Abdominal Separation (AKA Diastasis Recti): What is it, how to prevent it, identify it & repair it!
WHAT IS ABDOMINAL SEPARATION?
Abdominal separation is the separation of the most prominent abdominal muscle; the Rectus Abdominis down it’s midline (the connective sheath between it’s two sides).
“It is not a tear, but a sideways stretch that separates the two halves of the rectus abdominis, the “6-pack” muscles.” Every-Mother.
The separation can be measured in centimetres but most health practitioners measure it in “fingers width” (which can be less accurate due to the varying widths of an individuals fingers).
A Diastasis recti is diagnosed when there is a gap greater than 2cm.
It can occur in newborn babies and adults but it is pregnant women who are at highest risk. The more babies you have, the higher the risk.
Others at higher risk include mothers who:
Are over 35;
Have big babies;
Have multiples (twins or triplets); and
Those performing inappropriate abdominal exercises throughout pregnancy.
Interestingly, women who have incredibly strong “abs” from high intensity exercises prior to falling pregnant may be at a higher risk due to the rigid, inflexible nature of their abdominal muscles. The inability of the abdominals to stretch to accommodate the growing baby means that something has to give. Although I am not suggesting you should not look after your core prior to conception, as a weak core can lead to just as many issues.
Moderation is key in pregnancy and learning to monitor your own abdominals for separation allows you to identify one as soon as it arises. You can then modify the activities which may be exacerbating it and even start some specific exercises to resolve it quickly.
WHY LEARN TO CHECK YOURSELF FOR SEPARATION?
In practice, I ask every woman who is pregnant or has had a baby in the last 2 years if they have an abdominal separation. The most common response I receive is “No, I was checked in hospital when I had my baby and it was all good.” Or even worse; “I have no idea, no-one has ever checked me.”
This is incredibly frustrating to me. Especially if it turns out that she actually has a significant separation when I check her. Let me explain.
Once your baby has been delivered (regardless of the mode of delivery), it feels as though someone has removed a giant concrete brick from underneath your rib-cage. All of a sudden you have the ability to do amazing things. Like bending over to put your undies on or sit up in bed without having to shimmy one hip across before gracefully flinging one leg off the bed, hoping that thanks to it’s momentum, the rest of your body will follow through.
So we DO start sitting straight up again, we bend and lift and push like no baby was ever there. Not only that but we now have a baby. A baby who cries and needs to be rocked. A baby who is growing heavier by the day. A baby who travels in a car capsule that weighs more than your golden retriever. And it doesn’t stop there. That baby turns into a toddler who spends most of their waking hours perched on one of your hips so you can actually get anything done!
My point is, after birth is when your abdominals really have to start working. If there is an un-diagnosed separation because it was never checked properly or you had a slight separation and was told not to worry about it – can you see how getting on with life without a care in the world can lead to a worsening of that innocent situation?
SO WHAT’S THE BIG DEAL?
Abdominal separation can cause discomfort and dysfunction in many ways. These include:
Increasing the risk of low back pain;
Reducing hip stability that may lead to hyper-mobility and pain;
Pelvic floor dysfunction that can lead to continence symptoms;
Herniation of her umbilicus (belly button);
Make you more susceptible to symphysis pubis dysfunction (pain at the front of your pelvis);
Inefficient contractions in labour as the uterus is lacking a strong wall to push against. This can lead to longer more tiresome births for mother and baby; and
It can lead to a “mum pooch” or a lower abdomen that makes you look as though you are still pregnant.
WHEN TO START CHECKING FOR YOURSELF.
Start checking in your second trimester. It takes literally 1 minute of your time and can be done when you get into bed at night. Then check again in third trimester. Ask someone to check it after you’ve given birth and check it again 3 weeks later and again 3 weeks after that.
SO TELL ME HOW TO CHECK IT ALREADY!
The first thing to look out for is that bulge that sticks up vertically in your abdomen when you go to sit up from lying down. We call this “doming” or “coning”. Often women have noticed this themselves but had no idea what it meant. It means you have abdominal separation and your uterus is poking out between the 2 sides of your muscle!
Now I’m going to teach you how to measure a separation on yourself.
Start by lying on your back on the floor or a mat with your knees bent.
Place the fingers of one hand on the midline of your abdominals, about two inches above your belly button. Your fingers must be flat and pointing down towards your pubic bone.
Press those fingers into your belly slightly.
