Relief for Mama's Aching Back

More on sleeping positions

Another important and often cited study: Hills, G.H. and A.G. Chaffe. "Sleeping positions adopted by pregnant women of more than 30 weeks gestation." Anaesthesia, 1994, vol 49, pages 249-250.

In this 1993 study, researchers observed the sleeping positions of 52 pregnant women who were hospitalized at 30+ weeks of gestation against a control group of similarly age-matched women.

Pregnant Group
Left Sidelying -- 76.9%
Right Sidelying -- 21.2%
Supine (on the back) -- 1.9%

Control Group
Left Sidelying -- 25.8%
Right Sidelying -- 32.3%
Supine (on the back) -- 38.7%
Prone (face down) --

Their study was focused on aortocaval compression, which they indicate is easy for women to avoid while awake, but not so easy during sleep. They question whether women “naturally avoid positions which might encourage caval compression syndrome.”

I found this study to be quite interesting, but it left me with more questions. The pregnant group were all hospitalized because they were experiencing complications or were very high risk, and oftentimes, physicians and medical staff will actually tell women to avoid supine positioning, restrict their sleeping to left side-lying. Another group to gather data from would be a pregnant women not experiencing complications (but therefore not hospitalized). Also, this study was actually conducted in the early 1990s,a dn I’m not sure of the spread of information on sleeping positions during that time, but a similar study conducted today would be complicated by the copious information that women gather from friends, books and online – all which tend to staunchly support left sidelying as the ideal sleeping position for pregnant women. So I would ask, are women sleeping on their left sides to “naturally” avoid aortocaval compression? Or because they believe it is the “right” thing to do for the health of their baby?

Safety and Pregnancy Sleeping Positions

Ask almost any pregnant or recently pregnant woman and most will tell you that a pregnant woman should never sleep on her back, and is "supposed to" sleep on her left side at night. In my practice, I hear this from all sorts of pregnant women -- often as early as 12 weeks. Unfortunately, lying on your left side all night every night while you are already uncomfortable can be extremely frustrating for many women who have enough difficulty trying to get the rest their body needs (frequent bathroom trips, heartburn, fetal movements, etc.). Many women will start describing their aches and pains, and inevitably, say, “And, because I can only sleep on my left side…” She’ll then proceed to tell me how her limited sleeping positions are actually exacerbating her pain and discomforts.

A quick survey of pregnancy guides, and an online search on “pregnancy sleeping positions” yields a solid consensus, “left side-lying is the best sleeping position in pregnancy.” These books and sites proceed to describe a host of reasons why “left side” is best. The most wide spread logic given is that this position interferes the least with venous flow, though several also indicate that this position is ideal for the liver and kidneys. Despite the ever-presence of this information, when most of my clients actively engage their OB or midwife, they are told that if they are healthy, they should sleep however they are most comfortable  -- their bodies will actually let them know when it is time to change positions. Many OBs encourage women not to freak out if they wake up in the middle of the night flat on their backs; "waking up" is their body's way of telling them it's time to roll over. 

In my own training, I have spent a considerable amount of time studying safe positioning for women at various stages of pregnancy, and simultaneously, learning ways to always make sure pregnant women are comfortable. The safety concerns were always most restrictive for certain pregnancy complications and for women closer to term. But my job is to make pregnant women comfortable! So, over the next several week's, I will be delving into the medical literature to add some more complexity to this issue.

