What to know, look for & how to fix diastasis recti

How to fix diastasis recti - woman with therapist
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During pregnancy, it’s absolutely amazing how our bodies can expand to make room for a growing baby. We often notice this change most in our abdominal wall or belly, with a completely natural phenomenon called diastasis recti or diastasis rectus abdominus (DRA). It’s been reported that 100% of pregnant women will experience DRA to some degree by their third trimester. However, for some women and often in more severe cases, DRA can cause pain or a the look of a long-lasting “mommy tummy.” As a pelvic health physiotherapist and birth doula, let me tell you what all soon-to-be and new moms need to know about diastasis and how to address it.

What is diastasis rectus abdominus (DRA) and how do I fix it?

To understand DRA, it’s helpful to know how and why it happens, including what to look for. DRA occurs when the linea alba (the vertical ribbon of connective tissue that runs down the middle of your abdomen) softens, thins, and widens to accommodate your placenta, amniotic fluid, and growing baby. If you visualize your rectus abdominus muscles (the “six-pack” muscles), you can imagine that connective tissue line running down the middle. It isn’t just the linea alba that changes during pregnancy though; much of your abdominal wall stretches and changes to adapt to the growth of the baby, too.

How-to-fix-diastasis-recti

Signs and symptoms

Much of the time, the linea alba thins and widens painlessly and in a way that many people don’t even notice. Occasionally, a pregnant woman developing DRA might feel some tenderness or pain along the sides of the linea alba connective tissue or at the top where it connects to the sternum. Very occasionally, someone might feel a burning or tearing sensation; however, rest assured the tissue doesn’t actually rip! DRA can also be associated with rib or back pain during pregnancy, but definitely not always—pain can happen for many reasons during pregnancy, but typically it all responds well to treatment. Additionally, sometimes the appearance of severe stretch marks can occur with DRA too.

More commonly, DRA tends to be noticed after pregnancy. Some people will notice a doming, coning, or bulging in their abdomen when they sit up or return to core exercises. Some people notice a “mummy tummy” or a “belly pooch” that persists even beyond stopping breastfeeding or lactation.

The hormones contributing to diastasis recti

We definitely believe that pregnancy hormones play a role in the development of DRA. Relaxin is one hormone that commonly takes the blame for all the softening and stretching that happens in the connective tissue around the pelvis, but there are likely a number of hormones and factors at play. 

Clinically, we also hypothesize that lactation hormones play a role in DRA, particularly in those that don’t recover easily after 12 weeks postpartum. These hormones seem to preserve the thinning and widening of the connective tissue for longer. However, despite DRA being a common phenomenon, its causes aren’t very well understood. We don’t know why some women experience more widening and thinning and opening of the diastasis than others.

Will my ob-gyn check for diastasis recti?

Checking for diastasis recti isn’t usually a standard part of a pregnancy exam or even at your six-week postpartum follow-up. Some obstetricians and gynecologists do look for it, but it is best not to assume it will be checked for at your visit.

If you have concerns about diastasis recti, I recommend bringing it up during your second or third trimester of pregnancy. Your ob-gyn can help connect you with a pelvic health and pelvic floor physiotherapist. A pelvic health physiotherapist (or physical therapist) will have training and extensive experience in pelvic muscles and ligaments and can help support, reduce, or work with you on any issues you have. Coming to us while pregnant means we can provide support right away and then we know to start clinical work soon after the baby comes. Another good place to look for a pelvic health physiotherapist/physical therapist in North America is Pelvic Guru.

What does my diastasis recti gap measurement mean and how important is it?

A lot of emphasis gets placed on how wide the DRA or abdominal gap is. However, there is really no “correct” width. In general, 1–2 centimeters is considered normal. (We need a little bit of space in order to breathe well!)  We often commonly try and measure DRA with a finger test: how many finger-widths fit inside the gap when someone does a small head lift when lying down. A 2–3 finger gap will often close on its own. Gaps of 2–3 fingers or even up to 4–6 fingers are good candidates for conservative treatment and rehab (think physical therapy and exercise!). Gaps of 8 fingers or more may eventually need help closing with surgery. Sometimes (but not commonly!) the tissue becomes so stretched that surgery is what is needed to bring it back together.

