After giving birth I noticed that my abdominal muscles had separated significantly during pregnancy, leading to back pain, a weakened core and– worst of all– many months out of the water!
Through my own experience of searching for answers about diastasis and learning how to manage it, I asked physiotherapist and pilates instructor Pippa Carter to give me the lowdown about this condition, and how to deal with it.
Hi Pippa! Could you tell us a little bit about yourself and your journey into physiotherapy and pilates?
I’m Perform Physiotherapy Manager at Spire Hospital, Cardiff. After completing my MSc in Sports Physiotherapy at Cardiff University, my background and love of dance led me to work with some professional dancers from major West End shows, the BBC’s Strictly Come Dancing and the Royal Ballet Company.
I’ve always been really interested in movement and how this can help recovery, and this led me to finding pilates. After completing my instructor training, I started incorporating it into my clinical practice. I’m passionate about providing the best quality care for my patients and after recently becoming a mum to a beautiful and energetic little girl called Daisy, my interest in post-partum care has increased. I want to ensure this group receives the care and support they need.
So, what is ‘diastasis recti’ and does every post-partum woman have it?
A separation, or diastasis of the rectus abdominis muscle is common and normal during pregnancy. We have three sets of abdominals – the rectus abdominis, the obliques and the transverse abdominis – with the outermost muscle being the rectus abdominis. It connects from the sternum to the pubic bone , and has two halves which are joined together by long, stretchy connective tissue called the linea alba. During pregnancy, the body produces the relaxin hormone which loosens women’s joints and muscles ready for birth. As the uterus grows and the abdomen expands, the linea alba becomes thinner as it’s pulled sideways; and the distance between the two sides of the rectus abdominis muscle usually increases, causing a diastasis.
A diastasis usually appears in the second trimester of pregnancy and is found most frequently in the third trimester. Scientific papers state varying percentages of occurrence from 66-100%.
How can women tell if they have a diastasis?
Some women will be aware of it during pregnancy, but it’s most often noticed post-partum when they start to see or feel a ‘bulge’ in between the abdominal muscles.
If you’re unsure whether or not you have a diastasis, the NHS advises that women can check the size of the separation with this simple technique:
- Lie on your back with your legs bent and your feet flat on the floor.
- Raise your shoulders off the floor slightly and look down at your tummy. Using the tips of your fingers, feel between the edges of the muscles, above and below your belly button. See how many fingers you can fit into the gap between your muscles.
- You can do this regularly to check that the gap is gradually decreasing.
What should women do about it in the first instance?
In the first instance, I’d advise an appointment with their GP and a request to be referred to a women’s health physiotherapist for advice, education and treatment. There’s a lot of information online and you must be careful what you read. Just because something’s online doesn’t mean it’s always fact! However, I’d suggest that any online patient information leaflet produced by NHS Trusts are a reliable source of information. But if you’re concerned, then the best option is to follow the route of referral to a women’s health physiotherapist via your GP.
Is there anything that can be done to avoid the problem to begin with during pregnancy?
This is one of those million-dollar questions and unfortunately there is no definitive answer! Some research studies show that women who exercise regularly through pregnancy have a reduced risk of having a significant diastasis. However, there are some issues with these studies in terms of the number of subjects involved and how they were selected, so it’s inconclusive. From a personal clinical perspective, I’ve seen ladies have a less significant gap or recover more quickly if they’ve maintained activity during pregnancy.
Some people believe there’s a genetic link, and if your connective tissue is more flexible, then you might have a higher risk of developing a diastasis. Overall though, it’s difficult to predict who will have a more significant one, so if you do end up with a large gap, the main thing is please do not beat yourself up about it!
Can a separation be repaired, and if so, how?
The greatest recovery window for a diastasis is between day 1 and 8 weeks after delivery. In some cases, it can resolve naturally. Sometimes, a separation doesn’t close completely, but it’s possible to retrain other muscles to compensate for the gap.
You can begin pelvic floor exercises as soon as 24 hours after delivery. Even if you can’t feel them working you can start by improving the strength pretty much straight away. It’s really important to re-strengthen these muscles to lay good foundations for recovery and to avoid possible problems such as incontinence.
Experts agree that targeted exercises can be helpful in restoring postpartum abdominal efficiency. But they need to be of the right level and not put too much pressure on the abdominal muscles. The exercises need to be focused on the deep abdominal and pelvic floor muscles – any exercises that cause the stomach to ‘dome’ outwards such as traditional sit ups should be avoided. Pilates can be a great form of exercise to re-train the correct muscles, but again, the classes you attend need to be of the right level and the instructor must be aware of how to modify the exercises to suit your needs.
