Proceed With Caution:
Foot/Ankle Massage for Pregnant Clients
By Leslie Stager
Most massage students have heard the warning, “Don’t
touch a pregnant women’s ankles,” yet few can articulate definitive reasons for
this contraindication apart from a generic fear that it will trigger
contractions. Considering the high percentage of miscarriages each year,
perhaps there is good reason for caution, yet the warning does not appear to be
based on research or even much anecdotal evidence. It does raise questions,
however: How did this concern about touching the ankles develop and is there
documentation to validate it? Is gentle touch during pregnancy powerful enough
to cause harm?
As a pregnancy massage specialist and author of the
textbook Nurturing Massage for Pregnancy: A Practical Guide to Bodywork for the
Perinatal Cycle (Lippincott Williams & Wilkins, 2009), I researched further
with the intent of either alleviating unnecessary fears or clarifying what
precautions are truly necessary. This article is based on journal research,
interviews with bodywork and obstetrical specialists, and personal experience.
It explores the “ankle” contraindication, reasons why it developed, and
presents the information and conclusions gathered from this investigation.
Touch During Pregnancy
For thousands of years, midwives and
traditional birth attendants have used touch as an integral part of perinatal
care to maintain optimal fetal positioning, to assess a mother and baby’s
well-being, to support or stimulate contractions, to relieve pain during labor,
and to release a retained placenta or prevent hemorrhage after delivery. Birth
was considered a natural event that was not without its inherent risks, but
often a skilled attendant—who used her hands to palpate and sense the condition
of those seeking her care—helped mitigate those risks.
With the development and expansion of the medical
establishment in the early 1900s, doctors—rather than traditional
midwives—became the overseers of the birth process. Birth became a medical
event and the use of touch as a means of evaluating and supporting pregnancy
was eventually replaced by other technologies. Pregnancy was identified as a
dangerous and fragile condition with many forms of activity viewed as potential
adversaries to a healthy outcome.
In the 1970s, natural birth pioneers, such as
Frederick Leboyer, began to promote the idea of a gentle, less medical birth.
By the late 1980s, birthing centers became popular as they focused on creating
a home-like environment. This movement coincided with the mainstream expansion
of natural and complementary healing modalities, such as massage. While some
anxieties about the safety of pregnancy were diminishing, massage therapists
were being taught that it was potentially dangerous to massage pregnant women.
The 1990s brought increased research about
pregnancy health, and prenatal massage finally began to be recognized as
beneficial. Research indicated that massage could help decrease stress and the
production of catecholamines (stress-related hormones), improve hormonal
functions, speed labor, reduce pain from contractions, and increase the
frequency and ease with which a mother touched her new infant, benefits known
to traditional birth attendants long ago.
Even with a growing body of research, some myths
and fears still linger today regarding the safety of perinatal massage. Some
students are taught not to massage in the first or second trimester, others
learn not to touch the pregnant abdomen. One of the most common myths still propagated, is that
massaging a pregnant woman’s ankles can be dangerous, possibly stimulating
miscarriage or labor. Despite the prevalence of this contraindication, there is
no evidence that ankle massage is dangerous. The concern may have
developed from specific information that was gradually altered through oral
transmission, eventually becoming generic and essentially useless.
Understanding the rationale behind a
contraindication empowers practitioners with knowledge and the ability to
practice more safely. As we examine the warning against ankle massage—which has
permeated not only massage schools, but the general public as well—we must seek
clarification. What is really meant by the ankles? Is it the boney malleolus or
does it include the inner calf and foot? What type of massage it is referring
to—all touch, or specifically to effleurage, deep tissue, acupressure, shiatsu,
or reflexology? The term massage is not clearly defined, but to be
relevant to massage therapists, one might assume that it refers to effleurage
or other Swedish massage manipulations. It does not seem to specify
acupressure, which is the only technique that actually may have a relevant
following quotes demonstrate the abounding misinformation and various
interpretations of this contraindication, as well as the ease with which myths
can be perpetuated:
• “Don’t undergo reflexology from a therapist
who is not trained to work with pregnant women. Certain reflex points on the
lower legs, around the ankles, and in other areas may cause contractions.”
• “My doctor told me no foot massage. She said
that if foot massage is done incorrectly, it can induce preterm labor.”
• “… [ankle massage] is safe but there are two
points you should avoid. One is in the arch of the foot and the other is on the
inside of the ankle about 2 inches up from that ankle bone that sticks out. You
can rub gently over those areas but nothing vigorous or constant.”
