Diastasis Recti in the Pregnant and Postpartum Birthing Person

Exercising ONLY your core is one of the worst things you can do for diastasis (also known as DRA or abdominal separation) . Working out ONLY your core will not give lasting results. Or, addressing your core without addressing the whole body may increase other issues like prolapse or back pain. Why? Because Diastasis is a whole-body issue caused by the way you move in everyday life. Diastasis develops due to 2 issues: forces pulling OUT and abdominal forces pulling IN. Almost all programs only focus on 1 of these aspects resulting in reoccurance, difficulty healing or other issues like prolapse and back pain.

Diastasis is defined as greater than 2 cm width of the rectus abdominis or 6-pack muscles, roughly the width of your two fingers. It occurs when the linea alba (or connection between the 6-pack muscles) is stretched due to pressure. The pressure of carrying a baby (or babies!) puts a lot of strain and stretch through that connective tissue, which is why diastasis occurs at the end of most pregnancies. In fact, diastasis occurs in 66-100% of women in the 3rd trimester (Chiarello), 68% of women in the early postpartum period (Keshwani) and 32.6% at 12 months postpartum (Gluppe).

While having a DRA can cause body image concerns for some, there is literature supporting back and pelvic area pain if a DRA is not addressed. DRA can cause an increase in abdominal pain in the early postpartum period, (Keshwani), increase in low back pain and pelvic girdle pain and be related to incontinence and prolapse. You can check if YOU have a diastasis by following the video at the end of this blog post. Other clues that you have a diastasis are that you have "doming" or "coning" visible when you lift your head while laying on your back.

A common question fielded from pregnant and postpartum birthing people is how to prevent diastasis or prevent it from getting worse. Answering this question revolves around controllable and uncontrollable factors. Uncontrollable factors include: older age, having more than 1 baby, cesarean section, gestational weight gain, high birth weight of your baby and childcare (Gluppe). Our approach at RVA Holistic PT is to “control the controllables!” So, let’s chat about some things you can influence for the positive!

The "ABCs" of diastasis are

A is for alignment

B is for proper breathing

C is for core

Alignment:

There is much concern about the “pulling in” forces with exercises, but what about the “pulling out” forces? Our body is connected by

fascia, or cotton-candy like networks. When you lift your arm overhead, there IS a pulling in your mid-section because of the fascial connections. When you walk, one leg is drawn back. Tightness in that hip causes pulling at your belly button. In our modern society (ahem, this applies to me, too!) we sit too much! We are not walking 5 miles a day or squatting to pee/ poo. As a result, we have lost alignment mobility! Tight shoulders, hips and mid-back joints and muscles, a stiff and wide postpartum ribcage-- create a pulling out force that the abdominals may not be strong enough to counteract in the pregnancy and postpartum period! In order to compensate for the stiffness in the mid back and ribs, we often see womxn "rib thrust," which creates even more pressure going out the front belly. Manual therapy can be incredibly useful for healing diastasis: we work to restore the ribcage position, unstick any fascial stiffness, gently restore your organ position and release tension in the shoulders and hip sthat create those "pulling out" forces.

Proper alignment, from the feet to the head, allows the forces to be spread throughout the body (rather than forced all to the front abdominal wall).

Breathing:

Breathing is the next foundational element of healing diastasis. In pregnancy and after birth, birthing people have looseness in the abdominal wall and tightness in the back. This leads to a LOT of air / pressure going out the belly, which can worsen the diastasis. Their breathing muscle- the diaphragm- is short and stiff from creating space for the baby. We use breathing exercises in specific positions to create more space and movement in the back and diaphragm for a more balanced breath.

Core: This is what most people are familiar with when it comes to healing diastasis. Core is important, but it is the 3rd element because without the foundations of Alignment and Breathing, Core work will not truly heal your diastasis.

The most commonly accepted exercises to do for diastasis are transverse abdominis exercises. We use the latest research to strengthen the core from the inside out. This creates balance and strength in the abdominal wall. We use a step-by-step progression to help your abdominal wall get stronger, more coordinated, "wake up" those sleepy lower abdominals and eventually get back to planks and sit ups. Check out our Postpartum Core Recovery online self-paced course to start today.

In postpartum birthing people, we (here at RVA Holistic PT) also use hypopressives (also known as low pressure fitness). This is a way to use a breath hold to create a "vacuum" drawing in of the pelvic floor and transverse abdominus. Sit ups are HYPERpressure and planks are HYPERpressure. HYPOpressives are very useful in diastasis rehab (only in postpartum-- no breath holding while pregnant!) especially when other programs have not worked, when you also have prolapse or pelvic floor weakness and when you are overusing your upper abdominals. Plus, bonus of toning your abdominal wall! In Spain, there are "hypopressive" classes (just like we have pilates or yoga classes here in the US). Below is an example of a hypopressive being performed by ME!

What else can you do to prevent diastasis from worsening (or help it heal)?