Off Your Back! Most sources that recommend a left side-lying position are drawing on information gleaned from researchers in the mid-20th century(Kerr, et al) who found that when very pregnant women lay flat on their backs, the weight of the pregnant uterus partially compresses the inferior vena cava, and others soon after found that the aorta as well was partially occluded (Bieniartz, et al). These studies have found that in some women (approx 2 to 4% of third trimester women), the weight of the uterus on the inferior vena cava and aorta can cause blood to pool in the legs, decreasing blood return to the heartand reducing maternal cardiac output. This may then result in a  drop in mom's blood pressure and what has come to be known as "supine hypotensive syndrome" -- which often results in a feeling of faintness, and very rarely actual fainting may occur. Researchers have found that while lying flat on the back leads to vena caval occlusion in all full-term pregnant women, only 5-11 % experience symptoms of hypotension (Kerr, 1965; Kerr, Scott, & Samuel, 1964), and another review of the literature estimates only 2% to 4% of women have significant compression (Farine, 2007). It has been theorized that women who do not experience these symptoms may have a supplementary paravertebral collateral circulation that efficiently returns blood from the pelvis and legs (Kerr et al., 1964; Kinsella & Lohmann, 1994). This supplementary circulatory pathway may not be adequate in those who become symptomatic when lying flat. 

Left is Best. Why left side-lying? Research indicates that while lying on her left side (as compared to right side-lying and flat on her back), a pregnant woman's cardiac output is optimized, as is the oxygenation of her blood. All this suggests to the researchers that any aortocaval compression is less in left side-lying. I am still looking for a reference for this, but I had always learned that it was because of anatomy. The vena cava runs lateral to the midline of the body on the right side, and the aorta to the left. Veins are much less rigid than arteries (particularly the aorta), and would be more prone to compression from a heavy, pregnant uterus than arteries.

Yet, neither the American College of Obstetricians and Gynecologists, nor the Society of Obstetricans and Gynaecologists of Canada make any recommendations on sleeping positioning during pregnancy, and most of my client's obstetricians when approached around this issue, will tell their patients that a healthy woman doesn't need to worry about sleep positioning; she needs to focus on getting comfortable and listening to her body (ie., if she feels dizzy or faint while lying flat on her back, she shouldn't lie on her back).

I was amused to come across a 2007 "Commentary" in the JOGC by Farine and Seaward that reviews the medical literature on sleep positioning in pregnancy. These two MDs found that an increasing number of their pregnant clients were asking if they must sleep on their left sides. They write, "Finding that this relatively unimportant topic was increasingly encroaching upon our time with patients, we did some research." They proceed to discover that the internet was the major source of information on sleeping positions for their moms-to-be, and all but one site in the top search results encouraged women to sleep on their left sides (and from some of the sites I read, they also told women that they would be cutting off their baby's oxygen flow). Only a few of the sites distinguished between stage of pregnancy, or gave any guidelines as to whether a few minutes on your back would be safe. Farine and Seaward conclude:

"In conclusion, advising women to sleep or lie exclusively on the left side is not practical and irrelevant to the vast majority of patients. Instead, women should be told that a small minority of pregnant women feel faint when lying flat. Women can easily determine whether lying flat has this effect on them, and most will adopt a comfortable position that is likely to be a left supine position or variant thereof. Since healthy pregnant women often require more pillows (...and) since finding a comfortable position in bed in late pregnancy is not easy, physicians should refrain from providing impractical advice"(842).

While research does seem to demonstrate that sleeping positions do impact some women's blood pressure and cardiac output, this does not demonstrate fetal compromise in healthy pregnancies. Farine and Seaward wryly note, "If lying prone had been detrimental to a normal pregnancy, the species would long ago have ceased to exist." 

Conclusion: Don't believe everything you read online! While sleeping positioning can have an impact on both mom and baby, the reality is that most doctors and midwives tell women that any comfortable sleeping position will work; strict left side-lying is not medically necessary for most women. These websites and books are being overly cautious. The women who do need to be concerned with their particular positioning are women who are experiencing certain complications. Most women in healthy pregnancies should find positions that are comfortable and do their best to get a good night's rest. Some women will be advised by their caretaker that they should restrict their sleeping positions to side-lying or strictly left side-lying only -- often there are concerns about the functioning of the placenta or mom-to-be's blood pressure. If you are not sure about your own situation, call your caregiver!

NYTimes Doula Article Cont.