• “My friend is a certified pregnancy massage
therapist and he won’t massage woman’s feet because he doesn’t want to be sued
if something goes wrong. They taught him not to in school.”
These quotes represent a generalized fear about
causing harm during pregnancy. In these examples, the clients of one therapist
miss out entirely on foot massage, reflexology gets a bad rap as potentially
dangerous in pregnancy, a doctor warns against foot massage, and the location
of potent acupoints are described with total inaccuracy.
demonstrates four common reasons that the prohibition of ankle massage during
pregnancy seems to have developed:
There is still a common belief that pregnancy is a delicate or dangerous
There is misinformation about uterine and ovarian reflexology zones located
around the ankles.
There is misinformation about acupressure points near the ankles that may be
used to support labor.
There is an underlying fear of being sued if a woman miscarries after a
The perception of pregnancy as a vulnerable and
fragile state, and the fear that miscarriage or contractions can easily be
triggered, has developed in part due to unfamiliarity with the birthing
process, and in part due to the fact that there is uncertainty associated with
any early pregnancy. Miscarriage—birth before 20 weeks gestation—is very common
during the first trimester of pregnancy, occurring in about 15 percent of
pregnancies annually.The vast majority of these occur before 12–13
weeks gestation. According to the Centers for Disease Control and Prevention
(CDC), of the 6.40 million estimated pregnancies in the United States in 2000,
miscarriage occurred in 1.03 million. The numbers are much greater when we
consider all the miscarriages that happen too early to be recognized or
reported as pregnancies.
Most miscarriages result from a healthy response to
the early abnormal development of an embryo. Other known associations include
maternal issues, such as cervical or uterine problems or conditions such as
diabetes, infection, or virus. Miscarriage is also associated with increased
paternal age, as well as maternal drug use. Women who have three
consecutive miscarriages in the first trimester have a 35 percent chance of
having another miscarriage. Women with this experience will often have a
significant level of anxiety during consequent pregnancies until well past the
time of the previous miscarriage. Massage can be very helpful at this time by
encouraging relaxation and self-care, although very deep lower abdominal work
that could unintentionally physically manipulate the newly pregnant uterus is
Preterm labor is defined as the onset of
contractions that change the cervix and put the baby at risk of being born
before 37 weeks gestation. Early contractions without cervical changes can be
caused by simple things, such as dehydration or urinary tract infection, while
more serious preterm labor can be caused by issues with the baby’s health, a
shift in hormones, rupture of the amniotic sac, or infection. Most often the cause
the prevalence of miscarriage and the fear of preterm labor, gentle therapeutic
massage to the feet and ankles is not an associated cause. According to
obstetrician Pete Chandler, as well as midwives Carol Gray and Sue Firman, CNM,
if contractions could be intentionally started with a few minutes of effleurage
to a woman’s ankles, everyone would use reflexology to avoid medical inductions
Reflexology has also been, at times, labeled as
dangerous during pregnancy. Under the medial and lateral malleoli are
reflexology zones related to the uterus and ovaries (Image 1). Not uncommonly,
therapists express concern that reflexology might be overly stimulating in the
first trimester of pregnancy, or that reflexology or massage to the uterus and
ovary reflexology zones will cause contractions. Dwight Byers, director of the
International Institute of Reflexology, is emphatic that massage cannot
stimulate the uterine and ovarian reflexology zones, and that reflexology itself
applied to these zones will not stimulate miscarriage or preterm contractions.
Both Byers and Christopher Shirley, director of the
Pacific Institute of Reflexology, describe reflexology as facilitating improved
blood supply to the cells of the organs in the corresponding areas of the body.
This, in turn, facilitates optimal physiological functioning. Stimulation of
the pelvic reflex areas around the ankles produces relaxation and reduction of
stress and can be offered safely throughout pregnancy. Rather than dangerous, the effects of reflexology
to the ankles may actually reduce the occurrence of miscarriage by helping
nurture a healthy maternal environment and supporting the developing fetus.
Byers agrees with the midwives: “If it was that
easy to stimulate labor, reflexologists would have a big business running
reflexology-induced abortion clinics and pregnant women, partners, midwives and
doctors would use this noninvasive method for inducing labor.”
Enzer, a midwife, nurse, reflexologist, and author of the Maternity Reflexology
Manual (Soul to Sole Reflexology, 2004), says that reflexology cannot, does
not, and will not make the body do something unnatural. The balancing and
harmonizing qualities of reflexology will enhance the woman’s own self-regulating
mechanisms. Reflexology may give a boost of energy and tip a woman into labor
if her body was already prepared to birth, but cannot induce labor otherwise.
primary danger with reflexology during pregnancy, many reflexologists say, is
the use of very deep pressure by inexperienced practitioners that can cause
pain and/or damage to edematous tissues. Deep pressure that is painful also
causes stress, counteracting the benefits of nurturing touch.
