Keeping motherhood real – Let’s talk about Postnatal Depression

Friday, November 17 2017

Life is busier and we are more ‘connected’ than ever. Who would think that a mum or dad could feel so lonely, anxious or depressed after giving birth to their bundle of joy? The truth is parenting is hard, and feelings of Perinatal Anxiety and Depression such as sadness, guilt, hopelessness and difficulty bonding with your baby are incredibly common. 1 in 7 new mothers and 1 in 10 new fathers are diagnosed with Postnatal Depression, so you should not feel alone with statistics like this.

Becoming a parent is a big deal and whether it was a long, difficult road or a big surprise, it’s a life-changing journey for all parents and one of the toughest jobs you will ever take on.

When preparing for parenthood it’s usually the physical stuff we focus on; is my baby measuring in the healthy range? Which is the right pram for us? Is our car seat fitted correctly? However, it’s important to spend time preparing yourself mentally for the big changes that are occurring. Knowledge is power and through increasing your awareness you can develop skills to help reduce the overwhelming feelings of anxiety and depression postpartum.

At Women In Focus we have fallen in love with an awesome app called ‘What Were We Thinking!’ It is not just for expecting and new parents, but also for those supporting a new parent and/or healthcare professionals.

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Navigating your way through the app you will find an endless amount of tailored information from the birth up to six months postpartum, workshops, quizzes, journal writing, practical activities and videos from health professionals. Importantly it also gives you quick access to support helplines in your region of Australia.

For further information visit:
whatwerewethinking.org.au

Another initiative we love is ‘Ready to COPE’. It is a free and simple way to help you look after your emotional and mental health. It helps prepare women for the emotional journey of pregnancy and new motherhood with supportive emails and information.

At WIF we are dedicated to helping women with the physical challenges that come with becoming a mother. But almost every one of our clients faces emotional challenges during this time as well. It’s important to remember that being healthy, especially during pregnancy and early motherhood, requires you to look after both your physical AND your mental wellbeing.

For further information visit:
readytocope.org.au

If you or someone you know are showing signs of postnatal depression, please see your GP or a psychologist for professional help, there is support waiting for you.

You can learn more at:
panda.org.au – 1300 726 306
beyondblue.org.au – 1300 22 4636

We wish you the all the best on your journey to becoming a confident parent.

POST BY
Karen Crudden of WIF Physiotherapy
Women’s Health Physiotherapist

The Two-Second Health Check All New Mums Should Take

Thursday, October 05 2017

We spoke to PopSugar this week about abdominal muscle separation and why so many mums are getting it wrong. It’s about moving away from the ‘closing the gap’ approach and looking at the whole body. There is WAY more to an abdominal separation than measuring how many fingers width. The sooner women understand this, the more likely they can get rid of, or at least improve the ‘mum-tum’. We have great research that shows the importance of focusing on generating tension at the linea alba not about reducing the gap, and women need to know this. It’s a short article, you can read it here now.

 

 

Looking after those precious pelvic floors in pregnancy, birth and beyond…

Monday, August 21 2017

Recently Lyz Evans, our Practice Principal and Founder of Women in Focus Physiotherapy, chatted with Nadine Richards from She Births about exactly what the pelvic floor is, how it is affected by birth, and why it is so important that women look after it in the child bearing years. Lyz explains if women learn to connect with their pelvic floor prior to birth it can not only assist during labor, but also prevent ongoing issues such as incontinence in the long term.

A MUST read for any of you that are currently or planning to get pregnant, have already had children or simply are just keen to learn more about your your own pelvic health. Ladies, you only get one pelvic floor so lets spread the word on why we need to look after it.

For those ladies currently pregnant, make sure you also check out the She Births program, a scientifically verified birth preparation course that will ensure both you and your partner feel informed, supported and empowered leading into your birth. Check out their courses here or head over to their birth focused blog.

Pelvic Floor

At She Births we recommend for women to have a pelvic floor assessment prior to birth – can you explain why this is so important? How can a women’s health physio prepare you for birth?

