Does Everyone Get Diastasis Recti in Pregnancy?

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Diastasis recti abdominis (DRA) is one of the more notable changes that takes place during pregnancy. To accommodate the growing baby, the abdomen expands, stretching the skin, muscles and connective tissue (including the linea alba). As the abdomen expands in pregnancy and the linea alba stretches, the distance between the two sides of the rectus abdominis muscles (the inter-recti distance) usually increases.

This is a normal process in pregnancy and should not be considered to be abnormal or pathological.

If you delve into the research into diastasis recti during pregnancy, you will see that most women have some degree of separation in their final trimester. We don’t want you to obsess over your tummy muscles in pregnancy, but feel that it is a good idea to monitor your abdominal wall for any bulging of the linea alba between the two sides of the rectus abdominis muscles during exercise or daily activities.

The simple way to do this is to look and feel: place your fingers just above your belly button and feel for any bulging along the midline during activity. If you are wearing a tight T-shirt, sometimes you may be able to see the outline of the abdominal muscles, and if bulging occurs it will usually be obvious. For many women, it presents like a ridge running vertically between the six-pack muscles. If bulging is evident during a particular exercise, you can choose to eliminate that exercise or modify your technique. If you cannot see or feel on yourself, you can get a qualified health or fitness professional to check for you. Good alignment and breathing may help you control intra-abdominal pressure more effectively and eliminate the bulge.

Again, we don’t want you to obsess over your tummy muscles and be checking them constantly, but rather to be aware of DRA and monitor for bulging.

For some women, diastasis recti can manifest as pelvic pain or back pain. The pelvic joints rely on the passive and active structures for stability — this includes the ligaments, joint surfaces, joint capsules, muscles and connective tissue. Significant weakening of the linea alba may reduce the ability of the abdominal musculature to provide optimal stability to the pelvic joints and may lead to pain in some women. It’s important to acknowledge though that research shows that there is not more low back or pelvic pain in women with diastasis recti, so as always we need to look at each personal individually [1].

Is Diastasis Recti the Same as a Hernia?

A diastasis recti isn’t the same as a hernia, and should be approached differently.

Some women experience a more pronounced diastasis recti than others. As you roll over in bed, you might notice a large bulge that appears at the midline of your abdomen. As you start to get up from a chair or out of the car, you might feel discomfort along the linea alba as the tissue strains to maintain the pressure.

If you notice a large diastasis recti, you may want to see a physiotherapist that works with pregnant women. Often, the physiotherapist will perform an assessment and make recommendations for exercise and give specific strengthening exercises or an external support as required.

In contrast, you may notice a small, localized bulge with coughing or certain movements, which might be indicative of an umbilical hernia. A hernia is a weakness in the connective tissue which causes bulging of organs in response to an increase in intra-abdominal pressure. For instance, if you cough, sneeze, or lift something heavy, tissues may herniate through the weak point, causing pain. If you suspect a hernia, we recommend that you see a medical professional for assessment and guidance.

Can Diastasis Recti Be Avoided?

This is one of those ten-million-dollar questions, and there is no definitive answer. Some studies show that women who exercise regularly through pregnancy have a reduced risk of having a significant diastasis in pregnancy. However, there are some issues with those studies in terms of the number of subjects involved and how they were selected. A longitudinal study published in 2015 showed that there was no difference in the incidence of diastasis recti at six months between those who exercised pre-pregnancy and during pregnancy [1].

It’s believed that most, if not all women experience some separation of the linea alba during pregnancy. Pretty much every woman will have a diastasis of greater than 16 millimeters by weeks 35 to 39 of her pregnancy [1].

At this point in time, what makes a diastasis more pronounced during pregnancy isn’t known, but it is believed that genetics probably play a large role. One study looked at multiple risk factors, comparing women with and without DRA, and found that there was no difference between prepregnancy body mass index (BMI), weight gain, baby’s birth weight or abdominal circumference between the two groups [1].

It is difficult to predict who will experience a more significant DRA, so don’t beat yourself up over it if you do have a large gap.

Although there is currently no research to support this, it seems prudent to make modifications to exercises and other physical activity in order to potentially reduce the severity of this abdominal separation.This might include eliminating higher-level abdominal exercises but ultimately it will vary depending on the individual.

