BLL is a gravida 2, para 1 currently in her third trimester. Her miscarriage was last year. She is a couples therapist who started her own private practice a year ago. She has a history of SIJD and lumbar pain from gymnastics in her youth. She is a certified yoga teacher who completed prenatal yoga YTT last year. She is very informed but has anxiety especially surrounding perinatal and infant loss. Her two sisters have both had children. One had a difficult preterm delivery last year, placental abruption and postpartum preeclampsia. BLL expresses fears of loss in the 3rd trimester, as 2 of her close friends had stillbirths this past year and her parents lost her elder twin siblings in childbirth prior to her birth. She describes a fear of enjoying her pregnancy and connecting with her son in the event something should go wrong, the pain would be too great.

She currently practices 5-10 mins of asana each evening before bed. During this pregnancy she has had a harder time staying asleep through the night with occasional round ligament pain when turning from side to side, bruxism and jaw clenching, and 2-3 episodes of nocturia. She describes having an information overload but when she is stressed she scrolls social media, watches tv, or looks over her registry (without changing anything). When she has free time she often fills it with projects. For example, she is currently remodeling her kitchen & the nursery with her husband. BLL said she is more likely to practice self care if she is accountable to someone. She is currently under the care of a chiropractor, acupuncturist, therapist, midwife, OB, and pelvic floor PT (for vaginismus and fear of tearing). Client reports that the poses that feel the best right now are downward facing dog, groin & hip flexor stretches, and child's pose.

Activity: Breath Awareness, Elongated Exhalation, & Brahmari 3x.

Post-Intake/ Assessment Homework: Client mentioned she wanted to journal memories of pregnancy in a book for her baby but often forgets or avoids it. She mentioned that a good goal for this week would be to write in her journal. The journal entry and 3-6 brahmari breaths before bed are homework for the week.

Add to current daily Asana practice:
5 min brahmari & elongated exhalation pranayama, meditation, & daily belly mapping/ svadhyaya.
Before bed:
Baby journaling, nadi shuddhi & guided relaxation (hypnobirth).

Affirmation: What in this moment is true? (pratipaksha bhavana)

Not in the care plan but good to discuss:
Ask someone to help you with something/ have a close friend or family member start a meal train for you.
Partner journaling birth preferences activity

1) Villar-Alises O, Martinez-Miranda P, Martinez-Calderon J. Prenatal Yoga-Based Interventions May Improve Mental Health during Pregnancy: An Overview of Systematic Reviews with Meta-Analysis. Int J Environ Res Public Health. 2023 Jan 14;20(2):1556. doi: 10.3390/ijerph20021556. PMID: 36674309; PMCID: PMC9863076.

"Most meta-analyses (93%) underlined the importance of practicing prenatal yoga based interventions in comparison to different controls interventions to improve mental health during pregnancy, concretely, anxiety, depression, and stress symptoms."

2) Lin IH, Huang CY, Chou SH, Shih CL. Efficacy of Prenatal Yoga in the Treatment of Depression and Anxiety during Pregnancy: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2022 Apr 28;19(9):5368. doi: 10.3390/ijerph19095368. PMID: 35564762; PMCID: PMC9105819.

"the efficacy of prenatal yoga on anxiety for pregnant women was also investigated, with the results showing that yoga could significantly decrease anxiety for this group"

3) Saastad E, Winje BA, Israel P, Frøen JF. Fetal movement counting--maternal concern and experiences: a multicenter, randomized, controlled trial. Birth. 2012 Mar;39(1):10-20. doi: 10.1111/j.1523-536X.2011.00508.x. Epub 2012 Jan 9. PMID: 22369601.

"Women who performed fetal movement counting in the third trimester reported less concern than those in the control group. The frequency of maternal report of concern about decreased fetal activity was similar between the groups. Most women considered the use of a counting chart to be positive."

