The dictum Primum non nocere or “First, Do No Harm” is often attributed to the Greek physician Hippocrates. While Hippocrates made statements similar to this, the exact phrase is attributed to French physician Auguste François Chomel (1788–1858; Wikipedia: “Primum non nocere”).

While originally written for medicine, the rule to do no harm applies to our work as well. Before considering how to help, we must first consider how to prevent harm. Primum non nocere has special meaning during pregnancy. During pregnancy the stakes are higher in two ways: 1) there are two clients instead of one; and 2) pregnant women and, even more so, their unborn children are more vulnerable than most of our clients. Utmost caution must be exercised by the practitioner working on pregnant women.

This article first discusses some of the risks of Rolfing Structural Integration (SI) during pregnancy. There are two kinds of concern that will be discussed: physical/biological and emotional/legal. Next, the value of screening for such risks as a guide to whether or not to perform Rolfing sessions is discussed, and finally ways to proceed cautiously if a decision is made to do some Rolfing sessions.

Physical/Biological Concerns

Physical/biological concerns involve the ‘baby’ (whether fertilized ova, zygote, embryo, fetus, or baby), the mother, or the mother-baby unit.

Baby Death Rate: A large majority of fertilized ova die before reaching full term. Estimates of death before birth range for 67% to 90% of fertilized ova. Death of the zygote, embryo, or fetus can occur at any stage of development, and mortality is greatest in the early stages. A majority of fertilized eggs do not reach implantation. After implantation there are still lots of embryo and early fetus deaths. After the end of the embryo period at about forty-three days after conception, survival rates are higher, but there is still substantial loss during the first trimester. The longer a fetus survives, the more likely it is to survive yet longer; however, some babies are stillborn at term (Boklage 1990).

Mother Death Rate: Death rates in the United States among pregnant women from causes related to pregnancy have risen steadily over the past thirty years from 9.1/100,000 in 1980, to 18.4/100,000 in 2013. In developing nations, up to 5% of women die during pregnancy or delivery (Wikipedia: “Maternal Death”).

Mother and Baby Hardiness: Some mother-baby pairs are quite sturdy with both members of the pair known to survive severe injuries or illness. On the other hand, one or both members of other mother-baby pairs are fragile in varying degrees ranging from mild to severe. As described in the previous section, a majority of fertilized ova, etc. do not survive, and some mothers die. Any physical intervention with a mother-baby pair must be considered as an added stressor, a potential last straw. It is therefore essential to consider risk factors and to proceed with the utmost caution.

Risk Factors

According to the National Institutes of Health [see entry in bibliography for more detail], risk factors for the pregnancy include:

• Existing health conditions

??High blood pressure

??Polycystic ovary syndrome

??Kidney disease

??Autoimmune disease

??Thyroid disease

??Infertility

??Obesity

??HIV / AIDS

• Age less than twenty or, for a first pregnancy, age greater than thirty-five
• Lifestyle factors (smoking, alcohol use)
• Conditions of pregnancy

??Multiple gestation (twins, triplets or more; a majority of multiple pregnancies involve the death of at least one of the babies)

??Gestational diabetes

??Preclampsia and eclampsia

• Previous spontaneous abortion or stillbirth
• Lack of regular and sufficient prenatal care

Emotional/Legal Risks

Death of a child, even an unborn child, is one of the most painful of all emotional experiences (Rogers et al. 2008). Death of a spouse is a severe stressor (Watson 2015) – the most stressful life event on the Holmes-Rahe stress scale, rating 100 points [(Pain Doctor website (undated)].

If a woman and/or her baby come to harm and there is a healthcare professional involved, it is easy for the grieving survivors to blame the healthcare professional. For this reason, being an OB/GYN (obstetrics and gynecology) doctor is one of the ten medical specialties with the highest malpractice claim risks. About 12% of OB/ GYN doctors face a malpractice claim each year, compared to 7% for all physicians and 5% for family practice (Jena et al. 2011). The average OB/GYN malpractice payout is about $350,000, and million-dollar claims are common. Malpractice insurance rates are correspondingly high. In some states OB/GYN doctors pay annual malpractice premiums approaching $200,000 per year. When we work with pregnant women, we become part of this risk pool.

