The following essay is featured in the full prospectus, released Nov 1 in support of this IGG campaign to help fund publication.
On the morning of June 19th, 2013, Nancy Cochren, aged 32, was 38 weeks pregnant, and teaching yoga at the studio in Hamilton Ontario where she’d worked for seven years. She felt strong and supple, and almost ready for the enormous change ahead. She remembers the sweet feeling of squatting in malasana that morning, and the elation of side-lunges.
In the afternoon, her obstetrician at St. Joseph’s Hospital performed a stretch-and-sweep during her checkup, and accidentally broke her membrane. A gush of clear, sweet amnion splashed off the examination table and hit the floor. The doctor took her hand and said “Well. You’ll be having that baby now.”
Without a hint of natural labour to prepare her, Nancy was whisked away to a prep room where an I.V. of the induction medication pitocin was waiting. She hadn’t packed a bag. No toothbrush or baby blankets. She called her partner Phil, who rushed to meet her while her family took care of the details.
She entered a whirlwind of emotions, interventions, waiting, wondering, day turning to night, and then day again, and excruciating pain. In the final pushing stage, she remembers being on her back with Phil and a nurse holding her thighs in deep flexion to give her more room to widen. Her flexibility, whether natural or conditioned by yoga, was a boon. “I looked down and saw the stirrups,” she said, “and my legs were way above them in the air.”
At 3:45pm on June 21st, Nancy gave birth to a baby girl. They named her Parker.
Through the blur of joy, tears, nursing, hunger, and medicated wooziness, Nancy remembers gingerly making her way to the hospital room toilet, wobbly, feeling that her entire pelvis was at sea. Was this normal? Was it the epidural wearing off? Would she always be so unstable? She didn’t know, and there were more pressing concerns. Baby was a little underweight, and Nancy was bleeding more than the doctors were comfortable with. Mother and child were kept under observation for two days.
As it is for many new mothers, Nancy’s rushed, chaotic, painful, joyful birthing was the climax of a journey of bodily reorganization and estrangement. “I hadn’t felt as though I was in my body since before I was pregnant,” she wrote to me by email. And it sounded like her birth circumstances seemed to separate her from herself, making her feel as though she’d lost control.
I asked her during one of our phone interviews whether this general sense of raggedness helped to pull her back to her yoga mat, in the hope that she could perhaps reintegrate and ground. “Absolutely,” she said. “My mind wasn’t the balanced mind I knew. I thought, ‘I’ll use my body to bring me back to the mental peace that I recognize as mine.’” She hoped, as everyone who has been through transformation or trauma hopes, to quickly recover an older and better-known version of herself.
Nancy made plans to return to the mat as soon as she could—to dip back into the more familiar sensations of strength, ease, and autonomous presence that she had fallen in love with at the age of 19, when she first began to practice. When Parker was two weeks old, Nancy poured over the class schedule of her studio to choose the perfect time between naps and nursings to tuck the baby away with Phil, drive to the studio, and roll out her mat for a gentle Hatha class. Her friends and colleagues greeted her warmly, asked about Parker, told her how good she looked, and praised her strength and bravery in coming back to practice so quickly.
She expected to be tentative and sore, and she was. She experienced the common post-partum absence of core strength, and the strange new positions of her organs. At one point in that first class, she felt a little overwhelmed, and thought, “I’m just going to rest here in child’s pose.” But when she went to kneel and flex her hips, something felt wrong on the left side. She breathed deeply and settled in to begin the restorative work the pain was telling her she needed. This is where the next chapter of Nancy’s journey begins.
She committed to going to one class per week, and by August she was teaching again, though without demonstrating the postures. In daily life, she noticed the pinching in her left hip increase. But then it seemed to shift to the right side. Then back to the left. Then it was in both. In her personal practice, she approached the problem as she had been taught: to move towards—but not into—the pain, gently, prodding and compressing, trying to release it with breath and the spirit of relaxation.
This worked, somewhat. She felt wonderful right after practicing, every day. The pain would evaporate, and her hips were freely mobile. But over the hours following each practice, she would feel herself stiffen again. The pain would return, and she found herself counting the hours to the next time she could make it to the mat. Practice was a painkiller—but was it addressing, exacerbating, or even causing her problem?
Often, Nancy would just brush the pain aside, even though it was new for her. “Physical practice had always come easily to me,” Nancy told me. “I thought that these new feelings must be part of that regular discomfort of practice that I’m always helping my newer students accept and work with. In my own body, I felt like I was just getting the rust off. I only expected that I was getting better, that I was working away from injury.
“I was thinking: ‘I have to prep and prime so that I can get back to Mysore again’.”
By the end of August, Nancy’s hip pain was severe and unrelenting on both sides, interrupting her sleep as much as nursing was. She treated herself with ice and Tylenol, and continued to hope the injury would heal through the movements of this practice that had always been so soothing and therapeutic for her. She couldn’t imagine getting through this bump in the road without asana, without the familiar comforts of length, engagement, and compression.