While holding that gentle pressure, lift your head off the floor or mat just enough to feel your muscles engage.
Feel the boarder of the muscles squeeze against your fingers and work out how many fingers fit between the two sides snugly.
If you want to be really clever, you can measure how deep your separation is too. To do this, once you’ve measured how wide it is, just note how deep your fingers sink into the gap. Is it just the tips of your fingers, past your nailbeds, past your first or second knuckle? Note this information down so that you can track your progress.
Repeat these steps at the level of your belly button and 2 inches below.
If you’re still unsure or you feel that your separation may be wider than 4 fingers width, seek out a health practitioner in your area that can assist you in your diagnosis and rehab.
THE GOOD NEWS?
Diastasis recti is preventable and most are reversible without the need for surgery! And the healing can start while you’re still pregnant. If you are diligent with your exercises daily, it is possible to see a good improvement in your separation despite your belly growing.
In extreme cases, surgery may be essential for repair so speak to your health practitioner if you feel your separation is wider than 4-5 fingers width and has considerable depth.
I HAVE A SEPARATION, WHAT NOW?
The first thing you need to consider is “what am I doing that is making it worse?” I believe that during pregnancy and in the first 3 months after birth, your daily activities can "make or break" your abdominal rehabilitation. Often just by avoiding or modifying activities you do multiple times a day that put strain on your abdominals, can make a huge improvement.
What makes it worse?
Sitting straight up from lying down;
Heavy lifting (or not bracing your abdominals to prepare);
Abdominal exercises that recruit your outer abdominal muscles such as crunches, sit-ups and all kinds of planking;
Constipation and other forms of straining; and
Even sitting from standing if you aren’t engaging your core properly!
So what SHOULD I be doing?
Firstly, start by modifying the behaviours and activities listed above. Don’t sit straight up from lying down. Roll to your side and push up with your arms. Try not to lift anything heavy and if you have to, push through your legs and pull your stomach in – pulling your belly button to your spine. Eat lots of fibre and drinks loads of water and if you’re really keen, buy yourself a stool to put your feet on when you’re opening your bowels – you’re pelvic floor and haemorrhoids will thank you too. (Blessed pregnancy.) Pull in your stomach when you stand from sitting and DO NOT join a “mummy bootcamp” that involves crunching and planking. Personal trainers are really accommodating and if you mention your separation, chances are they will have alternatives for you to do. Even better though, start by doing the exercises I will show you below.
The first exercise I will explain below is very simple and you can do it standing/sitting or lying down but I recommend getting the hang of it lying down first. Then once you're proficient at it, you can do it while you're breastfeeding or every time you get a red light in the car.
Lie on your back with your knees bent.
Take a deep breath in, expanding your stomach as if you're filling up a balloon. Some people struggle here and find that their chest rises and their stomach draws inward as they breath in. If this is the case for you, refer to the breathing exercises below first. Then once you have the hang of it, come back to this exercise.
As you slowly breath out, draw your belly button towards your spine as if you are trying to hide your stomach or "hug" your baby into your body.
Hold that muscle contraction as you breathe normally for 5 breaths making sure you are breathing IN-to your stomach and not your chest.
After 5 breaths, relax your stomach and repeat the above steps 5 times. (5 pull-ins with 5 breaths each).
Try to do this at least twice a day.
Below is a video of me demonstrating this exercise.
Other important muscle recruitment.
The rectus abdominus needs a stable pelvis to contract correctly. So rehabilitating your separation goes beyond just this muscle. There are 3 additional muscles that make up your deepest “core” and work to support your spine/low back and pelvis. They are the:
1) Pelvic floor;
2) Transverse abdominus; and
If you are a patient of mine, likely you’ve heard me “bang on” about these three. They are your deepest and most crucial pelvic stabilisers, your “corset” muscle (that prevents the mum “pooch”) and spinal stabilisers.
To get your Rectus abdominus to pull back to the centre, you MUST have a stable spine and pelvis. If you can get these three working optimally, then likely you’ll be able to prevent a separation from happening in the first place. But the problem lies in our lifestyle. Prolonged sitting is detrimental to the strength and coordination of these muscles leaving us vulnerable to strain and injury. So anyone who sits at a desk or computer all day and suffers with low back pain should also be listening - Procreating or not procreating.
NOTE: you can have seemingly strong abs without a strong core.
I HAVE MORE GOOD NEWS FOR YOU!
