, and increased risk of blood clots during the first couple weeks postpartum. Your health intake form should ask questions about the type of delivery she had.
2. Cesarean Delivery: Any surgery automatically increases the risk of DVT’s.
3. Family or personal history of clots: There is already a predilection for clots.
4. Extreme pitting edema of the lower extremities: This can indicate preeclampsia, or other system compromise, that would make a woman higher risk for clots.
During Pregnancy:
1. (High Risk Pregnancy) Hereditary or acquired blood clotting conditions: This question needs to be on your intake forms—pregnant or not!
2. (High Risk Pregnancy) Extended immobility and bed rest: Any one on bedrest has a high risk condition for which you obtained a medical release, and are applying many more precautions in general —pregnant or not!
3. (High Risk Pregnancy) Obesity: Obesity is associated with a higher risk for clot dvelopment and for cesarean section. C-Sections are high risk for causing development of blood clots.
4. (High Risk Pregnancy) Preeclampsia: A high-risk condition that leads to other bodywork precautions as well.
5. (High Risk Pregnancy) Multiple pregnancies and births: Any woman who has had more than 3 pregnancies and births, especially with little recovery time between them, is at higher risk for bleeding, blood clots, and a variety of other concerns. Especially if she has had multiple cesarean sections! Multiple pregnancy leads to poor leg circulation and more likelihood of varicose veins, therefore more risk of clots.
6. Pelvic or leg trauma: Anyone with injury or accident involving these regions needs to be observed for blood clot symptoms—pregnant or not!
7. Obvious varicose veins: Have it on your intake form, visualize the legs before doing bodywork, and ask your client about them—pregnant or not!
So my recommendations at this time are that we maintain clot precautions for the following clients, pregnant or not:
1. All postnatal women within 3 weeks of giving birth by cesarean section, or with forceps or vacuum, or had other pelvic trauma or surgery during the birth.
2. Anyone with a family or personal history of blood clotting disorders, or DVT.
3. Any woman indicating high-risk pregnancy symptoms of preeclampsia, high blood pressure, or any condition requiring extended bed rest (more than a few days).
4. Extremely obese clients
5. Recent pelvic or leg trauma
6. More than 3 pregnancies and births within a couple years of one another
7. Obvious large leg or vaginal varicosities.
That said, if you are still uncomfortable with the idea of working on adductors or calves, by all means continue your precautions! That will cause no harm! Just know that, like the myth about acupressure points that many fear will cause labor if they touch them during massage, the precautions are not justifiable by any evidence in research of thousands of pregnant women.
