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Diastasis Recti in the Pregnant and Postpartum Birthing Person

Updated: Jul 15

Diastasis, or DRA or abdominal separation, 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 helaing diastasis. In pregnancy and after birth, birthing people have looseness in the abdominal wall and tightness in the back. Their breathing muscle- the diaphragm- is short and stiff from creating space for the baby. We use breathing exercises in specific positions to creaste 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, pelvic floor exercises, the “Noble” exercise and the “Tupler” technique. The “Noble” exercise encourages approximating the rectus abdominis muscles using your hands or a sheet to draw them together prior to a sit up. The “Tupler” exercises encourages drawing in + curling up while wearing a binder. Unfortunately, depending on which literature study you read, there are varying results and no clear consensus. Some studies advocate performing a transverse abdominis contraction prior to a curl up, while others showed a larger separation of our linea alba, the line in the center of our abdominals, when a pre-contraction was performed. Say, what?! Ok, now this is getting confusing! Relationship status: it's complicated.


We use the latest research to strengthen the core from the inside out. This creates balance and strength in the abdominal wall.


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)

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. When an abdominal separation is very deep and not necessarily wide, we often find that activation of the transverse abdominus closes the gap. In this case, following the video below can help you "find your muscles" of the pelvic floor and transverse abdominus and can help you heal. When the gap is wide, we often find that mobility is the first best step. 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.


Want to learn more? We work 1:1 with our clients virtually and in Richmond, Virginia and are hosting an upcoming workshop August 4, 2021 where you will learn what YOUR root causes of diastasis are and walk away with 3 core videos and 1 yoga for diastasis video. It is an unbeatable offer of only $37! We also offer a special 55-minute manual therapy session to work on ribcage, hips, shoulders, fascia and viscera to help you heal [book this session online].





If you are struggling with diastasis and are in the Richmond, Virginia area, contact us for a visit at 804-372-0291. We are Richmond’s most experienced team of women’s and pelvic health physical therapists offering clinic AND house calls. We offer telehealth consultations in the state of Virginia. Follow us on instagram @rvaholisticpt for free content. If you are not in the state of Virginia, find a Board-Certified Women's / Pelvic Health Physical Therapist in your area. Board-Certification indicates your physical therapist has written a case study, practiced for >2,000 hours in pelvic health and passed a rigorous examination.





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.


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










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