4) AlAmri N, Smith V. The effect of formal fetal movement counting on maternal psychological outcomes: A systematic review and meta-analysis. Eur J Midwifery. 2021 Feb 3;6:10. doi: 10.18332/ejm/145789. PMID: 35330616; PMCID: PMC8892388.

"This review has found that formal fetal movement counting in pregnancy has no detrimental effects on maternal psychological or emotional status and positively affects maternal–fetal attachment."

5) file:///C:/Users/jetle/Downloads/bellymap-parent-handout.pdf

6) file:///C:/Users/jetle/Downloads/Paper-Kick-Chart-English.pdf

7) https://evidencebasedbirth.com/evidence-on-induction-for-gestational-diabetes/

• Yes

Seated: check in, centering, body scan, breath awareness, pelvic breathing (drops/ reverse kegel), OM 3x, brahmari 3x.
Quadruped: cat/ cow, hip circles, pelvic breath in balasana, balasana rocker,
plantar rock + side bend, forward and side lunges and abducted rock back.
Deep Relaxation: reclined bound angle pose.

Belly Mapping 1x a day & choosing an affirmation to use when thoughts become unproductive or harmful.

During our check in BLL was very open about her insecurities around asking for help. She also expressed apprehension around being present in her pregnancy and enjoying this pregnancy and bonding with her baby. Her past experience with loss has made it more challenging to feel safe in this pregnancy. Additionally, she made the connection that she’s never really felt like her time is hers. She has felt the need to give her time and energy to others because prior to her birth her parents had twins prematurely that did not survive. BLL said that she grew up hearing this story and feeling a responsibility to be especially grateful for her time on this earth as nothing is guaranteed. BLL is making deep connections about her own world view, parenting, fears, and perhaps by observing these beliefs she can start to become less controlled by them.

After a series of movements in lateral flexion, she said that realized how much her body needed it and she could breathe more deeply. She notices that her baby is often settled on the right side and feels more tension on the right and holding.

I felt I was able to listen more and talk less in this session and hold back making suggestions or offering resources so that she had the time and space to come to these conclusions on her own. I felt that I asked open questions that could lead BLL to ask deeper questions of herself. She was very open and brave in this session saying things that may have been hard to face let alone verbalize. I feel that I still need to refine active listening and balance helpful suggestions with genuinely hearing someone out and not needing to find a solution. I am sure this will develop more over time, but I can see how helpful it is in yoga therapy to build a healing relationship of respect and trust. By not providing the answers or my answers to this client she is building confidence in her ability to work it out and “heal” herself.

BLL shared that she did not write in the journal yet this week. She did, however, practice breathwork and noted how much she enjoyed it. We discussed pratipaksha bhavana and the concept of replacing a negative thought with a neutral thought or positive thought or affirmation. Mindfulness practices that foster an appreciation of the present moment would be a complementary tool to help BLL manage her anxiety around this pregnancy. Activities that encourage maternal-fetal bonding could be helpful. When there is a loss, subsequent pregnancies are a bit more complex to enjoy. This fear of being hurt again is stealing away her present time with this baby she has now in this moment with her. By spending a few minutes each day to belly map and take note of what her baby is doing, where he is facing, his movements, and connect with him she can regain the gift of this time they have right now. Without explaining this particular reasoning behind the belly mapping, BLL was able to latch on to the benefit it may offer her in reducing anxiety at this time.

Add on meditation and nadi shuddhi and discuss a specific time frame in the day that BLL will be able to commit to her practices.

• Yes

Seated: check in, centering, OM 3x, body scan seated, breath awareness, elongated exhale, brahamari, alt nostril.
Quadruped: cat/ cow, hip circles, wags, child's pose with pelvic breathing, balasana rocker, lunge & side lunge + rock backs and windmill, (knee on one block) asymmetrical rock backs.
Seated: deer pose, OI rotation, hip movement, & seated PFM breathing with rolled up blanket. Supine: psoas release with bolster.
Seated: finger tap meditation.