Screening to Reduce Risk Factors

While there is no way to completely eliminate risk, there are ways to reduce risk:

• Screen for the risk factors listed above. Ask the woman if she is aware of any additional risk factors. The greater the number of risk factors a pregnant woman has, the greater our caution must be. A single risk factor may be enough to defer Rolfing sessions until well after delivery of the child.
• Make appropriate referrals for care other than, or in addition to, your work. Get to know the healthcare community in your area so you can make targeted referrals.
• Screen for emotional sturdiness. Do not take the woman on as a client if she appears in any way to be 1) in emotional distress; 2) prone to large mood swings; 3) emotionally fragile; or 4) a litigious-oriented person.

 

• Communicate clearly and consistently with your client. Listen attentively. Reflect in paraphrases. Ask clear questions. Describe what you are doing. Ask for paraphrase responses to check if your client understood. Watch your client’s response to your communication. Adjust your pace, tone, and vocabulary to achieve clear communication.
• Never use high-force techniques. There is no need for knuckles and elbows with body weight behind them in working with a pregnant woman. That is both potentially unsafe and unnecessary.

Considerations for Rolfing Work During Pregnancy

Relaxin Hormone

Relaxin hormone levels increase during pregnancy (Wikipedia: “Relaxin”). These hormones soften the connective tissue of the pelvic joints to facilitate the birthing process, and also soften all other connective tissue in the body. This generalized softening of connective tissue is sometimes quite troublesome to a woman late in pregnancy, giving her a generalized hypermobility resembling a temporary case of Ehlers Danlos syndrome (Wikipedia: “Ehlers Danlos Syndrome”).

Some good news for Rolfers and their pregnant clients is that the relaxin hormones make tissue much easier to change, allowing us to use truly gentle techniques to make tissue change, such as unwinding, first-barrier load techniques, and Harold Hoover DO’s centralizing technique.

Signs of Distress

Constantly watch for signs of autonomic arousal or any sign of distress. Signs include:

• Skin color changes

??Reddening

??Going pale

• Piloerection (body hair standing up)
• Breathing rate changes

??Breath rate speeding up

??Marked slowing of breath

??Stopping breathing

• Pupil dilation changes

??Wider

??Narrower

??Unequal between the two eyes

• Dizziness
• Confusion

At the same time you are vigilant, express calmness and confidence in your manner and voice. Besides watching, ask your client to tell you of the slightest distress. She may feel things that you cannot see. Stop at the first hint of a problem.

Work Smarter Not Harder

With a pregnant client, we want to work smarter not harder. Keep sessions shorter and spaced further apart. Weekly is too much input for a pregnant woman. Do not overwork the client.

During pregnancy the abdomen is not safe to work on, and the adductors of the leg are highly questionable to work on, particularly more proximally. Thus surface-core relationships cannot be addressed from the deeper layers. Therefore, the Ten Series is not possible during pregnancy.

The growing baby expands the mother’s body from the center, so providing space at the periphery will often provide comfort-producing accommodation. Work to provide ease and comfort as the pregnancy evolves. Working on the lower legs and feet, on the arms and hands, and cautiously on the neck often provide ease and comfort.

Specific Training

Gt s pc i f i c t r a iig iwo r k ig w i t h p rgat w o mn . Q u a l i t y training for working with pregnant women is available from Carol Gray (www.carolgray.com) and Carole Osbourne (http://bodytherapyeducation.com/ about-body-therapy-education/instructors/ carole-osborne). The methods taught by these teachers are gentle and precise. While they are not Rolfers, their methods are quite useful to achieve the goals of Rolfing SI, and Rolfing SI has always been defined only by goals, not by any particular method. In one famous anecdote, Ida Rolf agreed that if the goals of Rolfing SI could be achieved by whistling a popular tune, that would be Rolfing SI.

Get training in osteopathic listening and related assessment methods. These assessment methods nicely complement the visual assessment methods taught in the Rolfing training. If we but know how to listen, the body has a great deal to tell us about where and how to work safely and efficiently. Training in listening is available from The Barral Institute ( h t t p/ / s h o p . i a h. c o m /Wo r k s h o p s / Listening-Techniques1-An-Integrative- Approach-to-Evaluation-LT1) and the author (www.jeffreyburch.com/study-with-jeffrey/ f uc t i oa l – mt h o d s – f o r – m au a l – therapy-3/).