Another common reason cited for avoiding
massage to the ankles is the fear of stimulating acupressure points that might
trigger contractions. Again, misunderstandings abound regarding the use,
locations, and methods of accessing acupoints, as well as the differences
between acupressure as opposed to acupuncture prohibitions. Some
acupuncture contraindications exist to prevent causing direct harm using the
needling technique. These points are not necessarily contraindicated for
and shiatsu can be used to support the induction of labor when desired;
however, in order to have any hope of encouraging uterine contractions, a
different type of touch is required than is provided by general massage.
Acupressure typically requires applications of direct pressure stimulating
specific points over a period of hours or days in order to have a lasting and
cumulative effect. Even then, many skilled practitioners are not successful in
Acupoints that are often considered useful in
efforts to stimulate contractions are located on the inner leg, hand, sacrum,
and one adjunctive point just posterior to the lateral malleolus—Bladder 60. However, there are discrepancies in massage and acupressure texts
regarding prohibited acupoints. A variety of points around the ankles are
sometimes listed as contraindicated, including Kidney 3, Kidney 4, Kidney 5,
Kidney 8, and Bladder 62. These points can be used to support
labor, calm the mind, beneficially influence the uterus, drain heat, move
blood, or relax the back. But they are not considered points that trigger
contractions and are not standard contraindications during pregnancy.
Bladder 60 is the only point around the ankle that
the majority (but not all) of the sources I researched referred to as
contraindicated. It has properties of drawing energy downward and is often used
in combination with other points when attempting to induce labor.
and acupressure specialists indicate that there are no blanket
contraindications for acupoints and some suggested that the stimulation of
acupuncture points to help induce labor or dislodge a fetus may be “way
overrated.” Chad Dupois, LAc of the Chattanooga Acupuncture and Wellness Center writes, “As with all of
acupuncture, nothing is ever set in stone. There are people/styles [of
acupuncture] who regularly use contraindicated points during pregnancy.” An
example of this is a study investigating the use of acupuncture for reducing
back pain in pregnancy that used the ankle point Bladder 60 on subjects between
12–30 weeks pregnant, with no ill consequences.
Acupressure has its own rules of practice and
contraindications and can be very powerful when properly applied. But the
question being explored here is whether massage can stimulate these contraindicated
acupoints, resulting in serious consequences. Bronwyn Whitlocke, LAc and author of Shiatsu Therapy for
Pregnancy (Spinifex, 1999), says gentle massage or acupressure applied to the
ankles with the intention of relieving discomfort will not cause harm or induce
labor. Instead, it can help reduce edema in the feet and therefore be
beneficial. She finds acupressure to be more subtle than acupuncture. When
working with a woman due for labor, she stimulates points hourly with deep and
continuous pressure over 2–3 days in order to affect the type of cervical
changes that she might see in a shorter time span with acupuncture. One session
on the ankles in an effort to promote labor will not be effective.
Debra Betts, LAc, RN, and author of The
Essential Guide to Acupuncture in Pregnancy and Childbirth (Journal of Chinese
Medicine, 2006) finds Bladder 60 to be stimulating to the uterus. She feels
that general massage could stimulate this acupressure point and cause an
undesirable result if combined with Spleen 6 (on the medial calf) and used with
strong pressure over a period of time on a woman who is susceptible and
sensitive to acupressure points or who is at high risk for miscarriage. The
concern is greater, she states, with pregnancies earlier than 12 weeks or later
than 36 weeks, when the risks of miscarriage or preterm labor are greatest. She
suggests avoiding touch to this and all the contraindicated acupoints during
On the other hand, Suzanne Yates, bodyworker,
antenatal educator, and author of Shiatsu for Midwives (Books for Midwives,
2003), says that she often gently massages around the ankles with light
pressure as she connects with the mother’s womb. “I have done this kind of work
for 18 years now and not had any problems. Indeed, I feel it is of benefit. In
the first trimester, it is calming and supporting the flow of the jing, an
important energy which nurtures the baby.”
Stephanie Halderman, EMT, director of the Eastern Holistic Center,
has been instructing acupressure and massage for pregnant women for years, and
says she has not learned of Bladder 60 being a contraindicated point. “B60 is
not a forbidden point, so it is safe to massage. Light, gentle, full strokes
[effleurage] is fine and will not induce labor around the ankles (but focused
work can),” she says.
