Low Back Pain at 28 Weeks and a Request for Prone Deep Tissue

Positioning: side-lying (left lateral) is the default.

• Pillow under the head to keep the neck neutral; a bolster or folded towel under the abdomen to support the uterus and stop it dragging on the round ligaments; a pillow between the knees and ankles so the top hip does not rotate or adduct; the lower leg slightly flexed, the top leg supported. A small pillow under the top arm.
• A semi-reclined position with wedges is a reasonable alternative for the upper body and can be used if she becomes uncomfortable side-lying. Keep the torso inclined at roughly 30–45 degrees.
• No prone. After about 20 weeks the uterus is too large to lie on safely and comfortably; a pregnancy table or cushion system is needed for prone work, and there is none here. Telling her 'we will do it differently' is easier than letting her climb face down and then asking her to move.
• Supine only briefly, if at all. The weight of the uterus on the vena cava can cause supine hypotensive syndrome - dizziness, pallor, nausea, a drop in blood pressure. If she lies supine at all, use a wedge under the right hip to tilt her to the left and keep it under five minutes.

Pressure and areas:

• Moderate, comfortable pressure. Firm is not forbidden on the lower back - she is asking for relief and moderate lumbar work is reasonable - but deep, sustained pressure on the lumbar and sacral area in a side-lying position can be hard to tolerate and is reduced rather than pushed through.
• Avoid: the abdomen entirely; deep pressure into the inguinal area, the inner thigh and any varicose veins; strong breast work; deep pressure over the lower legs if there is swelling or calf tenderness.
• Acupressure points: strong, prolonged pressure at LI4 (web of the hand), SP6 (inner ankle) and GB21 (top of the shoulder) is traditionally cautioned in pregnancy. The evidence that these induce labour is weak, but the precaution costs nothing - use light contact, do not apply strong sustained pressure, and tell her why.
• Duration: 90 minutes is a long time on one side for a pregnant client. Offer 60 minutes with a position change halfway, or split the 90 minutes with a break; this reduces discomfort and the chance of dizziness.

Justification to give her: 'Everything I am changing is about your comfort and blood flow, not because massage is unsafe. You will get the same relief, just lying on your side.'

Before the session, ask and record:

• Any contractions, cramping or lower abdominal pressure? Any pattern to them?
• Any vaginal bleeding, spotting, or fluid leak?
• Is the baby moving as usual today, compared with yesterday?
• Headache, blurred vision, flashing lights, pain under the ribs, sudden swelling of hands or face? These point to pre-eclampsia and mean the session does not go ahead; she is referred to her obstetrician or emergency department.
• Pain, swelling, warmth or redness in one calf - pregnancy increases DVT risk; the same red-flag logic as any client applies.
• Any fever, vomiting, or feeling unwell today?
• Confirm the verbal clearance from the obstetrician and ask her to bring or send written confirmation; document that you asked.
• Her history of a birth at 35 weeks: this is not a contraindication to massage, but it is a reason to keep the session shorter, avoid over-stimulation, and be alert to any cramping. Do not treat it as a predictor that this pregnancy will repeat it, and do not tell her that.

During the session, monitor and stop if:

• She reports contractions, lower abdominal tightening, backache that comes in waves, or pelvic pressure.
• She feels dizzy, nauseated, clammy or short of breath - reposition her, sit her up slowly, check blood pressure if you have a monitor, and do not send her home alone if it does not settle.
• Any fluid leak or bleeding.
• The baby becomes noticeably less active during the session (though fetal movement patterns are hard to interpret in an hour; note it and tell her to contact her provider if it continues).

Escalation rule to state clearly: any of the above ends the session. The therapist's role is to recognise, stop, and refer - not to interpret. Write down what you observed and what you advised, and give her the written advice so she can show her obstetrician.

Answering the acupressure question honestly. She is asking you to do something with a specific intention - to start labour if she goes overdue. That intention matters, because it changes what you are doing from relaxation massage into a procedure you are not trained or licensed to perform, on a pregnancy that is not post-term yet at 28 weeks.

A defensible answer: 'The points you mean are LI4 in the web of the hand and SP6 above the inner ankle. Some traditions say strong pressure there can stimulate the uterus, but the research does not show that it reliably starts labour, and at 28 weeks we are not trying to start anything. I will work those areas lightly as part of a normal massage, but I will not do strong, sustained pressure on them, and I will not do anything designed to bring on labour. If you go past your due date, that conversation belongs with your obstetrician, not with me.'

Why this phrasing: it is truthful about the evidence, it does not frighten her, it does not diagnose, and it still sets a boundary. It also protects her from going to a non-clinical provider later for an induction-style treatment without medical clearance.

Aftercare education (specific, not generic):

• Drink water, and stand up slowly from the table - she is a fainting risk after lying on one side.
• Expect mild muscle soreness for 24–48 hours; report anything sharper.
• Continue the side-lying pillow setup at home for sleep and desk support for her lower back.
• Call her obstetrician, not the spa, for contractions, bleeding, fluid leak, reduced fetal movement, severe headache, visual changes or sudden swelling.
• Call the spa if she has questions about the massage itself or wants to rebook.
• Note in the record that these instructions were given, and book the next session at no more than 60 minutes, with a re-screen each time.