Blog # 1
Abdominal muscle separation (Diastasis Recti) after birth
I decided to join the blogging world and this is my first blog! I agree – the internet is already saturated with information on every aspect of health, including pregnancy and birth issues. However, I am stunned that, while there are heaps of posts on a variety of subjects, some topics of great importance to childbearing women are dealt with quite superficially, if at all.
During my almost 30 years of working with pregnant and postpartum women as a Prenatal and Postnatal Fitness Specialist, a Lamaze Certified Childbirth Educator, Birth Doula and also as a Pilates and Yoga Instructor, I have been approached by women from all over Israel who cannot find any satisfactory answers to their problem of abdominal muscle separation after birth (diastasis recti). These women come to me after being told by a surgeon that the only way to draw these muscles back towards the midline of the body is through surgery. I know that this is not true as I, personally, have helped many women return their abdominal muscles to their pre-pregnancy state through individualized, targeted exercises.
So why aren’t other fitness professionals, physiotherapists or doctors dealing with this topic? Why are women coming to me in Jerusalem from Netanya, Tel Aviv, Kfar Saba, Raanana, Haifa, Petach Tikva, Rishon LeZion, etc.? This information is so relevant to so many women, that I decided to dedicate my first blog to this subject. However, this is still a blog, rather than a university course in public health, so it will deal with only the most important information that new (and not so new) mothers need to know.
The woman on the left has never had a baby. The right and left sides of her rectus abdominis muscle (otherwise known as the “six-pack muscle”), which runs vertically from her sternum to her pubic bone, are held together at the mid line of the body by the fascia (connective tissue) known as the linea alba.
The pelvis needs to widen to enable the baby to move through it during birth. As bones do not stretch, the body releases hormones during pregnancy to soften the connective tissue in order to widen the pelvis for birth. These hormones (primarily relaxin and progesterone) affect all connective tissue in the body (not only the joints of the pelvis), including the linea alba. In addition, the linea alba may not be strong enough to withstand the force from the growing uterus on the abdominal wall, causing the right and left sides of the rectus abdominis muscle to spread apart at the linea alba. This is known as diastasis recti (see the woman on the right in the diagram).
This condition is more apparent in petite women, women carrying two (or more) fetuses, women with poor abdominal muscle tone, genetic factors and after a cesarean birth. During a cesarean, the abdominal muscles are not cut, but are rather separated with retractors which hold them apart while the surgery (and birth) take place.
It is normal to have a small separation during pregnancy and after birth. During pregnancy, about 30% of women develop diastasis recti, particularly in the third trimester. A woman may notice this if she sees a pyramid shape bulging between her abdominal muscles when she gets up from lying down in the bathtub (or from any supine position). According to a study published in the Journal of Women’s Health Physical Therapy in 2005, the occurrence and size of diastasis recti is much greater in non-exercising pregnant women than in exercising pregnant women. Women who have diastasis recti (DR) during pregnancy should do supervised abdominal exercises (mainly core stabilizing exercises) as certain standard exercises, such as sit-ups, will increase the separation. They should also lie down and get up by turning on their side first, bending their knees, and using their hands for support to lie down or to get up.
Most women have some separation in the first few days after birth, though this separation usually decreases by 1 – 4 weeks.
To check for DR (see photos above):
- Lie on your back with your knees bent towards the ceiling, keeping your feet and knees hip-width apart.
- Place 2 fingers 1 – 2 cms. below the navel, parallel to the waistband of your pants.
- Lift your head and feel how many fingers you can insert, widthwise, between your abdominal muscles.
- Lower your head.
- Repeat the check, but now lift up your pelvic floor muscles (see below), draw your navel towards your spine and slide your ribcage down towards your pelvis. Checking for a separation while activating your abdominal muscles is a more accurate check for DR.
- Repeat the check, while activating your abdominal muscles, 1 – 2 cms. above the navel.
A width of up to 2 fingers is normal. A width of 2 ½ fingers or more is considered a separation, or DR. Most women have a separation at the level of the navel, though some have a more extreme separation either below or above the navel.
All women after birth (whether vaginal or cesarean) should be checked for DR before resuming abdominal exercises. It is particularly important for women with DR to perform exercises to draw the muscles back to the midline before a subsequent pregnancy, otherwise the separation could be cumulative (it may increase with each additional pregnancy).
If you have DR, please see the following clip for some basic exercises to help return the muscles towards the midline of the body:
Of particular importance if a woman has DR, is awareness of the pelvic floor muscles. The layers of muscle and other tissues that form the pelvic floor stretch like a hammock from the tailbone (coccyx) to the pubic bone. While there are many ways to activate these muscles, for now it is important to learn the following pelvic floor exercise (to be performed in any position where the buttocks and thighs are relaxed):
- Inhale. While you exhale, tighten the muscles around the urethra and vagina as though you are stopping the flow of urine. Keep them contracted. (Although it may be helpful to check that you are doing this correctly in the toilet by stopping the flow of urine, after identifying the muscles, don’t do this exercise while urinating, as withholding urine in the bladder can cause a bladder infection).