It is wonderful that She births educates its women on the importance of the pelvic floor, as for the majority of women it is not until the child bearing years that they have even heard of the pelvic floor, let alone given it much attention. To understand why it is so important to have it checked prior to birth, first we need to understand what it is and what it actually does…

The pelvic floor is an intricate web of muscles, fascia and ligaments sitting deep within the pelvis spanning the base from the tailbone to the pubic bone. It is actually made up of 8-9 individual muscles that join together with the fascia to close off the pelvic outlet, hence creating the ‘floor’ of the pelvis. Although a relatively small muscle that is hidden from view, its importance should not be underestimated as it has some of the most critical functions in the entire body including:

• Keeping closure around the bladder to prevent urinary leaking

• Keeping closure around the rectum to prevent bowel leakage

• Providing a support system to the uterus, bladder and bowel to prevent downward descent (Pelvic Organ Prolapse)

• Provide sensation and tone required for enjoyable pain free sexual intercourse

• Provide the muscle activation to facilitate an orgasm

• Work with the deep abdominals and ‘core’ to assist with stability of the spine, hips, pelvis and rib cage

• Works with our diaphragm to ensure optimal breathing patterns

• Being able to open and fully relax at times when exiting from the pelvis is required such as when urinating, opening the bowels and of course birthing a baby!

Historically the focus for the pelvic floor has always been based around strengthening, however in recent years year’s we have realized that just like any other muscle in the body the pelvic floor has the potential to a become excessively tight (hypertonic) and this can become incredibly problematic for some women. Clinically, we are now seeing an increase in the number of women presenting with hypertonic pelvic floors and the reasons for this seem to be multifactorial in nature mainly based around lifestyle and behavior choices choices. Factors such as high level participation in exercise such as Pilates, pole dancing and weight lifting can encourage over activation of the pelvic floor, and constipation from poor dietary choices can lead to chronic straining and a pelvic floor that is always in spasm. The impact of today’s fast paced lifestyle has also lead to a pelvic floor that is constantly ‘switched on’ as a result of a lack of relaxation, diaphragmatic breathing and high anxiety and stress levels.

During birth the requirement of the pelvic floor is incredible as it needs to stretch beyond 3 times its normal length, can you imagine if you had to stretch your hamstring 3 times its normal length? It would end up at a 90 degree angle behind your head, not possible! The pelvic floor truly a remarkable piece of anatomical engineering, however in order for this impressive stretch to occur the muscle needs to have good flexibility and be able to completely relax during the crowning phase in birth. If a woman has a hypertonic pelvic floor that cannot fully relax or stretch then you can imagine how this has the potential to impact or prevent achieving a normal vaginal delivery.

One of the main reasons we encourage women to have their pelvic floor checked in pregnancy, is so that we can help determine what type of pelvic floor they have, and therefore how we can best help them. If a woman has a weak pelvic floor then a specific strengthening program will be given so that the pelvic floor can continue to support the bladder, bowel and uterus throughout the pregnancy and in the post natal period.

If a women however has a hypertonic pelvic floor, then we will work with her to restore optimal breathing patterns, work manually through the vagina and pelvis to help release overly tight muscles to ‘ down training ‘ and help restore normal mobility and length required for birth. This can be incredibly empowering and life changing for a woman who has always held tension in her pelvic floor.

Regardless of what type of pelvic floor a woman has once in the final stages of pregnancy, a Women’s Health Physio can work with her to teach her how to achieve full relaxation of the pelvic floor to achieve opening of the pelvic outlet rather than closure, which is what is required in birth.

We also recommend that women have one assessment with a Chiro or Osteo prior to birth – How is physiotherapy different from Chiropractics and Osteopathy?

Chiros, Osteos and Physios all have very different training so approach the body in differing ways, in many cases we can work harmoniously together to help women achieve optimal outcomes.

The main difference when seeing a specifically trained women’s health Physiotherapist is that we will do an internal check of the muscles, ligaments and organs within the vagina to check their tone and function and how this may impact the rest of the pregnancy and upcoming birth. We also utilize sophisticated real time ultrasound equipment that provides women with a visual of how their abdominals and the pelvic floor function, a wonderful way for us to educate and teach women.

Specifically trained Physios will undertake a thorough inside – outside ‘Pelvic Health Check’ for a pregnant woman. This will usually include:

• Checking the alignment and stability of the pelvis and hips to ensure it is has symmetrical mobility required to minimise any pelvic girdle pain in pregnancy but also to prevent restriction of pelvic opening required during birth.

• Assessment of the abdominal wall, rib cage and breathing patterns to address achieve optimal abdominal support and prevent excessive loads whilst the abdominal anatomy is so dramatically altered.

