Today I am going to take you on a journey- a patient called Annie’s (*) journey. One with sublime highs and some horrible lows, but I can tell you now, it has a happy ending. Annie is 41, has quite a small frame and has always been slim and fit. Annie has collagen issues. She had her first baby vaginally and not only had a five finger separation of her abdominal muscles post-natally – called a Rectus Diastasis – but also suffered a significant uterine prolapse. Rectus Diastasis is the separation of the rectus abdominis muscles that can occur during pregnancy, causing a bulge to occur when the pregnant woman attempts to move, especially visible when going from lying to sitting. It is quite common in pregnancy and is more prevalent in those women with the poorer type of collagen; in twin pregnancy; often with those women who over-exercise particularly doing sit-ups and will occur in subsequent pregnancies if it has occurred before.
The prolapse was able to be very effectively managed with a pessary. At her first physiotherapy appointment with me when she was 14 weeks pregnant with her second baby, we covered all the important strategies to manage both conditions:
- Pelvic floor muscle training.
- Learning the knack- bracing with increased intra-abdominal pressure such as coughing, sneezing, lifting, bending etc.
- Always sleeping with a thin cushion/pillow under her tummy to stop the drag down on the separation.
- Providing abdominal support with hands, towel or pillow when coughing.
- Moving safely by bracing, breathing and log rolling through her side to get in and out of bed.
- Using the correct position and dynamics for defaecation.
- Pelvic floor safe abdominal strengthening exercises.
- Education about using an abdominal binder/brace/high waisted undies/ SRC Recovery Shorts to help hold the abdominal muscles together in the early post-natal recovery period.
Annie was religious with all the strategies to help both her prolapse and abdominal muscles. Of course, the diastasis was even more significant with the second pregnancy, even though we were very proactive with wearing a full maternity corset throughout the pregnancy. This time Annie had an elective Caesarean to minimize the risk of further pelvic floor trauma and she had a really good recovery from the C-section. She went back to work at six weeks and her husband was the major carer during the day for the children.
As the months went on, Annie became increasingly depressed about her very large separation. She had significant loss of self-esteem, especially when everyone kept asking her if she was pregnant again. She decided enough was enough. She sought an opinion from a plastic surgeon who recommended an abdominoplasty. She was certainly worried about the stigma from having plastic surgery but she was getting sadder and sadder and decided to proceed with the operation. Annie returned the other day six weeks post operation. She was a different girl. She waltzed in with a real spring in her step- yes 6 weeks post-op! She turned side on, in a very slinky dress and showed me her profile. It was impressive. Her surgical outcome has been excellent. An abdominoplasty has an extensive scar – it is important to understand that it goes from one side to the other. She has a lovely ‘reconstructed’ umbilicus and her scar line will fade significantly after another year. She was lucky she does not have issues with keloid scarring. Her husband clearly understood what was involved and has supported Annie through the process, both psychologically and in a very real physical way, by always lifting the children – and this is an ongoing commitment. Most importantly, Annie is thrilled with the outcome and is feeling much happier.
So the moral of the story? Each of us is an individual and everyone’s needs are different depending on many factors. We mustn’t judge people for decisions they make, but understand that many factors -functional, aesthetics, psychological – contribute to those decisions. What is important is to research carefully all of the options regardless of the surgery being considered – whether it be for prolapse, incontinence or an abdominoplasty like Annie did.
(* Name changed to protect the identity of the patient who kindly allowed her story to be told. Surgery for either abdominal separation or prolapse repair is always best undertaken when the toddlers are not requiring lifting anymore and when breast feeding has ceased. Annie is very lucky to have such wonderful support from her husband with all the physical activities normally required with two toddlers.)