As I am writing this, I am feeling really cross.
I am cross that vulnerable women are being taken advantage of and being fed misinformation about their health. I am cross that some groups are playing upon the fears and insecurities of women to get them to sign up for treatments, which often do not do what they claim to do, and are unnecessary for many women.
What am I talking about? I am talking about pregnant and postnatal women who are being told their abdominal separation is TERRIBLE and they MUST do something about it. If they don’t, they risk having an emergency C-section, a difficult delivery with tearing, or having incontinence, prolapse or back pain after delivery. Oh and their tummies will look AWFUL to boot.
Sounds serious. The problem is, many of these claims are simply untrue.
Abdominal muscle separation is correctly known as a diastasis recti abdominis (DRA), and involves the widening of the space between the two rectus abdominis muscles in the midline of the abdomen. Most of the time, it involves the connective tissue between the two rectus muscles (the linea alba) stretching and widening. In some people, a tear may occur in the linea alba as well.
DRA is very common in pregnancy (over 60% of women have a DRA by the end of pregnancy) and the early postpartum period, because the growing baby stretches the muscles and other soft tissues to make space as it grows. That baby has to fit somehow, and this is a normal process. However DRA can occur in both men and women outside of pregnancy as well. The majority of women experiencing a DRA during pregnancy will see it resolve spontaneously within the first 8 weeks postpartum.
Some groups claim that a DRA has to be addressed in pregnancy, as if not, women risk a difficult birth with significant tearing, or may need an emergency C-section, as their abdominal muscles will not be able to effectively help to push the baby out. There is no evidence to support these claims. It is the contraction of the uterine muscles which push the baby out, and there are many reasons a woman may need to have an emergency C-section or may have a difficult delivery. None of them are related to the presence of abdominal muscle separation. DRA is a normal process in most to all pregnancies – not a condition to be fixed.
It has previously been hypothesised that DRA may contribute to numerous problems after you have your baby as well. These problems include back pain, incontinence and pelvic organ prolapse. Several older, not particularly well-designed, studies seemed to support these theories. A number of more recent studies looking at larger numbers of women in a more scientific way have debunked these theories, showing DRA is not associated with incontinence, pelvic organ prolapse or low back pain in postnatal women.
Certainly a lot of women do not like the appearance of their abdomen after having a baby, and a DRA can make this look worse. There is so much social pressure to look fit and trim again ASAP after having a baby - many women are distressed to find it can take time for them to lose the baby weight in general and the excess fluid and tissue in the tummy region in particular. Never mind that they are caring for a newborn, possibly other children too, and are sleep-deprived and frazzled. There is a reason for the term “the childbearing year” - the time during which a woman is pregnant (40 weeks) and then the roughly 3 months after she has had the baby. It helps us understand that there is a necessary recovery period after having a baby. Just as it takes time for women’s hormone levels, heart rate and circulation to settle back to normal levels after having a baby, it also takes time for stretched tissues to return to their normal state. How long can vary a lot from one woman to another. It can depend on what kind of delivery you have had, any postpartum complications, on genetics and other factors. The point is, our bodies need time to recover from all of the amazing changes that occurred during pregnancy and birth.
Certainly some women do have an ongoing significant DRA after having children. The most common complaint is they feel their tummy looks loose or flabby. Some women also say they feel they don’t have good strength in the abdominal muscles with a DRA, and they feel this has an impact on their functional abilities (such as lifting their children). Other women wonder whether their DRA may be contributing to low back pain. Studies indicate there is no link between back pain and DRA, and it is very likely a combination of factors which cause low back pain in many women after having children, as the rates are very similar in women with and without DRA.
There is a lot you can do to help recover from a DRA – but first let’s look at what some of the reported gurus claim.
Some groups emphasise the importance of abdominal binders to help “close the gap” between the rectus abdominis muscles, and recommend wearing these all day, every day for long periods of time. The theory seems sound – if we hold the muscles and connective tissues closer together, there is less tension, allowing them to heal better. Certainly a lot of women like the feeling of some support around their tummies in the early days postpartum. After that baby is out, the abdomen can feel quite loose and floppy for a while. However, there really is no evidence to back up the use of supports in the medium to long term. A few studies looking at the combination of a support and exercise for DRA suggest this helps – but was it the support, or was it the exercise? As for the suggestion that one particular abdominal support works better than another, there is no evidence for this at all. A $12 piece of tubigrip may work just as well as a $100 -$200 support.
Personally, I worry about women relying on supports in the longer term. Just like any kind of brace, they can be great in the early days when the tissues are first recovering. But the aim should always be to wean off these supports over a period of weeks, and learn to use your own muscles for support in a functional way. This is the kind of thing Women’s Health Physios do all the time. We teach women how to use their own muscles, as they should be used, in a supportive way, and carry this over to day-to-day tasks, so you can get back to living again.
I also worry about the potential increased pressure created in the abdominal cavity with strong abdominal braces, and the impact this may have on a weak pelvic floor in postpartum women. We could potentially be making weak pelvic floor muscles, incontinence or prolapse worse by wearing a garment that significantly increases intra-abdominal pressure.
What about exercises for improving DRA? As mentioned, this is the kind of management Women’s Health Physios will encourage, and there is some evidence to back this up. Recent studies have shown a controlled curl-up actually narrows the distance between the rectus abdominis muscles, and if we combine that with activation of the deep abdominals, appropriate tensioning is created in the connective tissue, which supports the abdominal wall and spine. As with all exercises, we should always bring it back to function! Once women learn how to use these muscles appropriately, we teach them how to carry that over to functional tasks, like getting out of bed, lifting their babies and squatting. What we do with each person will vary, depending on their individual abilities and what they want to get back to doing.
However, some groups suggest their particular exercise program is the ONLY way to fix a DRA, and everyone follows the same set of exercises. As for curl-ups, they are absolutely not allowed – ever. Sadly, these programs have not kept up with the evidence. This is out-dated advice, and times change. We need to change our management along with the evidence, and this is what modern healthcare should be about. Exercise management should never be a “one size fits all” approach. Individuals vary so much in their abilities, strength, flexibility and needs.
So my advice? If you are concerned about your tummy during and after pregnancy, see a Women’s Health Physio who has the training, knowledge and skills to help you to manage YOUR particular problem and meet your needs. And question anybody who tells you their way is the patented and ONLY way.
Yours in good health,
I mentioned a few articles in this blog post. If you want to read more, here are the references of some recent research on DRA.