• Internal assessment of the pelvic floor muscles via a vaginal exam (After 12-18 weeks gestation)

• Use of real time ultrasound on the pelvic floor and abdominal muscles for feedback on activation – a wonderful teaching tool for women.

• Education on what that individual woman needs to do to optimise her pelvic floor and pelvic health for the pregnancy, birth and postnatal period.

• Prescription of a home exercise program to encourage pelvic floor and abdominal strength or relaxation.

• Discuss regular exercises habits and what is suitable for the individual.

 

After birth, what happens to your pelvic floor? How can you strengthen it?

A vaginal birth is essentially the biggest load that your pelvic floor will EVER have placed on it, and studies show an average of 25 – 35% reduction in Pelvic floor strength following birth. We also know that in 80% of women the nerve the innervates the pelvic floor (the pudendal nerve) is bruised and some times partially damaged from the birth so the messages it sends to achieve activation of the pelvic floor occurs much much slower.

As a result greater than 50% of women will experience urinary or bowel leaking in the first few weeks and months following birth, so don’t be alarmed if this occurs. If the birth was slightly more complicated requiring an episiotomy, forceps, venous, long second stage, or a very large baby then these women are often more likely to feel the impact to the pelvic floor in the months following birth.

The good news is for the majority of women if a specific pelvic floor program is performed daily then good pelvic floor strength and control will return. In the early days, Women should reconnect with the pelvic floor on the post natal ward as this is an essential part of encouraging the pudendal nerve to regenerate and the muscles to reactivate. Starting by activating and holding gently for 1 second and repeating 5 -10 of these a few times a day is enough to get started. Timing this at that same time as feeding baby is a great way to remember to do them.

Once this becomes easy then the endurance and hold time should be increased. The term ‘ use it or lose it’ definitely applies to the pelvic floor, and if you want it to be with you and support you through life then you need to give it a little love and TLC in its time of need!

How do you know if you’re doing pelvic floor exercises correctly?

Unfortunately the answer to this question really is that you need to have it checked by a Women’s Health Physiotherapist to be 100% sure you are doing it correctly. Even the ultrasound cant 100% confirm a correct activation and breathing patterns will come into play.
We know from research that when the general population are given instructions on how to do a pelvic floor activation that greater than 50% will do it incorrectly, of which 25% were found to be actually bearing down rather than lifting up (Eeek!) If a woman doesn’t have access to a Women’s Health Physiotherapist and wants to check herself the best way would be to insert a clean finger into the vagina, and when activating the pelvic floor she should feel a tightening and a ‘suck’ up of the finger inwards and upwards. She should be able to breathe and hold for 10 seconds without the finger being pushed out.

My advice to women is to be proactive in their childbearing years is to find yourself a good Women’s health Physiotherapist and be sure to see them at least once in pregnancy and then again at 6 weeks post natal. These appointments will potentially save your pelvic floor in the long term.

It really bugs me that women are not routinely sent for pelvic floor rehabilitation following a birth, if you were to undergo surgery for a hamstring tear you would 100% be sent by the surgeon to a Physio for months of post operative rehabilitation, why does this not happen for the pelvic floor?! 
We have a long way to go in Australia and I would love us to look towards France whose government provides 6 -8 sessions of routine government funded pelvic floor Physiotherapy to help restore function post birth. Go France! Perhaps one day we will get there, but for now we either need to move to Paris or be proactive with our pelvic floors.

After all you only get one of them so please make sure you look after it!

Read the full blog post via She Births here.

An interesting read on the wave of new generation pelvic floor treatments

Friday, November 18 2016

pelvicfloorelle

Click on the link below for an interesting read from the November issue of ELLE magazine on the wave of new generation pelvic floor treatments, quoting our practice principal Lyz Evans:

Elle Magazine – The Way, Way Down

It certainly is an exciting time with new treatments for the pelvic floor such a laser for ‘pelvic floor tightening’  coming into the mix, at WIF we are hopeful that these new treatments may have a role to play in SOME pelvic floor conditions such as stress urinary incontinence. Trials for the laser are still being undertaken in Australia, so for the meantime we need to keep with the ‘traditional approach’ of pelvic floor muscles strengthening and watch this space for outcomes of clinical trials. If you find Pelvic floor exercises just that bit too ‘ traditional’ then why not mix it up a little with pelvic floor weights or funky blue tooth devices?! Have a chat to our pelvic floor Physio’s next time you are in the clinic to learn more. :)

Jogging 3 weeks post birth?! Please don’t.

