Ab Separation and Pregnancy
What is Diastasis Recti and what can you do about it
When it comes to pregnancy and exercise FAQs, it's all about ab separation or Diastasis Rectus Adbominis. Almost all mums I speak to bring this up as a concern or something that is generally very confusing. There is so much conflicting information out there and frankly, a lot of worry.
Dr Brandi has taken on the challenge to address this very contentious topic - bringing her experience as a doctor, a mum and self-confessed gym-junkie together.
Brandi takes you through the construction of your entire mid section and what the hell happens to it all when that baby starts to make space for itself in there.
If you have any questions, please hop into the comments section below, hit me up on social media or email me at firstname.lastname@example.org
Split down the middle: Diastasis Rectus Adbominis during and after pregnancy –does it really matter and what can you do about it
How many abdominal muscles do we actually have?
Believe it or not, you have 4 layers of abdominal muscles! The deepest layer is called the transverse abdominis and forms part of what we know as our “core”, helping to stabilize our midline. The next 2 layers are the obliques (internal oblique and external oblique) and as the name suggests they run at an angle and produce twisting flexion movements of our trunk. The top layer is the rectus abdominis (RA) and is your “6 pack muscle” mainly used in crunching type exercises, bringing the ribs closer to the pelvis as it contracts.
The RA is actually 2 strap muscles attached to the lower ribs and sternum at the top and the pubic symphysis at the bottom. The 2 muscles are connected in the midline by a dense connective tissue called the linea alba and the “6 or 8 packs” are created by horizontal bands of connective tissue that run outwards from the linea alba.
Connective tissue called fascia sits between the layers of abdominals and forms connections between the layers and helps them function as a unit. This fascia attaches into the linea alba in the midline after forming the rectus sheath that sits around the rectus abdominis (similar to if you vacuum packed lamb backstrap from the butchers).
What’s a “normal” gap between the rectus abdominis?
A study by Beer et al in 2009 used ultrasound to look at the normal width of the linea alba (the gap) in 150 healthy women between 20 and 45 years old who had never been pregnant. The gap was measured at 3 points: at the top, 3cm above the belly button and 2cm below the belly button. There were a big variety of distances, with the average distance being 7mm at the top, 13mm above the belly button and 8mm below it. Widths wider than 15mm were considered abnormal.
What happens to the gap when we use our abs?
In 2016 Diane Lee and Paul Hodges did a study looking at the inter-recti distance (the gap) during a curl up task in 17 men and women who’d never been pregnant (they all had a normal resting gap) and also 26 women with gaps bigger than normal at rest.
They looked at the gap at 2 levels, half way between the ribs and the belly button and just above the belly button. They measured the gap at rest, during a curl up task done until the shoulder blades were just off the ground with no further instructions given and also during the same curl up task where the subjects were instructed to activate their core and pelvic floor first.
In the normal group there was no change in the gap at both positions during all 3 tasks. When the women with wider than normal gaps did the first curl up (however they wanted), the gap narrowed back closer to normal distance but often their belly bulged or sagged in the middle. Pre-activation of core and pelvic floor lessened the narrowing of the gap (gap was bigger with the core activated but didn’t increase from rest) but also lessened the bulging or sagging.
Does the size of the gap really matter?
Not necessarily! When it comes to the width of the linea alba, recent evidence is starting to show that function of the connective tissue is more important that the distance between the abs per se.
The same study above looked at a“distortion index” which compared how distorted (domed, sagged or undulated) the linea alba became during each of the tasks.
When the core and pelvic floor were active before the curl up, the distortion index was much closer to resting values than when the curl up was performed any way they liked.
Even though the gap was wider when the core was activated compared to when it wasn’t, the abdomen looked and functioned closer to normal and didn’t dome up or sag in the midline.
The function of the linea alba is proving to be far more important than the width of the gap.
Interestingly, the linea alba in the subjects with DRA had lost its organised structure but was mostly intact and not torn (like a perished swimsuit that becomes saggy when you wear it).
