Guidelines for Teaching Yoga to Pregnant Women

Pregnancy is a normal and natural part of a woman’s life cycle and the majority of young pregnant women are fit and well. However, many will suffer from one or two discomforts which come with most pregnancies and a minority will encounter a problem needing treatment by a qualified health professional.

Yoga is a physical and spiritual practice and is ideal for pregnancy as it develops balance, confidence and self-awareness. Many women now do some form of exercise before they be- come pregnant and Yoga provides a perfect way to keep exercising to maintain health and fit- ness during pregnancy without strain. Furthermore, it develops the kind of flexibility of mind and body required in labour.

Yoga is as much a philosophy and way of life as an exercise. Whilst many of the Guidelines for Exercise in Pregnancy are still relevant (NHS 2014), not all are necessarily applicable, since they relate to exercise in general rather than Yoga. The following advice should be considered in relation to Yoga.

1. Advice to women

1:1 Discuss with your midwife the most appropriate Yoga class to join if starting for the first time. Ideally you should join a class taught by a teacher qualified in Pregnancy Yoga. Failing this, choose a beginners class or one with a slower pace. More physically stren- uous forms of yoga practice involving fast-flowing aerobic sequences, raising body tem- perature, and breath retention practices are not appropriate in pregnancy.

1:2 If already practising Yoga asana, continue to practise whilst acknowledging your chang- ing body, and be prepared to slow down, modify or cease practising postures which cause discomfort or pain, preferably with reference to your yoga teacher (Clapp 2006).
Always inform your teacher of any discomforts or concerns arising through your preg-
nancy.

1:3 Stop exercising or practising Yoga if feeling light-headed or fatigued. Sit or lie down and
practise simple relaxed breathing.

1:4 Drink plenty of fluids – bring a bottle of water to the Yoga class and eat something light
beforehand e.g. banana, piece of toast and bring a snack for the end of the class.

1:5 To complement your Yoga practice, choose a ‘light to moderately hard’ form of exercise
such as walking or swimming to develop muscle tone, strength and stamina. Gradually increase this exercise to two or three times a week (Clapp 2012). Note that a moderate level of exercise may protect both mother and baby e.g. from raised blood pressure (Yeo 2008).
Recommendations to Yoga Teachers

2. General advice
Reiterate all the recommendations and advice in Section 1 (Advice to Women) and in addition:

2:1 Direct women to a dedicated pregnancy Yoga class where possible.

2:2 Advise women joining a Yoga class for the first time to wait until 14 weeks or so. By this time the initial fatigue and possible nausea should be starting to lift. Pregnant women who already practise Yoga should be advised to slow down in their practice and be sensitive to the changes in their body. Moderate exercise is not a risk factor for miscar- riage (RCOG 2008) and may help to protect the baby (Clapp 2012) and benefit the mother (NHS Choices 2014). The most common time for miscarriages to occur, from
whatever cause, is usually before 13 weeks.

2:3 Ask women to inform you of any problems that might arise from week to week.

3. On practice
Consider the following with respect to movement, joints and breathing:

3:1 Focus on finding the ground (grounding), lengthening the spine and postural balance with breath awareness.

3:2 Encourage women to move their legs regularly when standing, especially women with low blood pressure or anaemia. Prolonged standing can result in pooling of blood in the lower limbs, leading to a drop in blood pressure – dizziness, nausea etc. This is more common in the hot summer months.

3:3 Encourage women to move slowly from lying down to sitting, carefully keeping their legs parallel to avoid stress on the pelvic joints.

3:4 Encourage fluidity of movement with an emphasis on flowing rather than static move- ment.

3:5 Focus on promoting core stability with attention to the pelvic floor.

3:6 Promote an awareness of optimal foetal positioning by including upright forward-leaning
positions e.g. all-fours, every week (www.spinningbabies.com).

3:7 Offer alternatives for women with pelvic girdle pain (PGP) (formerly known as SPD) –
primarily alternatives that promote the release of tension and restore the balance of
forces through the pelvis (www.pelvicinstability.org.uk).

3:8 Be sensitive to the fact that some women are uncomfortable touching other women. Of-
fer alternatives for any partner work.

3:9 Note that pregnant women may have a tendency to hyperextend joints and that this
should be avoided.

3:10 Take care when teaching any posture involving full flexion of the joints, especially with
beginners. In the first instance modify the pose using props e.g. cushions for kneeling.

3:11 Avoid jumping in and out of postures. These can cause unnecessary stress on the pel-
vic floor, joints and ligaments and can exacerbate structural imbalances.