After I posted yesterday, I stumbled across the website and blog of the article's author, Pamela Paul. The morning after the publication of the Times article she writes in her blog that she got a lot of flack from doulas and moms for writing a one-sided article. Ms. Paul writes that she hoped to provide a balanced perspective and treat all sides with respect. As I look at some of her other articles and reflect on my own reaction I think this is what I have to say: Her instincts are right on with this piece. Probably why she received so much "flack" is that this is a very sensitive and important issue within both doula and lactation consultant communities. And has been for quite some time. People and organizations within both communities have been working tirelessly for years to increase standards of professionalization. I do hope that if she writes on this again, she will give a much bigger nod to all of the work that is happening already within these communities.

Also, tomorrow is IBCLC Day! Hope to have more then on this important credentialing program.

Doulas giving doulas a bad name

Yesterday's NYTimes had an article on doula support (in the Sunday Styles section) that was a wee bit controversial; check it out at New York Times Doula Support. The article had me all in a tizzy, but it's not that I disagree with some of the content. The article gives the stories of families who do not have great experiences seeking support from doulas and lactation consultants. In one example, a doula tries to force her steadfast belief in natural childbirth upon a family in the labor and delivery room and ends up walking out on them when they choose an epidural, and then another family where a lactation consultant encourages a mom to get her preemies off of tube-fed formula (recommended by the neonatologist) and onto intravenous nourishment until breastmilk became an option. The article also sites examples of hospitals that have banned doulas because they were interfering with the medical staff.

Eeek. Doulas have worked so hard over the past few decades to professionalize and develop standards to prevent exactly these problems. But. Well. The article is not entirely wrong, it's just a little too one-sided. Childbirth often draws really opinionated, orthodox individuals -- ranging from the field of obstetrics to, yes, the Natural Childbirth Nazi doula or childbirth educator (Bradley Method gets awarded this prize more than most approaches). While it is usually an arrogant OB that outrages me when my clients tell me stories, sometimes it is definitely the Childbirth Educator who told my client that her gestational diabetes didn't exist and she should ignore the suggested medical and nutritional treatments. Or my friend whose doula thought she was a midwife and tried to do a vaginal exam (but, err, couldn't find the cervix). Or my two friends whose doulas didn't show up for them when they needed them (one decided to sleep through the night and called to check in when my friend was getting pitocin administered; the other doula asked if my friend minded if she took a quick nap just as she was starting to transition).

Despite these stories, I jumped at attending a doula training here in San Diego. And it was amazing. This DONA-approved training, simply put, rocked. Taught by a Penny Simkin-trained doula and childbirth educator, the training leaned toward as-natural-as-possible childbirth as yielding the best outcomes for mom and baby. However, the assumption was that our future clients would be laboring in hospitals, and that relationships with the medical staff were key. The training reinforced that our role as doulas was to support the family as they labored toward their best birth scenario. And for some families that might mean various interventions. Penny Simkin describes a doula's role as protecting women's memories of birth; it's not about forcing an unmedicated birth any more than forcing interventions. It's about making sure women and their families have a positive experience of the birth and have a good shot at materializing their own birth plan.

On the lastday of my training, each of us doulas-to-be took a little survey asking us various questions about how we felt about different birthing scenarios. We scored our answers and all found ourselves categorized in one of three camps: ProBaby; ProMom; or ProNaturalChildbirth. Our trainer wanted us to be really in touch with our own biases and intentions as we set out on this path. We serve nobody if we walk into a birth with our own intentions unclear; this is not our own birth we are attending and we need our own agenda off the table.

The article does give a nod to Doulas of North America which provides some sort of standardization and certification. Though, as the article points out, technically, anybody can be a doula and this certification is not actually required. But I think there are a few interesting bits about certification that the article could have highlighted. In order to become certified by DONA, you need to successfully complete trainings and then you must attend three births and have successful evaluations filled out by the mom, nurses and doctors for each birth. From the very beginning, each doula understands her role in relationship to medical staff. DONA sees the medical staff as important partners in the birth experience and gives them a say in whether each new doula passes muster.