By the third trimester (and sometimes by the middle of the second), many women opt to remove loaded rectus abdominis exercises such as planks, crunches, and sit-ups due to weakness in the abdominal wall or obvious diastasis recti. Some women can continue with these exercises without any problems, however, and we do not make blanket rules when it comes to abdominal exercise in pregnancy.

Another modification we often recommend is reducing the load used when exercising as the pregnancy progresses. When you take into account all the changes happening in the abdominal wall and pelvic floor, it is no surprise that you may be feeling weaker in the final trimester. Rest assured that it is normal to feel the need to use lighter weights as your due date approaches. You should never feel like a failure for doing so. Studies actually show that the abdominal muscles are unable to produce as much force in the final trimester as in earlier stages of pregnancy or your pre-pregnant state — so you really shouldn’t expect your weights to remain the same [2].

We don’t want to scare you, and these adaptations are not permanent, but the consequences of pushing beyond the capacity of the abdominal wall and pelvic floor may be.

Healing Diastasis Recti After Pregnancy

As mentioned above, the distance between the rectus abdominis muscles, also known as the inter-recti distance, widens in pregnant women in their third trimester. In the postnatal period, some women’s diastasis recti will “heal” without any intervention (assuming that no additional stress or aggravation of the separation exists).

More than half remain abnormally wide eight weeks after delivery, and although some recover by six months, many have not recovered at even one year. A study in Norway followed over 300 women through the first 12 months after giving birth to assess the recovery from diastasis recti [3]. In the study, diastasis recti was defined as a palpated separation of two finger breadths or greater, either 4.5 centimeters above, or 4.5 centimeters below the navel. Results showed that almost one-third of women had at least a mild separation at 12 months postpartum (and consequently that two-thirds didn’t — which, according to the study, means that the diastasis recti had “healed”).

Prevalence of diastasis recti abdominis categorized as normal, mild, moderate and severe.

What Does Healing Mean For Diastasis Recti?

Here’s where things get tricky. How studies like the one mentioned above define “healing” might not always be the healing that most women actually need. For example, what that study, and many others, define as “healing” refers to the distance between the two sides of the rectus abdominis becoming narrower, a closing of the gap. This distance used to be considered the gold standard for measuring healing of diastasis recti, with the overall aim of management being to reduce the wide of the gap.

However, many experts now recognize that the biggest concern in diastasis recti isn’t purely the separation. Rather, it’s the loss of density and ability to produce tension in the linea alba that can compromise the function of the abdominal wall. For some women, the linea alba is very thin and wide and does not transfer force between the two sides of the abdominal wall effectively.

Therefore, it’s important to remember that even if your linea alba remains wide, it may be still possible to regain what’s most important: function. On the flip side, just because the gap between the linea alba has narrowed or closed, doesn’t necessarily mean you’ve regained optimal function. We believe that working to regain optimal function of the abdominal wall is crucial because if the deep central stability system doesn’t functionally recover, it could potentially lead to problems with organ and postural support. For some women this may mean that they feel weak, can’t perform as well as they used to or they may experience pain in the back, pelvis or limbs.

A large diastasis recti can cause your abdomen to still appear somewhat pregnant because there is less support for the abdominal contents. Many women lament having what they call a “pooch” or “mummy tummy” which they believe is due to excess abdominal fat. In reality, it’s sometimes a result of a linea alba that is thin and wide, with the abdominal contents dropping forward in standing.

For some women, the appearance of the abdominal wall is not concerning as long as it functions well. For others, the aesthetics are the prime concern and the trigger for seeking assistance from a health or fitness professional. Just as exercise during pregnancy may help minimize the severity of diastasis recti, most women require some retraining of the abdominal and pelvic floor muscles during the postnatal period to help restore optimal function.

The amount of rehab and the length of healing time your diastasis recti will require will depend on your genetics, age, number of pregnancies, and the size of your babies during those pregnancies. For some women, just a gradual return to activities and self-monitoring is all that is required, but for those with more significant diastasis or concerns, a more individualized program may be recommended.

Assessing Your Diastasis Recti

A pelvic health physiotherapist can help you with assessing and treating your diastasis recti, and depending on the severity, you may only need a session or two in conjunction with following a postnatal training program (like our Moms Gone Strong program). Working with a professional who is trained in treating diastasis recti will allow you to monitor how well your diastasis is healing so there’s no guesswork, and you know how long you need to continue your diastasis rehab protocol. You can also learn how to assess your own diastasis recti in this article by Jessie Mundell — although we still recommend seeing a pelvic health physio for an assessment at least once.

