JP is a primipara/ primigravida nearing 2nd trimester. She has a history of L4-5 spinal fusion as a result of spondylolisthesis and sciatica. She suspects that she has HSD/hEDS but has not had a formal diagnosis.

Primary goal: to practice movement regularly to maintain as much of a pain free pregnancy as possible.

JP reflected that the idea of not having pain management in labor is something that causes anxiety when it comes up for her so tools to assist with pain management in labor would be a secondary goal for her. JP also has bipolar disorder and takes Vraylar for this and Adderall for ADHD, and Buspar for Anxiety as well as regular CBT. JP has ADHD and mentioned that she prefers more active mindfulness practices that involve movement or imagery. JP has a history of deviated septum so alternate nostril only breathing can sometimes be uncomfortable or inaccessible. She saw a UroGyn & Pelvic Floor PT about a year ago for pain and hypertonicity of the Pelvic Floor Muscles. She would like a routine she can practice in the office 20-30 mins up to 3 times a week.

Post Assessment Homework:
-Check in with medical provider at the next prenatal visit and see what type of pain management strategies they can provide at the hospital as the epidural may be more complex with a lumbar spinal fusion.

-Write one paragraph or more about birth preferences and how you would envision your ideal birth & postpartum experience and support.

Asana & Mindfulness Practice for Workdays (practiced in the office 2-3x a week)

Chair:
Tense & Release, Cleansing Breath, & Elongated Exhalation
Neck stretches & gentle chair warmup
Cat/ Cow & Circles, Knee extention & Leg Lifts with exhale on exertion, Figure 4 stretch at chair
Adduction and abduction into hands

Standing:
Chair Pose with dips 3x
Dancer pose holding on to chair with scarf for strap
Standing locust pose & side leg lifts at chair
Downward Dog, Wag, & Twist folded over the chair

Quadruped:
Shhh breath & belly lift to support back and pelvic floor
Bird Dog
Kneeling foot stretches, lunge, and side lunge
Child's pose with reverse kegel/ pelvic breathing

Seated:
Bound Angle & Wide Angle Pose with blocks

1 full minute of inhale 1 exhale 1-2 with finger tap (finger tap counting was taught during Raja by Swami Ashokananda)

1) Holden SC, Manor B, Zhou J, Zera C, Davis RB, Yeh GY. Prenatal Yoga for Back Pain, Balance, and Maternal Wellness: A Randomized, Controlled Pilot Study. Glob Adv Health Med. 2019 Aug 26;8:2164956119870984. doi: 10.1177/2164956119870984. PMID: 31489259; PMCID: PMC6710668.
"Based on the observed recruitment, adherence, and acceptability, a prenatal yoga intervention to improve gestational LBP and maternal well-being appears feasible and safe. In preliminary analyses, our ability to detect clinically and statistically significant differences between groups in several measures informs the design and outcome selection of future yoga trials in this population."

2) Babbar S, Oyarzabal AJ, Oyarzabal EA. Meditation and Mindfulness in Pregnancy and Postpartum: A Review of the Evidence. Clin Obstet Gynecol. 2021 Sep 1;64(3):661-682. doi: 10.1097/GRF.0000000000000640. PMID: 34162788.
"There is sufficient evidence to support the practice of mindfulness practices in pregnancy to reduce anxiety, depression, and stress during pregnancy, which may continue to have beneficial effects through the postpartum period."

3) Katonis P, Kampouroglou A, Aggelopoulos A, Kakavelakis K, Lykoudis S, Makrigiannakis A, Alpantaki K. Pregnancy-related low back pain. Hippokratia. 2011 Jul;15(3):205-10. PMID: 22435016; PMCID: PMC3306025.
This review article while informative about LBP, it did not provide specifics like the other two and was not helpful towards developing a care plan.

• Yes

This session started with a check in and JP shared she had been in traffic for an hour and just got home for the session. When asked if a later time could help next week, practicing in the office earlier, or practicing another day she shared those options would not work. JP also noted that she did not like getting an email with a list of what to prepare for the space one hour prior to the session as it was not enough time. That said, the only things that were suggested to prepare for the session were a mat, chair and long towel or shawl as we had discussed this at the end of the last session and it was simply a reminder email so she wouldn't have to gather anything during her session time.

We started with a follow up of how the past week went and JP's journal reflection. JP shared she needs to do lots of journaling for her CBT work and would prefer to not have any writing in our work together. She also mentioned she doesn't like affirmations or mantras whereas last session she mentioned them as options to explore.

We went over the chair & mat asana, pranayama, and meditation homework for the week and discussed tools that could be used in her office practice.

Practice the pranayama, meditation, and asana homework we reviewed in the session for this week. Aim to practice 1-3 times before we meet next week.

It was hard to get feedback from JP in this session when asked how things felt she either shrugged or said fine quickly. Building confidence in her body, its strength, and her connection to her breath might be the first step. It seemed she was checked out and almost disassociated during the practice. I would like to try a more TCTSY approach with her without overwhelming her with options. Building some interoceptive awareness might be the first step to gaining some confidence in her body and its ability to carry, grow, give birth, and make parenting choices too.

The situation with traffic and perhaps other things were a bit of a barrier and it was difficult to get feedback from JP in this session once we started moving together. She seems to do better with visual cues rather than verbal.

She shared that the chair she had out was the only chair in the house so we made due but it was rather small for her to fit into to sit let alone move. JP noted that her chair at work was wider and had arm rests. I said arm rests are fine as long as she is comfortable because I could see it was not a great chair for our practice and I didn't want her to feel uncomfortable in it. I asked if she wanted to work on the couch and she said she couldn't move to that room.

