My postnatal body: diastasis recti

Often associated with the mummy-tummy, unfortunately there is a lot of misconception surrounding diastasis recti and abdominal exercise during and after pregnancy.

If you have searched the term online, you are likely to have come across conflicting information and advice. Some of these claims can cause needless anxiety, probably the last thing you need while caring for a newborn! And some advice can be downright dangerous – doing a lot of crunches for example, which would in fact worsen abdominal separation.

It is generally seen in pregnant and postpartum women, but can also be found in babies and adults with excessive visceral fat. This post will focus on diastasis recti in prenatal and postnatal women.

But first things first…

What does diastasis recti actually mean?

Diastasis (from Greek): separation

Recti (from Latin): plural form of Rectus (abdominis) - a.k.a. six-pack muscle

Why does it happen?

Under the influence of the hormone relaxin, the abdominal muscles undergo a tremendous amount of stretching. The two bands of muscle (recti), which previously lay parallel, stretch away from the midline (linea alba) to accommodate the expanding uterus.

It is a normal structural adaptation occurring in most pregnant women and usually most noticeable right after delivery.

Can it be prevented?

A small amount of widening of the mid line happens in all pregnancies and is normal. Diastasis recti occurs in about 30% of all pregnancies. Some postpartum women's mid lines close to less than 2cm (approximately 2 finger-widths) spontaneously, but for many, the tissue remains too wide, causing problems.

You may be more likely to develop diastasis recti as a result of pregnancy if you:

• Are petite
• Are older than 35
• Are carrying multiple babies
• Have a pronounced sway-back
• Deliver a baby who has a high birth weight
• Have been pregnant multiple times
• Have poor abdominal muscle tone
• Are genetically predisposed.

NOTE: During pregnancy, aggressive abdominal exercises after the first trimester also might contribute to the development of diastasis recti.

When will my abdominal muscles recover?

Three to four days after giving birth, the Rectus abdominis begins to realign and the wide separation progressively reduces.

By eight weeks postpartum, most women’s midlines will have recovered to approximately two finger-widths (2cm) apart at the umbilicus, and many women will find that recovery plateaus at this point.

Diastasis recti, where the bands of abdominal muscle remain separated long after giving birth by more than 2cm/two finger-widths, affects roughly 30% of women.

Abdominal separation resolves when either your muscles have pulled back together to less than two finger-widths, or when you can feel that your midline has become strong and elastic, at about six to nine months postpartum. Once your connective tissue has regained its former density and elasticity, you are no longer at risk for an umbilical hernia or other serious associated problems.

How soon after birth can I begin exercising?

If you gave birth in Switzerland, the midwives in charge of your care, whether you’ve given birth at a hospital, birth house or at home, would have (with any luck!) encouraged you to perform pelvic floor and deep abdominal muscle re-training exercises soon after birth (two – three days postpartum).

The completion of early abdominal recovery training, or pelvic floor recovery (Rückbildungsgymnastik in German) will speed up the postnatal recovery process and is invaluable in regaining pelvic stability and integrity in the pelvic floor.

If you missed the opportunity - easily done whilst trying to figure out breastfeeding and getting to know your newborn (!), many insurance companies will partially or fully cover the costs of Rückbildungsgymnastik with approved practitioners such as midwifery and physiotherapy clinics. Some of these courses are offered from eight weeks of delivery only.

What if I’ve had a Caesarean section?

Most women who delivered by C-section feel that abdominal recovery is inhibited by the procedure. Although the muscles have not been cut, the rectus sheath (aponeuroses), which pass over the top of Rectus abdominis (RA) have.

Consequently there is often abdominal disruption leading to bruising and bloating, and this leads to difficulty in recruiting the abdominal muscles. Tingling and numbness may be experienced around the scar site, with sensation retuning in patches. Full sensory recovery could take up to six months.

Following a C-section, generally women should delay abdominal reconditioning until 4-6 weeks postpartum; however, some exercises are safe and recommended to speed up the recovery process, they include:

• Pelvic floor exercises (Kegels)
• Diaphragmatic breathing
• Abdominal compressions:  seated, standing, or supine (on the back)
• Abdominal compressions with pelvic tilt: standing or supine.

Is postnatal recovery training (Rückbildungsgymnastik) in the early postnatal period really necessary?

YES! And here’s why:

• Gentle abdominal recovery training targeting deep postural muscles together with the pelvic floor will help you regain pelvic stability and encourage RA to shorten
• Gentle pelvic floor exercises will help you strengthen your pelvic floor and contain/avoid postnatal stress incontinence; they will also help your perineum and vagina to heal faster.

How do I know if my abdominal muscles have recovered?

The midwife that provided your postnatal care at home would have likely checked for abdominal separation progress during an early visit. However, it is unlikely you would have this checked again by your OB/GYN during your postnatal check-up unless you have specifically asked for it.

However, if you feel ready to start exercising again (following your postnatal check), it is very important to check the condition of RA separation prior to commencing any type of abdominal strength training.  

This is exceptionally important because some popular postnatal exercises, including certain Yoga poses and Pilates moves, could in fact worsen the condition and cause doming. An extensive list of exercises that should be avoided can be found further down.

What is doming?

Doming is characterised by a bulging, or ‘doming’ above or below your belly button when you contract your abdominals. It occurs when the bands of abdominal muscle remain separated and/or the linea alba has not regained its integrity. Doming is harmful to the abdominal muscles.

Could diastasis recti be causing my mummy-tummy?

Possibly. Diastasis recti can cause doming, but it’s important to differentiate doming from carrying a little bit of extra weight in the tummy - which is only normal following pregnancy! So, in fact, you may have a combination of both.