An expert panel had a lot of suggestions (Dufour)!

• Good posture (avoid "rib thrusting", which is where you point your chest up and your ribs "thrust" forward, see picture below... instead... try softening your knees and drawing your ribs down... if this is hard- you probably need our help working on mobility!)

• Good body mechanics (a fancy way of saying to roll to the side to get up and avoid straining on the toilet)

• Avoid sit-ups (as in a full sit-up… but a head lift may be beneficial based on evidence that was published in 2020)

• Do deep core exercises

• Breath optimally

During birth

• Be mobile during labor

• Avoid pushing practices that increase intra-abdominal pressure for periods of time and close the throat. DO make noises such as grunting which can lengthen the pelvic floor

• Advocate for positions that free the sacrum (low, low back bone) rather than laying on your back, such as hands and knees, side-lying, squatting

• Advocate for practices that reduce the likelihood of use of forceps or vacuum. Some of the above suggestions can help this

Early Postpartum:

• Good posture

• Good body mechanics

• Avoid full sit ups

• Breath fully using the side ribs

• Do deep core exercises (see video posted)

• Avoid high impact exercise

• Avoid any exercise where you leak urine, gas or stool (have incontinence)

Another little known factor to diastasis is visceral mobility. This is hands-on work to make sure the organs are moving optimally. It is particularly useful for those who have had abdominal surgery or cesareans. In a case series by Kirk, the distance of the diastasis improved with 4+ treatments of visceral mobility. Those clients also had improvements in bladder and bowel symptoms. All of our physical therapists at RVA Holistic PT are trained in treating the digestive and reproductive systems through visceral mobility to help heal diastasis and positively impact other issues people have concurrently like back pain and bladder/ bowel issues.

Diastasis is not just an abdominal issue-- it is a whole body issue. With our patients at RVA Holistic PT, we look at each person as a whole and assess how your body responds to movement and prescribe a road map of exercises to improve recovery. Each person is unique and often a combination of strengthening from the "inside out" AND working on reducing the "pulling out" forces is usually essential for full healing. Our philosophy aligns with the current literature to address modifiable factors that are potential drivers of DRA. We seek to “control the controllables.”

No matter if you are pregnant, newly postpartum or decades postpartum, you can heal your diastasis through optimizing your shoulder, rib and hip mobility AND optimizing your core strength. Alignment, such as avoiding "rib thrusting" and softening the knees, is essential to balance the pressure in the abdominal canister.

And should you wear a belly binder? Binders can be helpful in pregnancy and immediately postpartum. However, they do not address the root cause of the separation. We always encourage use of a binder WITH a comprehensive, head-to-toe mobility and exercise program.

Are you struggling with diastasis? We work 1:1 with our clients virtually and in Richmond, Virginia at our 2 locations in the Fan District and the West End near Innsbrook. Book online! Not in Richmond? We have online course offerings including the postpartum core recovery course designed as a 6-week step-by-step program for diastasis and a Movement Membership for {M}others for $47/month with LIVE or REPLAY 20 and 45-minute classes designed to address the ROOT cause of diastasis in the postpartum person. Below is a 10-minute snippet of a 45-minute class. You can see how this is a whole body approach to address the head-to-toe issues that contribute to diastasis recti.

---

Dufour, Sinead, PT, PhD, Bernard, Stephanie, et al. Establishing Expert-Based Recommendations for the Conservative Management of Pregnancy-Related Diastasis Rectus Abdominis: A Delphi Consensus Study. J. women's health phys. therap.. 2019;43(2):73-81. doi:10.1097/JWH.0000000000000130.

Kirk B, Elliott-Burke T. The effect of visceral manipulation on Diastasis Recti Abdominis (DRA): A case series. J Bodyw Mov Ther. 2021 Apr;26:471-480. doi: 10.1016/j.jbmt.2020.06.007. Epub 2020 Aug 6. PMID: 33992284.

Sandra B Gluppe, Marie Ellström Engh, Kari Bo, Immediate Effect of Abdominal and Pelvic Floor Muscle Exercises on Interrecti Distance in Women With Diastasis Recti Abdominis Who Were Parous, Physical Therapy, , pzaa070, https://doi.org/10.1093/ptj/pzaa070

Nadia Keshwani, Sunita Mathur, Linda McLean, Relationship Between Interrectus Distance and Symptom Severity in Women With Diastasis Recti Abdominis in the Early Postpartum Period, Physical Therapy, Volume 98, Issue 3, March 2018, Pages 182–190, https://doi.org/10.1093/ptj/pzx117

Sandra L Gluppe, Gunvor Hilde, Merete K Tennfjord, Marie E Engh, Kari Bø, Effect of a Postpartum Training Program on the Prevalence of Diastasis Recti Abdominis in Postpartum Primiparous Women: A Randomized Controlled Trial, Physical Therapy, Volume 98, Issue 4, April 2018, Pages 260–268, https://doi.org/10.1093/ptj/pzy008