I decided to edit out journaling or deep relaxation from the care plan and only stick to the 15-20 min asana practice with breathwork throughout and a 1 min meditation at the end. I am hoping that some stress management will come from the movement, breath, and meditation practices even if they are short and not as regular at this point. If she starts with 1-3 times a week and starts to feel the benefits perhaps she will choose to do it more frequently on her own.

A few days after our session JP let me know she ordered some blocks and a knee pad and a thicker mat for our practice. I think this alone is a wonderful sign. I added some quadruped and seated poses due to this.

Review the asana practice from last week and add on the new kneeling and seated practices with JP's new props.

Use some somatic bottom up practices like "notice the feeling of your hands on the mat and see if you can feel the texture of the mat" to assist with interoception and staying present rather than disassociating or checking out so to speak.

Option to switch to a hand squeeze rather than finger tap during the meditation, focusing on the elongated exhalations for 1 minute. Ask if JP chose the finger tap or hand squeeze next week during homework practice.

• Yes

Follow up: JP reflected that the finger tapping meditation has been really helpful for her the past 2 weeks as she finds she is busier at work and it has helped to pace her breath with the movement of the fingers. She also practiced asana 2 times at work in addition to the pranayama.

We started with some centering in the chair and noticing weight, texture, scent, temperature, and sound. Moving on to tensing and releasing the body in the chair and 3 cleansing breaths. Today we practiced 2:4 breath with hand squeeze a variation on the naddi shuddi that Jivana teaches. We moved through the chair asana, standing (added a calf stretch at the chair that isn't in the care plan) and some balance in standing. Added a block between the thighs in chair to connect with adductors and pelvic floor. We finished with the finger tapping meditation. On the mat we used the new props JP bought. The knee pad doubled as a blanket to sit on and the blocks were helpful in going over the mat asana we had left out last time.

Aim to practice asana 2 times this week in the office and 1 minute of meditation with taps and breath focus 1 time (or as many times a day as needed) every day.

Today JP was smiling and seemed excited to work on the material. When I asked for feedback she was able to give descriptions of how the practice felt for her.
She is also remembering the material very well showing an effort to practice her homework too.

I think that last session may have been challenging for both of us for external reasons. Both of us were rushing to meet and its likely we fed off of the energy of that and I may have read into her abrupt one word answers too quickly. Sometimes we just don't have that much energy left at the end of a work day. I imagine that the stress of trying to get home in time with traffic, it made a perfect storm. I made an effort to be early, fed, rested, and center my own mood before this session today and I was able to notice JP's smiles in her practice and openness to share more fully.

Our plan for next week is to continue with the Chair, Standing, and Mat Asana and maybe add a few new poses in sitting and a deep relaxation at the end.

• Yes

Chair centering, cleansing breath, breath awareness, elongated exhalation, chair JAPA, standing half locust, lunge, & wide angle twist. Shhh breath in quadruped with belly/ baby lift to activate transversus, bird dog, foot stretches, 1/2 lunge & side lunge kneeling, pyramid pose, high lunge, wide angle forward bend with twist, deer pose, deep relaxation focusing on bringing light in with each breath first to herself then to her baby.

Continue to practice what she can on weekdays that she can can 5-30 minutes.

Even though the past week was quite challenging with added work responsisbilities, JP was able to lean into her practices on days she felt she needed them most. She practiced a shorter version of the practice (10-15 mins) twice last week along with daily pranayama.

JP was focused and showed both improvement in her posture and stamina in standing poses. While adding new material has been somewhat challenging in the past, this week she was able to take suggestions and cues very well and even give feedback on how it felt for her.

I don't feel that these sessions created a huge change for JP but they did lay ground work for a self practice and build some tools stress management and low back pain management in pregnancy. That said, these sessions did help me quite a bit as a new yoga therapist. I have worked in challenging situations before and I have had clients with depression and bipolar disorder. I think these particular sessions were challenging as I was working quite a bit and they came after a full workday for me out of both necessity for the client's preference and availability. This was a hard time of day for me energetically and I often came to sessions trying my best but still running close to empty. As a result I may have tried even harder to force some energy into sessions when JP was feeling equally tired or not as social after work. This didn't work well for either of us and caused a bit of unintended resentment on my part. On reflection, I think I carried this into my second session with JP.

I believe it is even more important to conserve my energy, schedule in ways that support this, and create healthy time boundaries when offering yoga therapy. If I am starting a session feeling drained, clients will undoubtedly sense this too. As these sessions are therapeutic in nature, I cannot put that burden on clients dealing with their own health issues, energy shifts, and schedule challenges. Instead, I need to be realistic about what I can handle within this type of work as it is quite different from teaching a yoga class or Pilates session. I also learned that I need at least 30 minutes to document after the session is over to reflect and prepare before starting another session. Having two clients only 15 minutes apart was not enough time and left me feeling a bit rushed and less grounded.

About half way through the past month working with JP I remembered Cheri Clampett and Nischala Joy Devi's advice about preparing energetically before a session. I made a conscious effort to spend time out in the garden practicing pranayama listening to the birds and sounds, smelling the grass and flowers prior to our sessions even when time was tight. I feel my energy was more balanced and that JP had a better quality of experience in our sessions than in the first two sessions we worked together.

In addition, I did see JP start to use the tools she learned electively. This shows both motivation, initiative, and also some confidence in the material. She was able to select what worked best to calm herself down during challenging times. This might mean that JP could recall these tools to fall back on throughout the rest of her pregnancy and any future challenges in labor and parenting too.

Our plan for the next session is to continue with some of the standing work we did this week (pyramid and lunge) and add some more down regulating the pelvic floor focus.