Friday, January 15 2016

To mums out there who have seen Michelle Bridges recent post about the exercise she is doing at 3 weeks post natal, then you would be right in feeling confused by her recommendations.

It boasts about her 56 min interval work out, which is comprised of 32mins of jogging and 24 minutes of walking. She goes on to say “Remember! I’m a professional trainer & have been training for 30yrs. So! For you please dial this down to 15 – 20 mins of total work.”

Michelle recommends you reduce the length of her workout, however has failed to identify that the real issue is not the length rather the type of exercise: Jogging!

 

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The reduced 20 minute workout would still include 12 minutes of jogging, which for a woman who has just had a vaginal birth or cesarean delivery is quite simply irresponsible, and would NOT be recommended by an experienced health professional.

If an individual decides to jog soon after giving birth, this is their choice. However as a public figure encouraging women who’s body types, birth and fitness histories are unknown, to start jogging is quite frankly concerning. It could potentially cause a woman more harm than good in these early stages, especially to the pelvic floor and the ligaments that support the bladder, uterus and bowel

After seeing this post on Tuesday, and letting it sit with me for a few days, I have become increasingly frustrated by the incorrect message that are promoted by the fitness industry especially for women in their childbearing years. As a health professional working in Women’s Health for over a decade, there is a duty of care to provide women with the correct information on how to best look after their bodies. I cannot tell you how many times I’ve heard comments like “If only I knew about the damage returning to exercise too early could cause. I might not have ended up with these problems.”

As I’ve noted in the past, I’m a great supporter of Michelle and the work she does in building healthier communities throughout Australia. But now what I’d love to see is Michelle using this time as opportunity to promote a positive post-natal message to her audience. Like rebuilding of the pelvic floor, deep abdominals and postural muscles that are so dramatically weakened during pregnancy. Or instead of jogging, encouraging more appropriate low impact cardio options such as the stationary bike or cross trainer.

 

So what exactly is wrong with jogging at 3 weeks post-natal?

Jogging is an exercise that results in a high impact force called a ground reaction force that travels through the body when the foot strikes the ground. This impact requires strength and stability from the joints, ligaments and muscles in the body to maintain good control, preventing injury and tissue damage.

In the post-natal body the ligaments and muscles have a reduced ability to generate strength due to the physical and hormonal changes of pregnancy and birth. These changes coupled with the downward force of gravity with vertical exercise such as jogging or jumping means that if undertaking high impact exercise, then excessive strain is being placed on already weakened structures including the pelvic floor and pelvic girdle, potentially causing a new mum long term damage.

 

Pelvic Floor Diagram

 

So what exercise can you do safely?

The most important thing to remember is that all women have different body types, have had different birth’s and have different levels of fitness leading into the pregnancy, so returning to exercise at the right intensity is individual. Start with low impact exercise such as pelvic floor exercises, pilates, yoga, stationary bike, cross trainer, and swimming (after your 6 week check) and build gradually from there.

If you are a runner or keen to return to more high impact exercise, then I highly recommend you see a Women’s Health Physiotherapist from 6 weeks who will assess your pelvic floor, postural alignment and abdominal muscles to ascertain the right exercise for you. Then to keep motivation up, find an experienced trainer or fitness group who specialises in the post-natal body who can guide you in your safe return to full fitness.

Ladies, remember you only get one body and one pelvic floor, which has been gifted to you to enable the growth of your special little human. So please, show it some respect and look after it.

We’ve all heard of Pilates but I think the biggest question that comes up is; What’s the difference between mat and equipment Pilates?

Wednesday, August 07 2013

I think the best way to answer this is by going back to the origins of Pilates.

The term Pilates is actually named after Joseph H Pilates who was born in Germany in 1883. A sickly childhood led Pilates to pioneer his unique training system, with which he hoped to rid all of his students of physical limitations. He spent time in a camp hospital during World War 1 where he worked with patients to employ the springs in the hospital beds to create rehabilitation equipment.

