I, _______________________________ have received and read the attached written information about the possible contraindications to massage therapy during pregnancy. I have also discussed this information with my physician and have had an opportunity to ask questions of the massage practitioner and of my physician about the information. I understand the information, and confirm that
· I have not experienced any of the complications listed on the attached sheet;
· I have not experienced any of the conditions listed which would make it unwise to have massage therapy;
· I am experiencing a low-risk pregnancy;
· I am receiving medical care including regular check-ups throughout my pregnancy.

If my physician and I have identified any exclusions to the statements above, they are listed here:

________________________________________________________________________

________________________________________________________________________

Signed: _____________________________________ Date:_______________________

Print name: _________________________________________

INFORMATION SHEET FOR MASSAGE THERAPY CLIENTS
AND THEIR PRENATAL CARE PROVIDERS
BENEFITS AND CONTRAINDICATIONS TO MASSAGE THERAPY
DURING PREGNANCY

BENEFITS.

There are several observed or identified benefits to massage during pregnancy. Massage can:

· Relieve muscular tension, especially in low back, upper back, shoulders and neck.

· Reduce stress on weight-bearing joints.

· Enhance body awareness-better posture-less discomfort. Assist with body mechanics
and movement during structural changes.

· Support birth process by relaxing muscles involved in labor and birth.

· Ease anxiety and stress during time of transition.

· Give emotional support and nurturance.

· Offer greater ease in ventilation due to relaxation of muscles of breathing.

· Improve sleep.

· Reduce stress hormones.

· Reduce back pain.

· Prevent labor complications and postnatal complications.

CONTRAINDICATIONS.

There are also contraindications to massage during pregnancy. These include the following:

COMPLICATIONS OF PREGNANCY

Early labor/miscarriage threat/placental or cervical dysfunction
Gestational Edema Proteinuria Hypertension (GEPH or Pre-eclampsia)
Eclampsia
Gestational Diabetes

Because Massage Therapy is contraindicated for the above complications, it is also contraindicated for women experiencing any of the following symptoms/signs related to the above complications:

SIGNS AND SYMPTOMS OF COMPLICATIONS

Bloody discharge
Continual abdominal pains
Sudden gush of water or leakage of amniotic fluid
Sudden, rapid weight gain
Increased blood pressure
Protein or sugar in urine
Severe back pain that does not subside with changing of position
Systemic edema, “pitting” edema
Visual disturbances
Severe nausea and vomiting
Severe headaches
Excessive hunger and thirst
Increased urination in the second trimester.

There are also additional conditions that contraindicate massage therapy, including any phlebitis, thrombosis or suspected clotting condition, any kidney, liver or spleen compromise, and infections. Local massage on areas with severe varicose veins and swelling are avoided due to clotting risk.

HIGH-RISK PREGNANCIES
The following high-risk pregnancies must be closely monitored by the physician in order to determine the advisability throughout the pregnancy of general circulatory massage, pressure, and massage position options:

Women under 20 or over 35 Rh or genetic problems
Asthma Liver or renal condition
Previous problem pregnancy Multiple births
Diabetes Heart Disease
Hypertension

These situations must be monitored closely, and if complications arise, general circulatory massage, pressure, and some massage positions may be contraindicated.