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
Using Your Body Correctly
Since midwives will have to adapt their techniques and body positions to accommodate their laboring clients, they need to learn body-saving and hand-saving techniques.
When standing behind or next to a client, keep your shoulders and hands relaxed and use your legs and feet for strength. Shift your body weight from leg to leg and lean into your client for additional strength rather than using your arms to do so.
When kneeling behind the mother, place a pillow under your knees and continue to shift from leg to leg while massaging or pressing. Keep your shoulders relaxed and remember to breathe. Stand or sit after each stroke to get the circulation back into your legs.
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.
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