Continue with evening routine add on nadi shuddhi and finger tap meditation. Set up a yoga space on the first floor of the house where BLL can practice or take movement breaks as needed.

BL seems to be doing very well this week. She was hit with the upsetting news that while her GDM was not just borderline and would need to be treated with a glucometer and nightly insulin. She had difficulty getting a hold of her providers a few times which caused her stress wondering if a complication could arise as a result. Her evening walks with her husband have been going well. BLL reflected that she is not just doing them now for the pregnancy or GDM, but because she enjoys this time outside alone with her husband. She would like to keep this practice up postnatally too in the form of an evening stroller walk. She stated that the unexpected gift of pregnancy has been caring for herself genuinely for the first time.

This past week BLL journaled in her baby journal and had her baby shower too. Over all she has incorporated her yoga therapy and stress management tools well. She has started to notice that going to bed is easier. She has been able to manage overwhelming thoughts better too. Her pratipaksha bhavana practice was used a lot this past week and she asked herself anytime negative thoughts become overpowering “what is true right now?”

I enjoy working with BL and wish I had both more time with her weekly and had a bit longer than 4 weeks as well. We have addressed some major issues with both mental and spiritual health and some physical health has improved too. That said I do wish we could work more on birth preparation and may see if I can meet with her one or two more times after this month.

Add on some more thoracic mobility, wall asana, and exhale on the effort.

• Yes

Seated: check in, centering, OM, body scan seated, breath awareness, elongated exhale, brahamari, & neck stretches.
Quadruped: cat/ cow, hip circles, wags, child's pose with pelvic breathing, balasana rocker, lunge & side lunge + rock backs and windmill, and malasana rock backs.
Seated: high release with protraction in vajrasana and seated foot stretches.
Standing at the wall: L (modified downward facing dog), push ups, calf stretches, cervical retraction, pectoralis stretch with block, nerve glide, chair pose/ wall slide with block, roll down, malasana (with block), legs up the wall (on bolster), and piriformis stretch at the wall.
Seated: vagus nerve stimulation & finger tap meditation.

Increase meditation to 2 mins daily and aim to journal once about how your baby’s movements have this week.

BL seems to be doing very well this week. She was hit with the upsetting news that while her GDM was not just borderline and would need to be treated with a glucometer and nightly insulin. She had difficulty getting a hold of her providers a few times which caused her stress wondering if a complication could arise as a result. Her evening walks with her husband have been going well. BLL reflected that she is not just doing them now for the pregnancy or GDM, but because she enjoys this time outside alone with her husband. She would like to keep this practice up postnatally too in the form of an evening stroller walk. She stated that the unexpected gift of pregnancy has been caring for herself genuinely for the first time.

This past week BLL journaled in her baby journal and had her baby shower too. Over all she has incorporated her yoga therapy and stress management tools well. She has started to notice that going to bed is easier. She has been able to manage overwhelming thoughts better too. Her pratipaksha bhavana practice was used a lot this past week and she asked herself anytime negative thoughts become overpowering “what is true right now?”

BLL has made some deep insights in a short period of time. I feel she would benefit from more time to continue to work on her goals as she goes through this challenging transition in her life. I think having a few sessions focused solely on preparing for birth & postpartum could be helpful. I provided a handout on evidence based practices the day before this session when BLL texted me that she had an upsetting prenatal visit with her provider. Her provider had mentioned that they may need to schedule an induction for her 38th week. It seemed that the resource I gave her helped give BLL some ideas of the risks and benefits of an induction at 38 weeks for someone with managed GDM. She was encouraged to bring those questions to her team at their next call or prenatal appointment.

This week in particular, I did feel that I had to tread carefully when BLL asked questions about induction being mentioned nearly 2 months before her EDD. She mentioned that her sister had a better experience because she was at Mt Auburn Hospital (the only hospital in MA that I will not attend births at anymore due to gross incompetence and racism). I explained that sometimes places have good reputations but that doesn’t mean we will have a good experience and the same is true for places that might be less trendy, they may provide a wonderful experience too! I tried to redirect questions about how she felt and what her concerns were and ask her to be sure to address them with her provider. She mentioned she may schedule a call for next week and I suggested that she write down her questions so that they are prepared for the call.