In the article, Falls Church, VA doula Mary Beth Harris referred moms-to-be to other doulas because these women knew they wanted to use epidurals; this is exactly the level of conversation that families need to have when they are interviewing doulas. If there is any scenario in which you envision yourself using pain medications or various interventions, a really orthodox natural childbirth doula is probably not the best choice for you. And please do note my use of the plural when discussing interviewing doulas. You want to do your homework ahead of time, and then talk to lots of doulas on the phone and then invite three of the potential best fits into your home for an in-person discussion. Remember, inviting somebody into your birth is really an intimate thing, and you want to see how you respond with them in your personal, home space. A lot of pregnancy books have various questionnaires you can use when interviewing a doula, but here's a good list from the DONA website, as well as some more info on using professional, well trained labor support from Childbirth Connection.

An Update on Pregnancy Massage at Spas, Massage Envy, Hotels, etc.

Of course, as soon as I posted some information on this, three more clients came in with stories that I think are pretty typical. Here they are:

• One woman was given a gift certificate for one of the massage mills for Christmas. She booked her session and when she arrived they told her that the original pregnancy massage therapist was not available, so they had another qualified therapist ready for her. This mams-to-be is a well-seasoned massage receiver and on her second pregnancy; far from timid, she agreed to the new therapist and went in for her session. The therapist asked her to start laying on her back (in her third trimester!). Our mom-to-be knew better and said she couldn't lie flat on her back. The therapist reponded that they could work in a side-lying position instead. He left the room and returned and was ready to proceed, but mama was left lying on her side with no pilllows supporting her neck and head, nor her legs. She had to ask for her own leg bolster, which the therapist provided. She made no disparging remarks about the establishment, nor of the individual therapist; she was simply relating that her comfort was compromised during the entire session.
• Another recent mama-to-be who has come to my office has her own regular massage spot that she goes to and loves, and received one prenatal massage there. Though she remains a loyal customer of this sweet day spa, she has decided to receive her bodywork elsewhere during her pregnancy. The therapists were too timid working with her pregnant body, almost as if they were "afraid to touch" her.

And here's one from a woman I saw a few months ago:

• A woman in her 5 month of pregnancy came to see me, exhausted and feeling the aches and pains. Her boyfriend made the appointment for her and had grilled me on my qualifications. She showed up just a few minutes late for her appointment (less than 5 minutes), really apologetic and the first words out of her mouth  were, "is this going to cut into my massage time?", with a real look of worry on her face. I told her, "usually, yes, but since it is your first session, I am holding a full 90-minutes for us, so I think we  will be ok." As we got talking, it turns out she worked as a receptionist at one of the massage mills until very recently. She said that she refused to get a massage there because she was pregnant (despite enjoying employee discounts), and didn't trust the therapists and didn't think they were really certified or qualified (perhaps she meant specific to pregnancy massage). She heard their comments about clients behind their backs, and saw the therapists as completely tip-motivated. She was blown away by the contrast of seeing a private therapist who has the flexibility and time to really engage her about her body and pregnancy, spend time with her, and be present with her.

Please feel free to share your stories as well. 

Now what about those special Pregnancy Massage Tables?

As the demand for pregnancy massage has increased over the past few decades, various products have come on the market aiming to make delivering that massage simpler. There are now special tables you can purchase or pillows that go on top of a table that have special cut-out sections for a pregnant belly and breasts, thus allowing a woman to lie face down throughout her pregnancy. This sounds like a dream come true to many pregnant women who have been struggling to adapt to lying on their side as their pregnancy progresses. In fact, this is often one of the first questions prospective clients ask when they call; "Do you have a special table so I can lie face down?"