Conclusion

In summary:

• Know and assess for pregnancy risks
• Work smarter not harder
• Assess well, and from multiple perspectives
• Use only the most gentle techniques
• Stop at the first hint of distress in the mother
• Space treatments farther apart

Jeffrey Burch was born in Eugene, Oregon in 1949 and grew up there except for part of his teen years in Munich, Germany. He was educated at the University of Oregon, Portland State University, and the University of Pavia, Italy, earning bachelor’s degrees in biology and psychology and a master’s degree in counseling. Jeffrey received his Rolfing certification in 1977 and his advanced Rolfing certification in 1990. He trained extensively in cranial manipulation with French etiopath Alain Gehin, and in craniosacral therapy with the Upledger Institute. Jeffrey trained to the instructor level in visceral manipulation under Jean-Pierre Barral and his associates. He has made substantial innovations in visceral manipulation, particularly for the thorax. Jeffrey has also developed groundbreaking new joint-mobilization techniques. He practices in both Eugene and Portland, Oregon and offers continuing education courses at several locations including Eugene, Oregon; Longmont, Colorado; Chicago, Illinois; and Newton, Massachusetts. For more details see www.jeffreyburch.com/biography.

Bibliography

Boklage, C.E. 1990. “Survival probability of human conceptions from fertilization t o tr m . ” Intrna t i ona l J ourna l o f Fertilization 35(2):75, 79-80, 81-94. Available at https://en.wikipedia.org/ w / idx . p h p ? t i t l= H u m a_m b r y o gns i s & o l d i d = 8 0 6 4 9 2 8 2 3 (retrieved 11/2/2017).

Jena, A.B., S. Seabury, D. Lakdawalla, and A. Chandra 2011. “Malpractice Risk According to Physician Specialty.” New England Journal of Medicine 365:629- 636. Available at www.nejm.org/doi/ full/10.1056/NEJMsa1012370#t=article (retrieved 11/2/2017).

National Institutes of Health, undated. “What are the factors that put a pregnancy at risk?” www.nichd.nih.gov/health/topics/ high-risk/conditioninfo/pages/factors.aspx (retrieved 11/2/2017).

Pain Doctor website (undated). “Top 10 Most Stressful Life Events: The Holmes and Rahe Stress Scale.” https://paindoctor.com/ top-10-stressful-life-events-holmes-rahe-stress-scale (retrieved 11/2/2017).

Rogers, C.H., F.J. Floyd, M.M. Selzer, J. Greenburg, and J. Hong 2008. “Long- Term Effects of the Death of a Child on Parents’ Adjustment in Midlife.” Journal of Family Psychology 22(2): 203-211. Available at www.ncbi.nlm.nih.gov/pmc/articles/ PMC2841012 (retrieved 11/2/2017).

Watson, S. 2015. “Death of a spouse or partner can lead to a heart attack or stroke.” Harvard Health Blog, Harvard Health Publishing. Available at www.health.harvard.edu/ blog/death-spouse-partner-can-lead-heart-attack-stroke-201402277055 (retrieved 11/2/2017).

Wikipedia, The Free Encyclopedia, “Ehlers Danlos Syndrome.” https://n . w i k i pd i a . o r g / w / idx . p h p ? t i t l= E h lr s % E 2 % 8 0 % 9 3 D al o s _ syndromes&oldid=808314350 (retrieved 11/2/2017).

Wikipedia, The Free Encyclopedia, “Maternal Death.” https://en.wikipedia.org/ w / idx . p h p ? t i t l= M a tra l _ death&oldid=807109670 (retrieved 11/2/2017).

Wikipedia, The Free Encyclopedia, “Primum non nocere.” https://en. w i k i pd i a . o r g / w / idx . p h p ? t i t l= P r i m u m _o_o cr& o l d i d = 786702417 (retrieved 11/2/2017).

Wikipedia, The Free Encyclopedia, “Relaxin.” https://en.wikipedia.org/w/ idx . p h p ? t i t l= Rl a x i& o l d i d = 792770589 (retrieved 11/2/2017).Concerns and Considerations for Rolfing® SI During Pregnancy[:]