3:12 Ask women to lie on their left sides and not on their backs for relaxation from about 30
weeks to avoid supine hypotension – experienced by about 10% of pregnant women.
(Fraser and Cooper 2009). Ask them to come up slowly after relaxation.

3:13 Be aware that prior to 30 weeks women lying on their backs should place some support beneath the thighs. This will release tension in the lumbar spine and psoas. Alternative- ly women can lie with the knees bent and resting together, with the feet placed on the
floor a little wider than the hips.

3:14 Avoid any breathwork/pranayama that involves breath retention. Focus on developing
an awareness of the breath and then on the benefits of extending the out breath. Use of sound can be particularly helpful in encouraging extension of the out breath and can al- so bring a calming quality e.g. gentle bhramari. Practices such as Kapalabhati and Bhastrika are not recommended in pregnancy.

3:15 Emphasise and teach relaxation and breathing practices. Pregnant women benefit par- ticularly from a longer relaxation at the end of a class with plenty of cushions and props for support.

4. Postures/asana
Consider the following in relation to specific postures/asana:

4:1 Focus on teaching narrower versions of the classical wide-angle standing postures such as Trikonasana (Triangle), Virabhadrasana (Warrior) etc. These postures, practised with any side-bending, can over-stretch ligaments, create torsion and shearing within the sacro-iliac (SI) joint, twisting in the knee joint, collapsing of the arch of the foot and do little to promote strength and stability (Blackaby 2012). Wide-standing with feet par- allel will offer some protection to the SI joints.

4:3 Recognise the difference between high and deep squatting (either on the balls of the feet or with heels down). In general, unless the woman finds squatting easy, deep squats should be supported (by partner) or practised using props (e.g. roll/blocks under heels/supported against a wall/sitting on a low stool/leaning forward onto support). Great attention should be taken to the position of the feet in relation to the knees to maintain alignment. In addition care should be taken in teaching how to come in and out of the pose to avoid excess loading on the knee joints, e.g. by rocking back and forth from all-fours. Consideration also should be given to avoiding deep squatting under the following circumstances:
· History of premature labour
· Knee problems where hyperflexion is contra-indicated
· Haemorrhoids
· Recent unexplained bleeding
· Baby is in the breech position in the last six weeks of pregnancy · The woman feels very uncomfortable
· Pelvic Girdle Pain
· Placenta Praevia

4:4 Be aware that kneeling involves hyperflexion of the knee joint and hyperextension at the ankle. Pressure on the calves can aggravate varicose veins, and can also impede the venous return from the lower limbs leading to light-headedness, particularly if blood pressure is low. So do not hold for too long.

4:5 Take care when teaching twists. Avoid strong twists as these can increase separation of the rectus sheath.

4:6 Avoid teaching full inversions e.g. Sirsasana (Headstand) and Adho Mukha Vrkshasana (Handstand). Only a few women with a strongly established Yoga practice may like to continue these into the second trimester – perhaps close to a wall for reassurance. Par- tial inversions such as Adho Mukha Svanasana/Sumeru Asana (Dog Pose), and modi- fied Viparita Karani Mudra (Half Shoulderstand) may be taught with legs up the wall with support of a wedge or cushions under hips and lower back. This will help increase the angle at the hip which will further help to relieve congestion in the legs. Adho Mukha Svanasana/Sumeru Asana (Dog Pose) and knee/chest pose can be used to encourage a baby in the breech position to turn. However, once head-down, the mothers of these babies (usually from 37 weeks or so) no longer wish to practise these partial inversions in case the baby turns back again.

4:7 Avoid the more advanced backbends e.g Ustrasana/Ushtrasana (Full Camel) and Urdhva Dhanurasana/Chakrasana (Wheel), as they tend to create further compression of the lumbar spine and to over-stretch the abdominal muscles (Robin 2002). Teach Vi- rabhadrasana I (Warrior I) and modified Eka Pada Rajakapotasana (Pigeon) as more helpful alternatives.

4:8 Note that postures that strongly tighten the abdominal muscles e.g. Navasa- na/Naukasana (Boat Pose), are contra-indicated as these tend to further separate the rectus abdominis. Choose a flowing Cat sequence (Cakravakasana/Marjariasana) in- stead for abdominal and core stability.

4:9 Take particular care when teaching balances. Balancing postures in themselves pro- mote strength, concentration and a deepening of internal focus. However, pregnant women tend to lose their balance more easily and feet may be swollen, arches less supportive etc. Practising close to a wall may be helpful.

4:10 Setu Bandhasana/Dvipada Pitham (Bridge Pose), pelvic tilts, Apanasana (supine squat) or any posture that involves lying on the back can be continued for short periods after 28 weeks as long as the woman remains symptom-free and the practice is not static (see 3:13) (Clapp 2012).