Working with BLL went very quickly. I plan to see her for at least 2 more sessions with her prior to her baby’s birth. While she has many tools at her disposal as a counselor, she struggles with prioritizing herself and taking breaks to avoid overwhelm. During our sessions mindfulness practices seemed to make the most impact in both downregulating her nervous system when it was activated and providing insight as an objective observer. She was able to make connections about her own tendencies and deep family trauma that was connected to her identity. I felt very honored to be able to work with BLL and move into some of these more difficult topics she faced and provide space for her as a sounding board as she worked through them. So often sessions are focused on exercise and asana but these sessions with BLL were very much a jnana yoga practice involving the emotional, energetic, spiritual, and physical layers in various ways.

After our fourth session BLL was given a follow up form with repeat questions from her new client intake form to gain insight on areas that may have been influenced by weekly yoga therapy this past month. She noted improvement in her sleep, stress management, connection to her family, and overall feeling of wellness. In addition, her PHQ-2 form went from a 2 (some of the time) to 1 (not at all). This indicates an improvement in her mood and reduction in perinatal anxiety and mild depression. She was able to return to the present moment, observe her thoughts, recognize unhelpful thoughts and pause recalling her affirmation “what is true right now in this moment?” She was able to maintain her peace despite some challenges getting formal diagnosis of gestational diabetes mellitus (GDM), needing to monitor blood sugar levels, start insulin, and having an upsetting discussion about potentially inducing preterm labor with her provider.

I found it very rewarding to see this type of brave work take place during her third trimester. Similar to working with other clients during pregnancy I found the challenge for myself was using active listening rather than giving advice or trying to “fix” the situation by troubleshooting or problem solving in our session. This is a bit more challenging with perinatal clients than it is with other clients. When I am asked "what do you think?" or "what would you do?" I need to separate myself in my role as the yoga therapist from my birth advocacy, my doula/ lactation work, and my own opinions and preferences as a parent too. I asked myself what is this client really wanting by asking me this? She may not want my answer but instead may just want to be heard, feel safe, and have support to consider her own options. Redirecting questions back to her or to her to reach out to her care team was the most simple way to do this. It is not that I avoided answering questions honestly but when I did I would think is that even helpful? I was reminded of the Sufi saying often used in childbirth education (but also taught in Raja yoga): is what I am about to say:
True
Helpful
Inspiring
Necessary
Kind
Using the THINK acronym to be mindful with my own speech may have helped provide BLL a non-judgemental space to be as honest and brave in our sessions together as she was. I will continue to use this practice when I feel the urge to say something or answer client questions not just surrounding topics I feel confident in like evidence based birth, but all topics in general.

While I do feel there is more work to be done in my sessions with BLL I am impressed with her courage to work so deeply in just a short period of time together. In the future I would like to address some of the new aches and pains she is having as her baby grows and she gets closer to her estimated due date. I would also like to address her fears of tearing and provide some resources as well as helpful sensory feedback tools to ease discomfort to assist with childbirth preparation and relaxation. I would also continue to gently add in additional bonding opportunities with her baby during asana, pranayama, and relaxation practice to stay present with the gift of spending time with him right now. I feel that both BLL and myself learned a lot about ourselves during this healing relationship of yoga therapy practicum.

I would like to focus a bit more on BLL's fear of tearing with some education around why tears can naturally occur, contributing factors during labor and second stage management, and how to encourage good circulation and relaxation of the pelvic floor muscles in the third trimester. In addition, spending some time creating a list of birth preferences to communicate with her providers now could help her plan for any differences in her expectations and their practices/ policies. In addition, shifting out guided relaxation a bit to focus on her baby could be something she might be more open to explore in the following weeks and month.