In some severe cases that do not resolve/are not able to be controlled through a specific graded exercise program, surgical repair may be warranted. But this would need careful consideration of possible risk factors and side effects, so in the first instance I would suggest conservative management as the first line of treatment.
Which are the muscles to strengthen to compensate for a gap?
The main areas of the body that need to be strengthened are the deep abdominal, oblique and pelvic floor muscles. However, as mentioned above, these exercises need to be of the correct level for ladies with a diastasis – if you jump into too high a level too soon, you could make things worse.
Do subsequent pregnancies worsen an existing diastasis?
Not necessarily – if you’ve had a previous separation this doesn’t automatically mean you’ll have one in subsequent pregnancies. However, if you’ve had a previous diastasis, then I would advise following the same advice as above: and also taking care with high load abdominal exercises such as movements with both legs held long and off the floor, and sit ups.
Are there any do’s and don’ts when the body is recovering from a diastasis?
Everyone’s different so it’s difficult to say exact do’s and don’ts, but below are a few things to consider:
- Avoid strenuous exercises that cause your abdominal wall to bulge out.
- If you must bend forward, activate your deep tummy muscles before you do this.
- Avoid heavy lifting.
- Avoid straining on the toilet.
- Avoid aggressive abdominal exercises that would put strain on the mid-line of the abdominals such as sit-ups or crunches, or rising from a lying position by pulling up and twisting at the same time.
- When getting out of bed, roll on to your side first before pushing up, avoiding the sit-up motion.
- Avoid holding your baby on one hip.
- Start exercises to strengthen your deep core muscles.
- Start with low level strengthening working on the deep tummy muscles first.
- Physiotherapy can also teach you more strengthening and stretching exercises that may help.
For the post-partum surfer with diastasis recti , is there a set length of time that will keep them out of the water? What could help recovery?
This is a hard question to give a specific answer, as each individual is different, and has a different degree of fitness and different births. If someone has undergone a C-Section then the advice is 12 weeks before increasing abdominal load. On average I would say 6 weeks’ post birth is when low level exercise can begin in the form of pilates or increasing abdominal strengthening exercises and then depending on how the separation is recovering/being controlled will determine when a surfer can get back in the water. If you have a diastasis and would like to return to surfing I would suggest seeing an appropriately trained professional for advice and exercises.
You mentioned earlier that targeted exercises can be helpful in restoring postpartum abdominal efficiency, especially during the first 8 weeks post-birth. Could you share some with us?
The following 4 exercises can be done as soon as the body feels ready after birth. They focus on the deep abdominal and pelvic floor muscles and don’t put too much pressure on the abdominals:
Exercise 1 – deep tummy muscles
- Lie on your back or your side with your knees bent up and your feet flat.
- Keep the normal inward curve in your lower back throughout.
- Place your fingers on your lower abdominal wall just inside your pelvic bones.
- Imagine you are wearing a low-slung belt across your hips.
- Gently draw in the area between your tummy button and pubic bone towards your spine as if you were trying to do the belt up a few more notches.
- Start by holding this for 5 seconds. Repeat 5 times.
- Increase how long you hold for as you become stronger, up to 10 seconds.
You can also try this exercise in sitting or standing when you feel confident.
Exercise 2 – bent knee fall outs
- Start on your back with your knees bent.
- Activate your deep tummy muscles and gently lower your right knee down towards the floor – keep your left knee bent and pointing upwards towards the ceiling.
- Keep your pelvis stable throughout this exercise – try to avoid trunk rotation.
- Return your right leg to starting position as soon as you detect movement in your trunk.
- Relax your deep abdominal muscles.
- Repeat 2-3 exercises each side when starting out and build up.
Exercise 3 – heel slides
- Lie on your back with your knees bent and feet flat.
- Place your fingers to feel your lower abdominal muscles just inside your pelvis and gently activate your deep abdominal muscles.
- Straighten your right leg slowly, sliding your foot along the floor and then slowly return to starting position when you feel your lower back begin to arch.
- Repeat 2-3 exercises each side when starting out.
Exercise 4 – pelvic tilt
- Start by lying on the floor. You can also do this exercise sitting, on a chair, or on a gym ball.
- Round your lower back and roll your pelvis backwards over your sitting bones.
- Feel the stretch in your lower back. Return to the starting position.
- Repeat 10 times.
Thanks for the great advice Pippa. See you on the mat!