But she also reached out for help. She visited her osteopath, who seemed puzzled and concerned. He applied compression manipulations to Nancy’s hips, which felt really good, but the effects were short-term. Then she saw a chiropractor, who suspected bursitis. Through internet research she learned about and resonated with the descriptions of Pubic Symphysis Diastasis—chronic, painful separation of the pubic bones, and through her family doctor was referred to a physiotherapist specializing in pelvic health. The recommended exercises were only moderately helpful.
It seemed to her that the richest sensory indications that she was almost ready for full practice—or that perhaps she was even healing—came through deep extensions and rotations of her hip joints in lunging and pigeon postures. The movements were paradoxically uncomfortable and greatly relieving.
As an aside: understanding the neurological competition between pain and pain relief is something I’ll be exploring throughout this book. In part, it has to do with distraction. The nerve fibers that register pressure, for example, are different from those that register inflammatory responses. Activating the former can temporarily disable the latter. It is likely that Nancy, like any yogi inclined to move towards the source of pain to greet it, know it, and soothe it, was unconsciously using this distractive mechanism.
Finally, in October, her osteopath revealed his concern. He suggested that her hip cartilage on both sides—her labra—might be torn, and that the damage might have come from giving birth. He encouraged her to ask her family doctor for imaging tests.
The family doctor was puzzled, conservative rather than proactive, and frugally triaged Nancy through the less-expensive imaging tests, all booked months out, even though her own research convinced her that she needed Magnetic Resonance Arthrography, which is the only real technique that can verify labral tears. It’s basically an MRI with contrast dye injected directly into the joint to highlight abnormalities.
Fall gave way to winter. Parker burbled over her first Christmas presents. Nancy’s pain ebbed and flowed as her mobility decreased. At times she had to stop, but as soon as the pain eased she would try again. “You know that thing women say: ‘I wanted my body back’.” Such a heavy cultural trope.
When spring arrived, she went for her x-rays and ultrasounds, which all came back all normal, aside from showing inconclusive swelling in the hip capsule. They were better than normal, in fact. The orthopedic specialists told Nancy that her hips looked “beautiful”, with “no abnormalities at all” that would constitute risk factors for labral tearing: shallow hip sockets, asymmetries, or femoral necks with wide angles of inclination. The imaging showed no signs of arthritic damage. It gave Nancy the relieving impression that her years of practice had not made her vulnerable to her injuries. She campaigned for an MRA.
In March, Nancy’s first set of arthrograms confirmed “uncomplicated bilateral anterior superior labral tears.” They were exactly the same place on both sides, and exactly the same length. She had a meeting with an orthopedic surgeon on May 29th, and was put on a list for surgery, and told that the wait could be up to fourteen months. More recently, her physiatrist has administered cortisone injections to suppress the inflammatory response of the tissue damage. She’s also received injections of a new medication called Monovisc, a viscoelastic solution of sodium hyaluronan that supplements a natural substance called hyaluronic acid. This acid, along with the protein lubricin, gives synovial fluid its slippery quality. The shots have been very helpful. On the phone, Nancy and I joke that Monovisc is like the Tin Man’s oil can.
Meanwhile, Nancy has had to adjust to the reality of losing a treasured identity, and the depression that has followed. At 16, she’d started teaching martial arts, earning two black belts before a slipped disc in her neck forced her to withdraw. “I poured my entire focus into yoga after that” she says, “to fill the gap in my free time, and ego. I envisioned a 90-year-old me practicing with the same freedom I felt when yoga was new. All I had to do, I believed, was to keep moving.” As with so many yoga practitioners, Nancy’s faith in the practice made it difficult to accept that immobility was the healing modality she needed now. In a culture convinced that healing and hard work are inseparable, she has had to learn stillness, and non-attachment.
Unless an earlier opening comes up, Nancy will be having her first hip repaired in the summer of 2015. She’ll have to be immobilized for up to six months before they attempt to repair the second hip. Her surgeon has told her it would be ill-advised to try to carry another pregnancy before both hips are repaired, and have proven stable.
“Am I on the wrong path?” Nancy wondered aloud. “Do I need to take up something hip-friendly, like painting? I shouldn’t give up on this body, should I?” I had no answer for her, but I hoped for her enthusiasm to return. “Constant questions,” she says, “and lots of time to think.”
Including, as it turns out, lots of time to re-design how she will continue with her yoga teaching career. For the last year or so, Nancy’s been leading asana classes by voice alone. She’s largely stopped demonstrating, and has sharply changed her attitude towards students going too far with effort in their postures. Her students are aware of her condition, and she’s been transparent with them about her process. She’s also figured out what actually does work for her therapeutically, at least for the moment. She’s been practicing a lot of restorative yoga, finding the poses that bind her thighs together very comforting. She’s training to be able to teach this form as well.
So how did both of the labra of Nancy Cochren’s hips tear? We cannot know for sure. The arthrograms give doctors a clear view into the state of her labra in March, 2014, but can tell us nothing about how old the tears are, or how they got there. But we do have a number of possibilities to consider.