Well, no, I don't. In fact, experts in the field caution against using these tables and recommend other positions as optimal for pregnant clients, for the following reasons:

• No matter how well these tables try to support the belly, they still force women into a position in which her very heavy uterus is now suspended from her lowback by an already stressed ligament structure. These stressed ligaments are often the cause of many pregnancy aches and pains that women are looking to alleviate in massage.
• Having massage applied to you while lying face down risks increasing intrauterine pressure. Not good.
• Many women are very uncomfortable lying face down as they feel they are lying on top of their baby, despite the accommodations of the belly cut-out.
• For women who are quite advanced in their pregnancies, it can be quite awkward to attempt to lower both your belly and breasts into these pre-cut holes, and then turn over later in the massage.
• One size does not fit all. Though these holes are meant to accomodate the average woman, the varation in sizes of women's torsos, pregnant bellies and breasts complicate the ability of these tables to support all women.
• One alternative to this style of table is a large pillow that covers much of the table and provides similar cut-outs for the breasts and belly, allowing the woman to lie face down. Depending on how the therapist uses these systems, sometimes there is not enough of an opening for the woman to breathe and she can sometimes leave feeling suffocated.

Most experts agree, the optimal positioning for pregnancy remains a side-lying and semi-reclined positions; the same options women have at home. Fortunately, however, most trained therapists have high-tech pillows and enough experience to make you a lot more comfortable than you are in your own bed (or so my clients claim). This photo is from the maker of the Body Support Cushion -- what most professional pregnancy massage therapists use (I'll try to get a better pic soon). They also feature ways to work with women lying face down, but again, experts in the field discourage lying face down during a pregnancy massage.

Pregnancy Massage at Day Spas and other Massage Establishments

I've had another round of new clients who sought me out after an experience at a day spa or similar establishment that offered "maternity massage" but didn't deliver what the woman was expecting, let alone needing. Some of my clients tell me they are initially drawn to day spas or massage centers because they assume that these places are more professional and trustworthy than a random independent therapist (who might be working out of her home). Following that logic, these establishments would seem even more a safe choice during pregnancy. This is sometimes a good conclusion, but not necessarily so! Here are some actual experiences of my clients:

• The therapist was great, but was afraid to touch certain parts of the woman's body, including her low back and feet -- which were quite in need of touch!
• One woman came to see me who actually developed some neck pain after a "precious moments" maternity massage at a day spa because the therapist did not know how to safely accomodate her pregnant body and kept her in uncomfortable positions throughout the massage.
• Another woman felt suffocated as she went face down on a "pregnancy pillow" on the table with no air hole to breathe through.
• In general, clients tend to complain that the therapists didn't touch them confidently and were afraid to give deeper touch that is so helpfully in alleviating the strong muscle tension created by pregnancy.

This is not at all meant to be a slam against therapists working in day spas and massage centers; there are great therapists who have worked for a long time in these arena, many of whom are properly trained in pregnancy work. In many places, therapists have reduced control over the types of massages they give and to whom -- these decisions are being made by non-therapists. We have moved from a time when massage schools taught everybody that pregnant women should never be massaged, to a time when therapists are being asked to deliver pregnancy massage with little or no training. Experts in the field fear that as the massage industry continues to grow (in a climate where "maternity" is big money), therapists' ability to deliver quality work is continually compromised.

The Rapid Growth of the Massage and Spa Industries
Over the past several years, the spa industry has grown by leaps and bounds as massage and related services are sought by a larger section of the population. Day Spas are proliferating and new types of establishments such as Massage Envy, Just Massage, and, here in San Diego, the Knot Stop, are turning up in more and more neighborhoods. Their mission is to make massage available to more people, and in the case of the latter, usually below market rates. Admirable idea and smart business given the increased demand for massage services. And, often you can get just what you need at these establishments. But. Because you can tell there is a "But" coming. Massage centers such as Massage Envy are, from a therapist's perspective, often nothing more than "massage mills." They are not optimal settings for therapists who often report that their quality of work is consistently compromised. Below I detail some stuff to keep in mind as you wade your way through your options:

• If you are receiving a "deal" on your massage, then the therapist is most likely not being paid well. Which is wrong. And it begs questions around how committed the therapist is to his or her work, to your massage session. Are they present in the room with you, or racing through to get to the next massage to make more money? The rise of Massage Envy has yielded affordable massages and droves and droves of disgruntled therapists -- a quick search online will give you a peak into the hostility therapists tend to feel towards this employer in particular (here's one example).
  