- Inhale. While you exhale, tighten the muscles around the anus, as though you are trying to control diarrhea. Keep them contracted.
- Inhale. While you exhale, bring the front and back parts that you have contracted towards each other and draw them up as though you are lifting them up deep inside your body.
- Breathe normally, without contracting the muscles of your buttocks (gluteal muscles) or thighs, for about 5 seconds.
- Slowly release the muscles (rather than dropping them down).
- Rest and repeat several times.
While doing any abdominal exercise, lift the whole area up as one unit during the “work” part of the abdominal exercise, and relax the whole area during the rest phase.
Many new moms are so weak in their abdominal and pelvic floor muscles that, while doing any abdominal exercises, they bulge out these muscles rather than drawing them in. If you always activate your pelvic floor muscles (by just lifting the whole pelvic floor up, rather than doing the isolated exercise as described above), you will notice that you will also feel some slight activation in your lower belly. What you are doing is gently contracting your transversus abdominis muscle (TA), the deepest set of abdominal muscles, as the TA works in synergy with the pelvic floor muscles. This means that, when you lift up your pelvic floor muscles while doing any abdominal exercise, you cannot inflate your abdominal muscles (the incorrect way of doing abdominal exercises) as you are automatically working your TA, which serves to draw the belly inward. The TA muscle can (and should) be further activated with targeted exercises.
Activating the pelvic floor muscles and the TA muscle is the most important first step in resolving the problem of separated abdominal muscles.
The two exercises I have included in the video clip (the corset exercise and the see-saw or pelvic rocking exercise) are basic exercises to begin to correct the problem of DR. In addition to these exercises, it is important to learn stabilizing exercises, i.e. learning to control the abdominal and pelvic floor muscles while moving the arms and legs in certain directions. It is always advisable to exercise under the supervision of an experienced fitness professional who understands the problem of DR and is familiar with ways in which to solve the problem.
Certain exercises should be avoided if you have DR:
- Regular sit-ups (or any exercise lifting the upper body against gravity) without supporting the abdominal muscles
- Diagonal curls that activate the oblique muscles against gravity
- Extreme rotation (twisting) of the upper body
- Exercises that excessively stretch the front of the body (e.g. lying on your back over a large exercise ball, excessive backbends as in yoga or Pilates, etc.)
- Severe coughing without supporting the abdominal muscles
Most of the women who come to me with DR come for aesthetic reasons – they don’t like the belly bulge that they have and they’re embarrassed by people asking them when they’re due to give birth! However, if the problem of DR is not corrected, it may very well lead to additional problems such as lower back pain which can become quite severe.
For a personalized consultation, please call me at 052-2342909 to schedule an appointment.
(Following is a summary of the testimonial, translated from Hebrew, from the above link):
“I had a serious (abdominal) separation after the birth of twins. I tried physiotherapy but it did not really help. Meanwhile, four months ago I gave birth to another baby. This time I told myself I would opt for surgery if there was no alternative. I was referred to Rachelle through an internet forum. I went to Jerusalem specifically to meet with her and … within a month and a half of doing the exercises she taught me, my separation of four fingers was reduced to two fingers. I must add that I’m not really the sports and fitness type, but the exercises are not physically difficult. It’s important to do them correctly and to do them regularly. It is quite shocking that at physiotherapy and at the postnatal exercise class I attended nobody talked about the problem of separated abdominal muscles. Lots and lots of thanks! Keep referring to Rachelle – she is an amazing woman and a true professional.” Shirley, mother of 3.
Rachelle Oseran (BA) became a Lamaze Certified Childbirth Educator in 1984 through the UCLA School of Nursing and has prepared more than 3000 couples for normal birth over the past 29 years. She is also a Birth Doula, certified by DONA International, a Fitness Professional certified by ACE (the American Council on Exercise), specializing in Prenatal and Postnatal Fitness and a Certified Yoga and Pilates Instructor. She lectures in Israel and internationally on Prenatal and Postnatal Exercise.
Rachelle teaches a Lamaze-Accredited Childbirth Educator training course. She also co-founded and co-directed Great Shape/YMCA, the group exercise department of the Jerusalem International YMCA for 23 years.
Rachelle was recently inducted as an FACCE (Fellow of the Academy of Certified Childbirth Educators) in recognition of her significant contribution to the field of childbirth education. She lives in Jerusalem, Israel, with her husband and 3 sons.