These critical muscles work together as co-contractors. Therefore, if you are contracting one effectively, you are also contracting the other two. Conversely, if one is weak and dysfunctional, so are the others.
Learning to appropriately and effectively isolate and contract your pelvic floor and transverse abdominus as well breathe appropriately take a great deal of focus and concentration and are best done initially under the supervision of a skilled and experienced physical therapist.
Here is a video I found on Youtube that demonstrates a gentle way of activating your Transverse abdominis.
WHAT ABOUT BELLY BANDS?
I am in two minds about belly bands and I often steer patients away from using them. If used correctly, they can be very beneficial while providing a lot of relief from back strain in the early DAYS postpartum, especially after a c-section. BUT with prolonged and inappropriate use, belly bands can also lead to “laziness” of your abdominal muscles which will only make your separation worse.
If using beyond the early postpartum days, the belly band should be used during periods of prolonged walking or standing as a “cue”. When your brain registers that you are wearing the band, this should trigger you to engage your own muscles by “pulling your belly button to your spine”. If worn for too long, your brain no longer registers it’s presence and you forget to engage your inner core.
Eventually, engaging your inner core should become an inherent part of your posture which will accelerate your rehabilitation more than doing exercises. I’d prefer you to achieve this without a band but if you need a physical reminder, a band can be useful. Another technique I use with patients is to set a timer to go off every 2 hours to remind you to properly engage you inner core. This regular reminder will eventually lead to an unconscious awareness.
NOTE: If you feel that engaging your core in this manner exacerbates your low back pain or incontinence issues, you may have a tight and overactive pelvic floor that may need releasing. See an experienced postpartum pelvis chiropractor or physiotherapist for a check!
BREATHING, yes there’s a wrong way to do it.
Unfortunately, while most of us sit all day and get stressed-out in the process, we have often forgotten how to breathe properly. I usually discover this when I take a patient through the Rectus abdominus activation exercise - see above. I say to them “Take a deep breath in..” and I see their chest expand and their stomach pull in toward their spine. My response is usually, “You’re breathing like an asthmatic!” (or someone having a panic attack). This shallow breathing is detrimental to the proper decent and activation of the diaphragm, which directly affects it’s relationship with the rectus abdominus and pelvic floor. As a result of this type of breathing, incorrect muscles are utilised which leads to weakness, pain and discomfort including:
Further stress in your body as your body perceives danger; and
When you breath in, your chest should hardly rise at all. I instruct my patients to place one hand on their chest and one on their stomach. When they breath in, I tell them to imagine they are filling up a balloon in their stomach. That balloon should cause their stomach to rise but also push out and expand their lower ribs. If this is too confusing, sometimes I instruct them place one hand on either side of their lower ribs applying light pressure in toward the centre. When they breath in, they should try to breath "into their hands", pushing them sideways. Below is a demonstration of this.
Your breathing practice can occur at any time of the day – the more the better. I like to do it when I get into bed at night, it calms my mind and helps me relax.
PELVIC ALIGNMENT and a CHIROPRACTORS ROLE IN HEALING YOUR ABDOMINAL SEPARATION.
Your pelvis and spinal stability and alignment is inherently related to appropriate core activation. Identifying poor posture and associated postural muscle weaknesses can be the key to switching on the correct core muscles associated with separation. For example, an over-active pelvic floor can lead to a pelvis that tilts too far forward. This causes you to engage inappropriate muscles such as hip flexors that place excessive load on your knees, abdomen and low back and prevent the core from engaging. This is also associated with weak glute (buttocks) muscles, poor breathing patterns, tight muscles of the low back, chest, neck, shoulders and base of the skull. All leading to weakness, pain and discomfort. This is such a common presentation and is so easy to identify and correct and can make all the difference to your abdominal rehabilitation.
IN SUMMARY – YOUR TO DO LIST
Check yourself! And do it at regular intervals during your pregnancy and post natal journey;
Stop doing the things you shouldn’t eg. sitting straight up from lying down, and modify your daily activities;
Perform Rectus abdominus activation;
Perform Transverse abdominus location, activation and exercise;
Practice appropriate breathing; and
Have a pelvic alignment check.
Image 1 by @iamannelti, image 2 by Zoe Young, image 3 by deliciously fit and healthy, Image 4 by@rowansterenberg, Image 5 from Pinterest, image 6 by @Kelly Colchin and image 7 from Shutterstock.