Pilates migrated to the United States in 1925. His studio just happened to be housed in the same building as a number of dance studios. Naturally the dancers flocked to learn the method and they were soon followed by many devotees. But Pilates had the intention that his unique system of physical conditioning, originally known as Contrology, was to be practiced by everyone.

Pilates is uniquely adaptable and the moves in the method were created to address total fitness. Each exercise has a strength component as well as a flexibility component.
In its first incarnation Pilates consisted of floor exercises. Experimentation with springs and equipment followed.
The resistance created by the pulley and spring system can provide a more challenging strength and endurance workout than mat classes.

It may also provide visible results sooner; arm, leg and abdominal muscles can look more toned after a dozen or so regular sessions . The flexibility of equipment and the many attachments of the Pilates apparatus increase the range of modifications that can be made to the exercises and allow additional exercises beyond what can be offered on the mat. This combined with the support afforded by the resistance the machine provides allows people with limited range of motion or injuries to safely perform modified exercises.

I personally practice both mat and equipment Pilates and love the variety of exercises and the challenge and control required to work against the springs of the equipment.
The best way to know which form of Pilates is right for you is to give both a go and then see.

I look forward to seeing you in the studio!
Sarah

New Classes Added – Friday and Saturday!

Friday, July 26 2013

We are currently adding more Exercise Classes to the timetable. From Friday August 2nd there will be a 11am Postnatal Class. From Saturday the 10th of August, 3 new Exercise Classes will be offered! Please book online so you don’t miss out.

Pelvic Floor Exercises – NOT Just One More Thing to Add to your “TO-DO” List….

Wednesday, March 27 2013

I’ve recently been asked to write an article for Sydney’s Wedchild Magazine. For those pregnant and postnatal women who keep adding pelvic floor exercises to your ‘to-do’ list, click on the link below:
http://www.webchild.com.au/pregnancy/pregnancy-focus/pelvic-floor-maintenance

Until the childbearing years the majority of women have never really taken much notice of the pelvic floor muscles, let alone done any exercises for them. You then enter a life phase, when all of a sudden you expected to be doing them and various people around you including your doctor, yoga instructor and women in your mothers group start reminding you about doing your pelvic floor exercises.

The problem is that women often feel confused as to what exactly they are suppose to be doing and although they know they should be doing them, the instructions on the brochure don’t really help, and it seems like just one more thing to add to the ever growing “to do list’. There are often no signs of any pelvic floor weakness for women in the early years, and so the priority drops further and further down the list.

In order to prioritise correctly however, women really need to understand the role that the pelvic floor plays, and the effect the childbearing years has on its function.

The role of the pelvic floor

The pelvic floor is a group of muscles that sit deep within the pelvis running from the pubic bone at the front, wrapping around your bladder, vagina and bowel then connecting to your tailbone. There is always a certain level of subconscious activation in the muscles called ‘ resting tone’; this helps with postural control and core activation as well as maintaining continence during low-level activity.

The muscles also have an ability to increase strength during higher load activities such as during lifting, sneezing and running, or when you have a strong urge to go to the toilet. If the muscles are unable to increase the strength when needed then symptoms such as urinary incontinence, bowel incontinence and prolapse often commence

The pelvic floor also plays an important role in sexual function. as it must be able to relax to allow penetration, then contract for sensation and orgasm.

The effect of pregnancy, delivery and the postnatal period
Pregnancy is often the first time the pelvic floor has really been challenged and as a result many women start to get the first signs of weakening such as leaking during a sneeze. The reported prevalence of urinary incontinence during pregnancy during is 40 – 59%, with highest rates in the third trimester. The main reasons for weakening in pregnancy is 2 fold:
1. There is an average weight gain of 12 – 18 kg, which dramatically increases the loading through the pelvic floor and bladder.
2. There is a natural softening of the pelvic floor muscles due to hormonal changes throughout the pregnancy, this softening occurs to minimise obstruction to the pelvic outlet during birth.

Despite the type of delivery a woman goes on to have, whether it is a vaginal delivery or a caesarean, there will still be a degree of pelvic floor weakening due to the changes occurring during pregnancy. It is without doubt however that a vaginal delivery places much more stress on the pelvic floor muscles. In particular those women that have had a baby over 4kg, had an assisted delivery with forceps or ventouse or have pushed for greater than 2 hours need to prioritise have a greater strain to their pelvic floor and need to be proactive in the postnatal period.