• Therapists at these "massage mills" often work double shifts and you could be the 8th massage of their work day. No matter how amazing the therapist is, they have human limitations. Massage is physically and emotionally draining work, and for most therapists (surveying my peers), their ability to deliver good work is significantly diminished after 4 or 5 sessions. (I was somebody's 8th massage at one of these places last summer -- he was revved up on caffeine, super chatty, sloppy with the sheet, and rough with his elbow. And he tried to get me in "on the ground floor" of some great opportunity!).
• You will often be churned on through: an hour massage is really only 45 to 50minutes, and the therapist will be starting another massage at the end of the 60minutes.

In my experience, your best luck is going to be with a place that has low therapist turnover -- they tend to take care of their employees and have a healthier environment that their therapists can thrive in (don't you want the therapist who is touching your body to be thriving?). And, when you go in, make a point of really connecting with the therapist and letting her know you appreciate her time; tip accordingly as they work hard and are usually quite underpaid. And if a friend recommends a day spa or other establishment, get the name of the therapist they saw.

Pregnancy Massage Specialists
So most of these places offer pregnancy massage. Most licensed therapists with some training should be able to deliver safe touch to you during your pregnancy (assuming your pregnancy is healthy, not high risk and without major complications). That does not mean, however, that most therapists know how to accomodate your body on the table to make you super comfortable, nor does it mean they know how to work specifically with pregnancy aches and pains. A therapist with specialized training is going to do more than adapt their regular old massage routine to your body; the massage will be designed for your pregnant body from start to finish. Here are some points to be wary of:

• Wide range of training. Many establishments (most!) offer prenatal massage and most of these are conscientious about hiring therapists who have some sort of training in prenatal work; however this training could range from 3 hours in massage school to a 4-day training. You and the receptionist booking your appointment are not always going to know how extensive the training was.
  
• False training. Occassionally a day spa or similar venue will send one therapist to a training, and then he or she will come back and teach what they learned to the other therapists. (as I read recently in Massage & Bodywork magazine).
• Experience. Even if they have solid training, therapists in a more general setting often may see one or two pregnant women a month at best which limits their ability to really get to know pregnant women's bodies and needs.
• Policy limitations. Many establishments limit the types of touch that therapists can offer to pregnant clients. This is partly about safety, but mostly about liability. As in the case of some my clients, this may mean little or no work on your low back or feet!

All that said, you can get good massage during pregnancy at lots of day spas and massage establishments. Particularly if you and the baby are healthy, and you are experiencing a low risk pregnancy and no complications. If you are nervous about pregnancy massage, experiencing a lot of pain or complications, or have a higher risk pregnancy, check with your doctor/midwife and seek out a specialist who works with pregnant women regularly.

Plus Size Pregnancies

I have spent hours this weekend reading through the Plus-Size Pregnancy website. I first stumbled upon it while researching some details on pubic symphsis pain. And uncovered so, so much more. This website is authored by "Kmom", a plus size mom of four and childbirth educator. After a tumultuous first pregnancy that turned into a "self fulfilling prophecy" of high risk, multiple complications and many, many interventions, Kmom sought out a different way with each of her subsequent pregnancies. In the process, she has become an important advocate for the needs of plus-size moms-to-be. While at first her website started as a directory of resources for larger women (maternity clothes and bras, baby carriers for big moms, support groups for plus-size pregnancies, etc.), her work soon turned to advocacy as she delved deeply into the pages of medical journals uncovering much disagreement in the medical community over such critical issues as gestational diabetes.