To Brace or Not to Brace? Belly Wraps and Other Postpartum Supports

Many women like to wear belly wraps to help the linea alba heal following pregnancy. Splinting, bracing, or wearing a support garment is a popular recommendation in the management of diastasis recti. There are a number theories supporting this recommendation including but not limited to: supporting the abdomen, bringing the rectus abdominis muscles closer together, giving gentle compression to help with swelling, offering support to the lumbar spine, and giving women more confidence in their body.

At this stage, research does not clearly demonstrate whether or not external supports are truly effective. Some experts believe that the use of splinting, bracing, and wearing of a support garment may have more adverse effects, such as increased pressure on the pelvic floor, encouraging reliance on an external device, and reducing muscle strength and activation through the abdominal musculature. Others believe that use of an external support may reduce tension on the healing linea alba and result in a better outcome.

To our knowledge there are no studies showing that bracing is beneficial for managing your diastasis recti, but we believe that these are useful guidelines in deciding on whether or not to use a support.

Wraps may be helpful if:

• You can’t rest very much in the six weeks following delivery and you feel that you need some extra support. This could be because you have a toddler or because you have a cough that stresses your abdominal wall.
• You are having back, pelvic, or pubis symphysis pain. The compression from the wrap can help relieve the pain in some cases.
• You’ve had a C-section and need to support the incision.
• You are exercising and want a little bit more support.
• You have a separation wider than three fingers.

Wraps may be harmful if:

• You wrap the support too tightly or you use one made of rigid material which limits abdominal movement and may put excess pressure on your pelvic floor.
• You don’t perform rehab exercises because you think the wrap will do everything for you.
• You wrap the support from top (ribs) to bottom (upper pelvis), which can also increase pressure on the pelvic floor.

If you choose to use an abdominal wrap, use one that you find comfortable and supportive, but not restrictive. You should be able to take full breaths while wearing your support wrap. That said, because there isn’t any definitive data as to whether or not belly wraps are helpful in recovery, we recommend that you discuss wraps with your pelvic health physiotherapist to determine what’s best for you.

Belly wraps are simply not a solution on their own. To strengthen and retrain your abdominal wall  you will still have to do rehab exercises.

Other supportive garments that you may consider include pelvic supports and compression shorts. Pelvic supports wrap around the pelvis to help support the pelvic joints and help relieve pain in the pelvis. These will not have much impact on the diastasis itself but may help relieve pain in the pelvic joints. Compression shorts look a bit like biking shorts or shapewear (like SPANX), but they feature medical grade compression and work to support your abdominal wall following pregnancy.

Some women prefer compression shorts instead of wraps, binders, and other garments simply because they offer support to the perineum as well as to the abdominal area, as they support from the bottom up. (Remember, applying pressure from the top down can increase pressure on the pelvic floor.) They also don’t shift or bunch like some other wraps or binders, and they are easier to wear than many wraps or binders — just pull them on, and you’re good to go.

That said, what’s most important is that you choose the option that feels most comfortable to you, and that your pelvic health physiotherapist is in agreement with your choice. Sometimes a simple elastic tubular bandage can be all that you need!

When to See a Physical Therapist for Your Diastasis Recti

• You have a diastasis of wider than two fingers.
• You have a deep diastasis of more than 1 centimeter.
• You have minimal tension in the gap.
• You have concerns regarding your abdominal muscles.
• You experience bulging along the linea alba with exercise.

Remember that even if you gave birth 10 years ago, you can still address this issue, so don’t write yourself off just because you are some years postpartum.

A diastasis is not a contraindication to general exercise, but you can work closely with a physical therapist to make sure you’re moving well and exercising safely.

References

1. Fernandes da Mota PG, Pascoal AGBA, Carita AIAD, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther. 2015 Feb 20(1):200–5.http://www.mskscienceandpractice.com/article/S1356-689X(14)00181-7/fulltext
2. Gilleard, WL, Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate postbirth period., Phys Ther. 1996 Jul;76(7):750-62. https://www.ncbi.nlm.nih.gov/pubmed/8677279
3. Sperstad, JB, Tennfjord, MK, Hilde, G, Ellström-Engh, M, Bø, K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016 Sep;50(17):1092–6. http://bjsm.bmj.com/content/50/17/1092.info

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