In the postnatal period, the pelvic floor starts to recover from the pressure of the birth, the healing of stitches and from the hormonal effects of pregnancy. There is however a new load put on the pelvic floor, which comes in the form of constantly lifting a newborn baby (and in may cases a jealous toddler as well!). As the baby gets heavier, so do the loads and learning how to activate your pelvic floor during lifting plays a crucial component in minimising further pelvic floor weakening.

So what can you do?

The truth is, many of these effects during the childbearing years are unavoidable, so don’t be too hard on your self. There is however a few things you can do to minimise any ongoing effects on the pelvic floor:
– Avoid becoming constipated, as this strains the pelvic floor. Increase your water intake and ensure you are getting large amounts of soluble fibre such as from porridge, dried fruits, and psyllium husks. In some cases a supplement may be needed, which you should speak to your pharmacist about.
– When opening your bowels, take a tip from the males and take your time! Lean forward, place your elbows on your knees and rise up on your tippy toes. This position helps to open up your bowel with the least amount of pressure on the pelvic floor. Be sure not to hold you breath or push, or rush as an extra minute on the toilet can make a difference to your pelvic floor in the long run.
– Minimise heavy lifting and if you do weights at the gym, sit on a fit ball do arm weights, and ensure you are not holding your breath.
– Learn to activate your pelvic floor during increased loads such as with a sneeze, cough or lifting.

Of course however the most important thing, is to do regular pelvic floor exercises. For those of you that feel confused on how to do them correctly I would highly recommend you see a qualified health professional such as a Woman’s Health Physiotherapist or your Gynaecologist to teach you the correct technique. As much as I would love to describe them in this article, research has shown that if women are given brief verbal instruction in performing pelvic floor exercises in the form of a brochure, 51% were ineffective and 25% were actually bearing down as opposed to lifting. (Bump et al 1991).

For those of you how have been taught correctly how to do the exercises, try and make them apart of your daily routine such as during your normal exercise routine, whilst rocking the pram back and forward or whilst breastfeeding.

Pelvic floor exercises really do play a crucial role in prevention as well as treatment of symptoms such as incontinence, prolpase and sexual dissatisfaction. and are most important during the childbearing years. So stop procrastinating, learn how to do them and then add them straight into your daily routine (not on to your to do list!)

WIF goes Gaga

Tuesday, July 31 2012

Those of you who are Lady Gaga fans may be interested to know I was rubbing shoulders (well really rubbing backs and necks!) with the Lady Gaga dancers last month at the Born This Way Tour, Sydney.

I was asked to be the Physiotherapist to diagnose and treat the injuries that these incredible dancers develop from performing and rehearsing their amazing routines night after night. Injuries ranged from acute back pain, hip impingements, pelvic girdle dysfunctions and headaches. Despite these dancers being highly trained agile individuals, the rigours of the tour demands have unfortunately resulted in the development of these injuries. We all may not be professional athletes, but it is important to realise that regardless of how fit, strong or skilled you are if you repeat the same movement over and over sooner or later you too may develop an injury.

Have a think about what movements you do repeatedly in your day, such as lifting your baby or sitting in front of a computer and look for ways you can modify it, and strengthen your body to cope with the task.

Just like these dancers, you too need to look after yourself as the show must go on!

Physio at Lady Gaga

Physio at Lady Gaga

The WIF Vision

Monday, July 30 2012

Welcome to Women In Focus (WIF), we are now officially up and running!

Hopefully you have had a chance to peruse my website to see what this ‘ female only’ Physiotherapy clinic is all about (and before you ask, no I am not sexist or a man hater!)

It is a concept developed from years of treating both Men and Women. Since graduating as a Physiotherapist I have treated a broad spectrum of patients, ranging from professional athletes, to professional dancers, pregnant women and elderly men. And I must say, this had led me to the realisation that the saying   ‘Men are from Mars and Women are from Venus’ actually has some truth behind it.

Over the last 4 years of specialising in women and completing related post graduate studies, I have realised that us girls have very different anatomical structures, hormones, and stresses on our bodies (such as child birth!) which our male counterparts simply don’t have.

‘Women In Focus’ is my vision is to create a clinic where the female body is understood, and things that may be rare in other clinics such as pregnancy related conditions or pelvic floor dysfunctions are our specialty.