Her website is almost all text...and a lot of it. Sections range from articles she has written for midwives and other providers on how to have Plus-Size Friendly Practices to special issues well-endowed women face with breastfeeding. Larger women have higher rates of c-sections and other interventions, much associated with the medical communities fear that larger women will have complicated deliveries, excessively large babies and possibly babies with birth defects. Kmom tackles the numbers and reminds women that while a larger size does make their pregnancy and birthing experience potentially a little more complicated, healthy larger women have healthy pregnancies and babies all the time.

*Choosing a size-friendly provider
*The importance of large blood pressure cuffs
*Avoiding surgery: lowering the c-section rate in big moms
*Dieting and pregnancy
*Weight Gain during pregnancy
*Facility and equipment concerns
*Connections between Obesity and Birth Defects: Don't Panic

 

Her work is heavily researched and has an extensive bibliography, and, very importantly, she strives to be very self-reflective as an author -- making it clear when she is expressing her own opinion and bias. She is continually encouraging her readers to seek out more information elsewhere and ask even more critical questions. Quite refreshing in the birthing community when so many experts are so righteous about "the right way" to give birth and care for moms and their babies. And quite refreshing in an industry that doesn't always understand that moms are smart, thinking people who can understand complex issues.

I highly recommend her website if you are curious about navigating the birthing world as a plus-size mama-to-be, and/or if you are looking for deeper information on gestational diabetes.

Are your boobs hurting your back??

Breast size fluctuates several times during our lifetimes and this change can often lead to back pain for many women. During pregnancy, changes begin early in the first trimester, and many women whose non-pregnant breasts never contributed to back strain begin feeling the effects. Increased breast size and weight can lead to or worsen headaches and back, neck and shoulder pain for many pregnant and nursing women. While the most dramatic changes happen during pregnancy and the postpartum period, the changes are ongoing throughout our life cycles and the impacts on our posture are similar.

Increased breast weight and size change your center of gravity and impact your posture. This rolls your shoulders forward and collapses your chest muscles which can result in pain in your neck, shoulders, and upper back. These changes in your posture can further lead to headaches and low back pain. And for some women, it can contribute to "thoracic outlet syndrome" - putting enough pressure in the shoulders (combined with overall fluid retention) to compress a group of nerves and arteries producing pain, numbness and tingling in the hands, wrists and forearms.

As your shoulders round forward and hunch up toward your ears, your chest muscles collapse and your rib cage is restricted. This further restricts your breathing and can contribute to shortness of breath and shallow breathing. For many people, this shortness of breath can leave you feeling tense and anxious, and even lead to headaches.

Ideally the weight of your breasts is supported by your core postural muscles. In addition to exercise to strengthen your upper body muscles for good posture, the proper bra can make all the difference (though, of course, some women are more comfortable without a bra). This might be particularly helpful at times when your breast size changes more quickly and your muscles have not had enough time to catch up. It is worth getting re-fitted whenever you buy new bras to make sure you have the proper support.

A well-designed bra that really does fit is going to provide support from the band and cups, not the straps. A bra that doesn't provide enough support or fits poorly, such as relying on the straps (particularly if the straps are digging in to your shoulders) is going to wreak havoc on your posture, putting pressure on your shoulders, forcing your shoulders to roll forward, straining your neck and upper back.

Steps to prevent your boobs from being a pain in your back:

    * Get properly fitted for a bra and check on your size as your body shifts through pregnancy, breastfeeding and fluctations in your weight. A quick search online will give you various methods of self-measuring, but the best way to get fitted properly is go to a good department store.

    * Maintain proper posture and ergonomics. Whether it's sitting at your desk typing or holding your baby for breastfeeding, proper alignment of the spine is key. Be sure to always keep your shoulders down and back. If you are not sure what "good posture" is - please check-in with me or a yoga teacher.

    * Yoga and massage can help you relax and strengthen those shoulder and neck muscles, and your chest muscles