This week’s blog contribution has come from Martine Lange, one of the excellent Women’s Health (and musculo-skeletal) physiotherapists who work with me at Sue Croft Physiotherapy. Women are always distressed about the changes that occur to their bodies with pregnancy and this is important to acknowledge and respect because it can play with their sense of well-being and happiness. If a woman has a large abdominal separation and/or stretch marks and loose skin and she is miserable with her ‘changed look’ of her body, this can lead to significant anxiety and depression for her. Martine’s blog follows.

“I still look pregnant!”, “Look at all this flabby stuff!” (as she grabs at her belly), “Why hasn’t my tummy gone back to normal?” These lamentations are commonplace within the walls of a physiotherapy clinic for women from 2 months to 20 years post-baby. Sometimes the problem can be attributed to DRAM or Diastasis of Rectus Abdominus Muscle, otherwise known as abdominal separation, rectus diastasis or diastasis recti.

Image from Pelvic Floor Essentials 2018 (Sue Croft)

What is DRAM? 

It is the excessive separation between both bellies of the rectus abdominus muscles and can occur anywhere along the linea alba from the xiphoid process (tip of the breast bone) to the pubic bone. Most of the separation often occurs at the belly button (the umbilicus). It is measured by something called the inter-recti distance (IRD). (1) A strong, intact abdominal muscle is important for abdominal organ support as well as postural support.

If we think of our rectus abdominus or six-pack muscles, (yes we all have them even if we’ve never seen them!) – as your belly expands during pregnancy (or with abdominal weight gain), the rectus abdominus muscle needs to stretch to accommodate the growing baby and the increasing weight and dimensions of the expanding uterus (from 40 to 1000 grams and the capacity from 4 ml to 4000 mls) (1)

Muscles, however, can only stretch so far, so when they have stretched to their maximal capacity, something else has to happen to make room for the abdomen. So, the muscles separate sideways. They remain joined centrally by the fibrous structure -the linea alba -which is made up of collagen fibres (called an aponeuroses) from the deeper abdominal muscles such as transversus abdominus and the external and internal obliques (1). The linea alba is one of the important structures for good strength and function of the anterior abdominal wall but it can increase in length when the mechanical stress is prolonged such as with sustained increased intra-abdominal pressure (as in pregnancy). (2) 

Abdominal separation is very common- in fact some researchers believe some degree of separation is found in up to 100% of women during pregnancy (Mota et al 2015), but it commonly affects between 30-70% of pregnant women and in studies has been coincidentally found in 39% of women undergoing abdominal hysterectomy (3) and 52% of menopausal urogynaecological patients.(4,1)

After the baby is born and suddenly there is much less stretch on the muscles, then everything should just bounce back… right?

For some, with great genetics (meaning great collagen elasticity) this does happen and within six to twelve weeks after giving birth, their separation may be minimal and not symptomatic for the woman. For the rest of us, the process is a little slower or never seem to completely resolve.

Imagine that you are wearing a corset, it holds the abdominal contents up and in. Now imagine you loosen the corset down the middle, everything  sits a little lower and a little further out. This is somewhat analogous to what happens with an abdominal separation, we no longer have that taut fibrous band down the centre of the muscles, instead the band (linea alba) is more stretched or loosened so things can tend to “pooch” out a bit more.

Functionally, if you are getting bulging in the belly with exercises or getting out of bed or a chair, this is not a good thing, because it means there is not enough tension across the linea alba to hold the abdominal contents. If a person can increase the tension (i.e. take out the slack) in the linea alba whilst they are doing exercises that may otherwise cause bulging, then they are preventing worsening of DRAM. This tensioning is done by contracting the transversus abdominus and pelvic floor muscles. This co-activation of muscles can be performed to protect against increases in intra-abdominal pressure (such as during cough, sneeze, lift, bending etc) and is called “bracing” or “the knack”.

For women who worry about the appearance of their tummies (and let’s face it that’s most of us at one time or another), often we are holding / sucking the belly in for significant periods of the day. When these muscles are “turned on” for long periods, they tend to fatigue, and then are no longer able to assist in the support of the pelvic organs effectively and it may increase the risk of pelvic floor dysfunction such as stress urinary incontinence or worsening of prolapse. These muscles should be contracting (and relaxing) regularly throughout the day to protect the pelvic organs from excessive descent or from bladder leakage which can occur with increases in abdominal pressure (such as with cough/ sneeze / lift etc).

What strategies can we use to help improve / prevent DRAM?

• Bracing with the pelvic floor and low abdominal muscles for strong movements (sit to stand, lifting, sneezing, coughing etc) and relaxing the muscles afterwards when the task or activity is finished
• Ensure good bladder and bowel habits to maintain good pelvic floor health
• Move well – for example log-rolling to get out of bed rather than doing a sit up
• Sleep with a thin pillow under the belly when on side to minimise drag on the separation
• Use of abdominal supports in the early post-partum period such as tubigrip, SRC recovery shorts and other brands of support
• Using your hands to support the abdomen with coughing / sneezing etc

For some women, especially those with poor collagen elasticity and who have had multiple pregnancies their DRAM may not recover to a point that they are happy with, and this is completely understandable! Who wants to be asked how many weeks along they are when they aren’t even pregnant? For these patients there are surgical options:

• Plication-based repair – these can be done either open or laproscopically or a hybrid repair (both laproscopic and open), usually the linea alba is brought closer together and then stitched, (and may be reinforced with mesh).
• Hernia-based repairs
• Abdominoplasty – In this case a plastic surgeon may also be repairing other things such as excess skin, performing liposuction. (Here is a link to another blog on a patient’s story about her Abdominoplasty)

There is no robust evidence regarding recurrence rates, cosmetic outcomes, quality of life or complications following surgical repair. It is also worth noting that these are fairly invasive surgeries, so for optimal recovery it is important to minimise lifting / housework etc afterwards, which is not always easy if you have a couple of toddlers! Having said that, for many women having these surgeries can significantly improve their quality of life and body image.

All the changes that happen to our bodies after babies can be intense, mortifying, painful and sometimes wonderful, but for each of us it is a different and unique experience and our management is therefore going to be different for every individual. With guidance from an experienced caring pelvic health physiotherapist and healthcare team you can get a satisfying outcome

(1) Mota P, Pascoala A, Bo K (2015) Diastasis Recti Abdominis in Pregnancy and Post Partum period. Risk factors, functional implications and resolution. Current Women’s Health Reviews 11,59-67. Sourced 17/02/19 https://www.researchgate.net/publication/282271189_Diastasis_Recti_Abdominis_in_Pregnancy_and_Postpartum_Period_Risk_Factors_Functional_Implications_and_Resolution

(2) Hernández–Gascón B, Mena A, Peña E, Pascual G, Bellón JM, Calvo B. (2012) Understanding the Passive Mechanical Behavior of the Human Abdominal Wall. Ann Biomed Eng 2012 13; 41(2): 433–44

(3) Ranney B. (1990) Diastasis recti and umbilical hernia causes, recognition and repair. S D J Med; 43(10): 5–8

(4) Spitznagle T, Leong F, Van Dillen L Prevalence of diastasis recti abdominis in a urogynaecological patient population.  Int Urogynecol J pelvic Floor Dysfunction