It’s important to consider that there are a number of factors influencing how DRA heals and recovers. Hormones are a big factor, and from a tissue healing perspective, we know that connective tissue like the linea alba can continue to remodel and change for up to 2 years. With breastfeeding, clinically we often don’t see significant changes until 3–6 months post-weaning. 

How important is my gap measurement?

However, please keep in mind that gap measurement (width) is not the only thing that’s important—or even the most important thing. We also want to look at how thin or soft the gap is, and whether or not the connective tissue can generate sufficient tension for good function. The tension also helps a therapist determine which exercises will be best to for rehabilitation.

Another thing to consider is that your abdomen is only one part of you. It is an important part! But it’s connected and works together with many other parts of your body. You are a whole person, and it is important to take a full-body look. A good physical therapist will consider how your abdomen is working with your pelvic floor, your back, and your diaphragm. And maybe even with your knees, shoulders, feet, etcetera.

Should I exercise with DRA? Are there exercises I should avoid?

Yes! You should exercise! Both muscles and connective tissue need to be exposed to progressive overload (or effort and work) to promote strengthening and growth and adaptation. Believe it or not, there are no bad exercises for DRA either. That is a myth. 

What’s more important is to figure out is what your muscles and core are currently capable of handling. Then it is best to work from there. Jumping into exercises that are too challenging or demanding may cause challenges; sometimes, traditional core exercises may need to be modified or adapted for your level of ability at the moment. However, exercise and training will help the tissues adapt, and, with training, you will get stronger. Just because you can’t do a crunch or a sit up now without doming doesn’t mean you never will! 

If you have concerns about what exercises are best for your body right now, then it’s definitely worthwhile to find a good pelvic health physical therapist or a good trainer. Look for one who specializes in pre- and postnatal fitness to help guide you on your exercise journey.

What to expect at your appointment with a pelvic health therapist

Moms-to-be and new moms are under so much stress and dealing with so many trials and tasks and feelings. It’s one of the most challenging experiences many of us will ever have. A good pelvic health physical therapist will understand that and be ready to guide you through strengthening your body while gently caring for your emotions, too.

Getting to know you

When you come in for your first visit, expect to spend quite a bit of time with us—an hour or more. Wear comfy clothes, like what you might put on to exercise or hang around home. For the first half hour, we’ll chat about your birth story, listen to your experience, and just gain an understanding of who you are and what you’re feeling.

Physical examination

Every exam should start with an outward physical assessment. While in your regular clothes, your therapist will evaluate you doing certain movements and ask you to lay down on our table to check your pelvis, hips, abdominals, and breathing.

Depending on your personal comfort level and symptoms, we may or may not do an internal vaginal exam. The internal exam we do isn’t like your annual ob-gyn pap smear and checkup; it’s very individual. Based on what we’ve learned from talking with you, we may gently palpitate some muscles internally while communicating with you about what you’re experiencing. This lets us gain more information and understanding about what’s going on with your pelvis. Ideally, we would do an exam like this 4 to 6 weeks postpartum. From here, we can make more personal and specific recommendations for your treatment plan. Pelvic pain is a heavy burden, and we want you to feel better.

Are support garments safe and should I wear one?

For women who are symptomatic with pain several weeks postpartum, I often recommend a gentle support garment—but your therapist can offer more personalized guidance on what works for you. With support garments, you don’t want anything that cinches the waist. This will ultimately create more pressure on the pelvic floor, which is already dealing with a trauma.

Garments that offer slight compression such as a short, brief, or panty are usually the safest and most helpful. For the first two weeks postpartum, I don’t recommend any support garments at all. Your body is still normalizing its fluids. This is especially true after a c-section, where you were given an IV. My favourite support garments can be found at https://supportyourcore.ca/.

Things to consider if surgery is suggested to fix your diastasis recti

When conservative treatments haven’t yielded the results you want, surgery can be recommended. You’ll want to hold off on making a decision until you’re sure you’re done birthing babies. You should also wait if you’re lactating. Only 3 to 6 months after lactating can we really say if DRA isn’t responding to rehab.

You are a whole person with a whole body, and you deserve to feel whole.  If something doesn’t feel or look right, or you aren’t feeling confident in the physical function of your body, please seek out help.  The demands of mothering and parenting are large—and many of them are physical. We all deserve to feel strong. Strong mothers and parents build strong families, which in turn build strong communities.

Mandy Rempfer-Kuncio, MScPT, BSc, CAFCI, CD(DONA)
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