Connective tissue is constantly remodeling and regenerating and needs loading to promote protein synthesis and collagen formation along lines of tension. Therefore “rest” is not likely to fix your gap and there will actually be an optimal amount of loading that will be required for healing. Like all connective tissue such as tendons, too much loading will also cause it to fail.
How common is DRA during and after pregnancy?
Very! One of the first studies to look at DRA in 1988 followed 71 newly pregnant women during their first pregnancy and reported that 66% had DRA in their third trimester and 36% of them remained abnormally wide at 7 weeks post partum.
A more recent study in 2014 followed 84 healthy first time pregnant women from 35 weeks of pregnancy. They used ultrasound to measure the gap 2cm below the belly button and used a cut off of 16mm as normal. All othe women had DRA at 35 weeks (the smallest gap was 22mm and the biggest was 126mm, average 64mm). At 6-8 weeks post partum, 52% still had DRA but the average gap had reduced to 19mm, and at 6 months post partum 40% still had DRA with the average gap 15mm.
Can DRA be prevented during pregnancy?
Probably not. A Norwegian study in 2016 followed 300 first time pregnant women during their pregnancy and for a year afterwards. They defined DRA as a gap of at least 2 fingerbreadths at the belly button or 4.5cm above or below it.
A third of their mums had DRA at 21 weeks of pregnancy and 60% had DRA at 6 weeks post partum. This reduced to 45% at 6 months and 32% at 12 months post partum.
There was no difference in risk factors between the group that ended up with DRA and the group that didn’t. They did mention that the women with DRA were more likely to have lifted heavy weights > 20 times per week during their pregnancy than the ones without but this wasn’t significantly different (31% of women with DRA at 12 months had participated in this heavy lifting but so had 17% without DRA). There was no difference in the amount of pelvic or low back pain in those with DRA compared to those without.
What does this mean for training after pregnancy?
DRA is so common that it is likely that you will have some separation of your abdominals after you have your baby.
There is not much you can do during pregnancy once this occurs and there’s no need to worry. Just avoid doing any exercises that makes a bulge in the middle of your belly appear.
The most important thing in the first 6-8 weeks post partum is to allow your body to heal after birth and spend time adjusting to life with your new baby.
What you can do
It’s a good idea to start pelvic floor exercises as soon as you can after birth (and you should actually be doing these all the way through your pregnancy).
You can also add in some gentle core abdominal activation exercises as you feel comfortable but should wait at least 6 weeks to do this if you’ve had a caesarian delivery. These are easiest to perform lying on your back with your legs bent up and you should focus on activating pelvic floor and core together and trying to flatten out your abdomen gently, without letting it dome or sag in the middle and without holding your breath.
When you feel comfortable and have good control of your pelvic floor and core abdominals (can perform 10 contractions lasting 10 seconds each without any trouble), then it’s safe to start resuming your normal exercise activity.
Start slowly and build intensity gradually. The most important thing is the function of your abdominals. If you can perform an exercise without pain and without your belly sagging or doming then that exercise is probably safe for you. There is no need to stick your fingers in to check your gap, if your belly doesn’t sag or bulge then you are fine.
What to watch out for
If you are having trouble with signs or symptoms of DRA after 8 weeks post partum then it is wise to see a physiotherapist who specializes in women’s health and ideally uses real time ultrasound for assessment and treatment, as waiting for longer is not likely to change much after 8 weeks.
The reason for dysfunction in people with persistent DRA is varied and therefore there isn’t one specific exercise program that can be undertaken to correct a DRA and individual assessment and exercise prescription is needed.
Many people can improve the dysfunction associated with their persisting DRA with specific individual muscle retraining under the guidance of a physiotherapist. There are a small number of women in whom the distortion of the linea alba can’t be reduced despite optimal coactivation of pelvic floor and core abdominals after a period of physiotherapy and these women are the ones who benefit from surgery to restore the normal anatomy of the rectus abdominis.
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