Some obvious indicators of diastasis recti to watch out for:

• A gap wider than 2cm/ two finger-widths when the rectus abdominisis fully contracted
• A gap that does not shrink as you contract your abdominal wall
• A small bulge protruding above or below your belly button when you contract your abdominals.

How can I assess my abdominal separation?

You could have a professional check it for you- an OB/GYN, physiotherapist or pelvic floor specialist for example, or you could do the test yourself at home. Here’s how:

• Lie on your back with your knees bent and the soles of your feet on the floor. Relax the abdomen and place two fingers of one hand immediately above your bellybutton with the palm of the hand facing up towards your breastbone. Apply gentle pressure to the abdomen – long nails may be a hazard!
• Inhale to prepare and as you exhale recruit your Transversus abdominis (deepest abdominal muscle) by drawing your abdomen in very softly. Slowly raise your head and shoulders off the floor, keeping gentle pressure on the abdomen with the fingertips. As the head and shoulders lift, you should be able to feel two bands of recti muscle closing in around the fingers.
• If the gap between the two muscle bands appears to be wider than two fingers, repeat the test using three fingers.
• Repeat the test just below your bellybutton.

NOTE: this test should be conducted by post-caesarean women only after incision has healed, about 6-10 weeks postpartum.

What happens if my separation is wider than 2cm/two finger-widths?

If the gap is wider than 2cm/two finger-widths, the muscles can still recover. Remember, this is a process that can generally take between six-nine months, sometimes longer. However, extra care should be taken to avoid activities that place stress on the midline until you have recovered fully.

These include abdominal strength training exercises, but more importantly, they include everyday activities such as getting down to the floor, getting in and out of bed or bending and lifting the baby for example. 

The “log-roll” technique should be used when rising from the floor or getting out of bed in order to prevent abdominal strain. This means rolling onto one side with your torso and head aligned, then using your arms to help push yourself up to a sitting position.

If left untreated, diastasis recti can cause an array of problems. Weakness in the abdominal wall can jeopardize trunk stability and mobility, contributing to:

• Back pain
• Poor posture
• Pelvic floor dysfunctions such as stress urinary incontinence, faecal incontinence, and pelvic organ prolapse
• Development of an umbilical hernia, which would in most cases require surgery to repair the separated muscle bands.

NOTE: If at any time you see a round, hard, or painful bulge protruding from your belly button area, or along your mid line, consult with your OB/GYN.

How is diastasis recti managed?

Conservative management, such as specific therapeutic exercises directed by a specialist physiotherapist, or pelvic floor specialist who has experience working with diastasis recti, is usually the first line of intervention.

Through therapy, you would receive guidance on:

• Correct body mechanics
• Proper posture
• Appropriate exercises to activate the abdominal musculature, and
• Appropriate exercises to shorten abdominal wall separation without increasing intra-abdominal pressure.

What exercises should I avoid if diastasis recti is suspected or confirmed?

• Movements where the upper body twists and the arm on that side extends away from the body, such as "triangle pose”
• Exercises that require lying backward over a large exercise ball
• Yoga postures that stretch the abs, such as "cow pose," "up-dog," all backbends, and "belly breathing”
• Abdominal exercises that flex the upper spine off the floor or against the force of gravity such as: as crunches, Obliquecurls, "bicycles," roll ups/roll downs, etc.
• Pilates mat and reformer exercises that utilise the "head float" position, upper body flexion, or double leg extension
• Any exercise that causes your abdominal wall to bulge out upon exertion.
• Lifting and carrying very heavy objects
• Quadruped exercises without adequate abdominal support
• Intense coughing without abdominal support. 

Can diastasis recti be prevented? How can I lessen the severity of diastasis recti?

There is no proven way to completely prevent diastasis recti. However, the common consensus amongst doctors, health and fitness professionals nowadays, is that most women could benefit from keeping their “core” strong during pregnancy.

By doing so you are helping support your pelvic organs, alleviate pressure on your lower back caused by pregnancy weight gain, and maintain correct body posture. A strong core is also believed to help you recover quicker after giving birth.        

Strengthening your core requires learning to locate and activate your Transversus abdominis (TrA) muscle. TrA is our deepest abdominal muscle. It acts as our body's internal "girdle" and when contracted, compresses the abdominal wall. Most pregnant women can benefit from performing basic TrA exercises throughout their pregnancy.

Which exercises are appropriate or safe to perform?

Some of the exercises you could perform to train TrA recruitment and improve pelvic stability include:

Prenatal

• Abdominal compressions (drawing abdomen in very softly)
• Pelvic tilting (standing or sitting after 1^st trimester)
• Four-point kneeling (cat pose/cow pose)

Postnatal

All of the above plus:

• Scissor arms
• Arm circles
• Leg slide
• Bent knee fall-out
• Knee raise
• Kneeling arm and leg raise
• Knee roll
• Toe touch
• Leg slide

When will I be ready to move on to abdominal strength training?

The overstretched abdominal muscle bands must be shortened before abdominal strength training can begin. If you begin strengthening exercises such as crunches and torso rotations before the muscles have realigned, doming of the abdominal wall could ensue. 

If you’re keen to keep active while pregnant or feel ready to return to your previous fitness regimen (following 6-week postnatal check), make sure that you are working with a trainer who has experience coaching prenatal/postnatal women. 

A prenatal & postnatal fitness specialist will fully understand the changes your body goes through with every trimester and following birth.

Furthermore, a trained professional will take a number of things into consideration when prescribing an exercise programme, including but not limited to: your changing body and posture; the importance of maintaining a strong and toned pelvic floor; and abdominal strengthening without compromising muscle integrity.

Disclaimer: Although I am a SAFS qualified fitness instructor, you should consult a medical professional before starting any exercise programme. If you choose to do any of the exercises featured on this post, you do so at your own risk.