Labral tears from the stresses of childbirth definitely happen, although rates of occurrence are difficult to find. In one study of 43 women (Baker, 2010), three cases of labral tearing (7%) were strongly correlated to birthing stress. However, the sample was drawn from the regular client list of an orthopedic surgery clinic, and not controlled for age or other variables. It seems that no one has yet tracked how many birthing women generally sustain this injury, nor what the risk factors might be. As in: would a prenatal yoga career predispose a woman to labral vulnerability, or would it give her a more flexible, forgiving, and resilient hip joint? We don’t know.
There has been one focused study (Brooks, 2012) done of ten women ranging in age from 23 to 36 years who are quite sure that birthing was the primary cause of their tears. Four of them reported the injury occurring during labour or birthing itself, describing distinct popping or twisting sensations as their femurs were flexed or rotated by their birthing partners to help widen or mobilize the birth canal. The study proposes that the most dangerous position is the simultaneous combination of flexion, adduction, and internal rotation.
Nancy’s injury would not seem to fall into this category. She doesn’t recall being manipulated into this hip position. Nor did she feel any particular hip pain that she could distinguish from the pain of labour or birthing. Her hip pain only started after she returned to practice. It’s possible that giving birth to Parker was the primary injury cause, but the evidence is inconclusive. What makes it unlikely in my personal, non-medical view, is that it isn’t just one tear, but two. I haven’t yet come across any cases in the medical literature that describe both hips being identically injured during childbirth. The similarity of her injuries would imply that the extreme range-of-motion manipulation associated with the injury was repeated with great precision on both sides. My thought is that the exact symmetry of the two injuries may be a reflection of Nancy’s alignment precision, and how she brought herself with great care and attention into one pose after another, first on one side, and then on the other, in that early postpartum phase. Nancy has generously invited me to the next preparatory meeting with her surgeon, and I’ll be asking him about this possibility.
Is it possible that the birthing exerted enough stress on Nancy’s labra that they were less resistant to the flexions, extensions, and rotations of the asanas she returned to? Yes. Is it possible that she entered labour with the articular cartilage in her hips weakened by years by asana practice? Yes, although much of the imaging would deny this. Is it true that the biochemistry of post-partum women is flooded with the labour-catalyzing hormone relaxin—which softens the cartilage—for up to sixth months? Absolutely.
There are some things we can be surer of. Whether the injury preceded, occurred during, or followed Parker’s birth, the beloved and pleasurable asana actions of flexing, adducting, externally or internally rotating, or applying traction or compression to the hips 1. could not have improved her condition, 2. might have worsened it (given that her general pain increased through the postpartum months), and also, 3. paradoxically, relieved it, albeit temporarily.
We also know that for Nancy, yoga nurtured an expectation of joint mobility and physical autonomy that the birth of Parker interrupted. We know that the asanas felt good enough to reinforce her well-conditioned belief that they were therapeutic, instead of merely analgesic with diminishing returns. And we know a little of the strong enticement to “try harder”, with which women are especially burdened. Nancy was praised and rewarded by her colleagues and students, held up as proof that childbirth is no obstacle for the woman who wants to do everything, and who actually must do everything if she wants to avoid disappointment and shame.
Even deeper than this gendered tension, perhaps, is our collective wish to perform changelessness in the face of life. We so desperately want to show our constancy, perhaps because we know we are never the same person from day to day.
Year by year, hundreds of thousands of women around the world who are committed to modern postural yoga are also negotiating childbirth, effectively bringing two forms of spiritual practice into contact. The lived reality of these practices collides with the social narratives of how they are supposed to be in the world, throwing off stories of pain, bravery and learning like so many sparks.
One final note for now. In our most recent interview, Nancy described the process of receiving the cortisone and Monovisc injections. She was awake for the procedure. The physiatrist froze both of her hips with a local anesthetic. She could move, but oddly, couldn’t feel anything. The gurney was next to an x-ray apparatus that projected the image of her hip onto a screen. The doctor aimed the 5-inch long, 18-gauge needle towards her joint. She watched the needle pierce the skin and sink in. She turned to look at the x-ray screen along with the doctor. She watched him guide the needle tip to the round joint capsule, and nudge against it until it gave way with a small pop. The doctor depressed the plunger and the medication filled the capsule.
This is the weirdness of yoga meeting the hospital. The yogi can now see, but not feel, what she’s trained so hard to visualize and feel. Her mindfulness to sensation is numbed, while the direct image is broadcast for her consideration, perhaps displacing that inner self of discernment she worked with and breathed through for years. A man in a white coat seems to have more access to the source of her pain than she does.
He is a strange new guru in modern postural yoga. He holds a needle, an x-ray gun, an ultrasound scanner and a clipboard in his many hands, a nonchalant deity with semi-sacred implements. He probes to the depths of the yogi’s pelvis, so close to that line of chakras, documenting her being in ways the ancient seers could never have imagined.
Note: All citations can be found in the “Working Bibliography” section of the prospectus.