Kensen Saito, director and co-founder of the
International Academy of Tokyo in Canada and author of Shiatsu-doh
(Cross Media, 2004), trained under Tokujiro Namikoshi, the founder of shiatsu
whose motto was, “The heart of shiatsu is like a mother’s love. Pressing the
human body stimulates the fountains of life.” Saito says that safety is the key
to treating clients. He works gently on the whole body with pregnant women,
including the ankles in most cases. The only danger and concern Saito expresses
is the improper application of pressure that may be too deep and strong. This
type of intensive pressure application would be injurious to both the tissues
and the emotion of the client, he says.
In the End
Ultimately, the ankle massage warning seems to refer to stimulation of
acupoint Bladder 60. The other ankle points that pregnancy massage sources have
labeled with concern do not have properties that bring on contractions, and may
actually support a pregnancy. So the question remains: what is the likelihood
of causing significant or dangerous contractions by stimulating Bladder 60 with
stroking and squeezing along the Achilles tendon for a few moments during a
likelihood seems remote for several reasons: massage therapists typically do
not repetitively massage one specific spot posterior to the ankle for extended
periods; general effleurage does not have the same effects as acupressure; and
Bladder 60 is not generally used alone or as a primary contraction stimulator.
This is not to say that one should rub the Achilles tendon with gusto for hours
on end. Nurturing, gentle touch is always expected and appropriate during
Clarifying contraindications can reduce both
therapist and client’s fears about the delicacy of pregnancy and improve
awareness about the prevalence of miscarriages unrelated to external forces. If
we have concern about stimulating Bladder 60 with effleurage and want to avoid
it, then to be consistent, we must, as Betts says, also avoid massage to areas
of all the prohibited points. Ironically, the more powerful contraindicated
acupoints on the hand (Large Intestine 4), inner calf (Spleen 6), and sacrum
(Bladder 32) have not formerly elicited massage contraindications.
Alternatively, we can offer nurturing gentle
massage that includes those areas, while following more critical and relevant
guidelines for safety in positioning, pressure, and observation for thrombosis
and varicose veins. And we can educate the public on the benefits and safety of
prenatal massage along the way.
Despite the difficulty of intentionally inducing
contractions with bodywork, one of the greatest fears therapists have about
working with a pregnant woman is doing something that could cause her to
miscarry or experience preterm labor. Not only would the burden of guilt be
unbearable in thinking that your nurturing touch caused a miscarriage, but
potential litigation is frightening as well. Could a massage practitioner be
held responsible for a miscarriage if they did indeed rub the ankles of a
pregnant woman? I could
uncover no legal evidence of a case where massage to the ankles was shown to be
related to miscarriage.
As for anecdotal evidence, none of the experts
interviewed for this article knew of any successful lawsuits. Enzer had heard
of two unsuccessful lawsuits against reflexologists—one in the United Kingdom and one in Australia—where the reflexologists
were accused of causing a miscarriage with their work. The outcomes were in
favor of the reflexologists, but tensions and fears increased.
One massage therapist reported that years ago at a spa
a massage therapist was unsuccessfully sued when a pregnant client suffered a
miscarriage after the massage. The therapist was accused of rubbing the client’s
ankles and causing the miscarriage, but there was no evidence to support the
live in a litigious culture, and miscarriage can breed fear and angst for
women, leading them to seek a reason for their loss. However, there is no
research or evidence to support a lawsuit accusing a therapist of causing a
miscarriage by rubbing the ankles.
Ultimately, It’s Her Call
Some clients will have heard that touch to the ankles must be avoided during
pregnancy. If they are hesitant or concerned despite your reassurances, by all
means abide by their wishes. The ankles will not miss a little touch, and the
mother will feel more relaxed knowing you are respectful of her concerns.
Leslie Stager, RN, LMT, is a perinatal
massage specialist, doula, writer, and hospice nurse. She has taught perinatal
bodywork at the Oregon School of Massage since 1993, initiating the 60-hour
Maternity Massage certification program in 2007.
She is the author of Nurturing
Massage for Pregnancy: A Practical Guide to Bodywork for the Perinatal Cycle
(Lippincott Williams & Wilkins, 2009) and the instructor on the DVD,
Mastering Pregnancy Massage. Her other DVDs, Mothertouch: Nurturing Touch for
Birth and the upcoming Touch Techniques for Birth, are based on her experience
attending hundreds of hospital and home births.
Reach her at
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