Over the weekend, I had the opportunity to participate in the annual research update for pelvic health physiotherapists worldwide. One of the key takeaways from this event was the realization that we need to stop catastrophizing what is considered "normal" when it comes to diastasis recti abdominal muscles (DRAM). For too long, there has been a significant amount of fear placed around what we think is "too much" separation of the abdominal muscles postpartum. It's time to shift this perspective.
What is Normal DRAM?
Diastasis recti refers to the separation of the rectus abdominis muscles, the “six-pack” muscles that run down the front of the abdomen. This separation occurs when the linea alba—the connective tissue between the two muscle sides—stretches during pregnancy. But how much separation is considered normal?
For someone who has never had a baby, a separation of up to 2.8 cm is typically considered normal. For women who have had children, anything up to 3 cm at rest is also considered within the normal range. This means that during pregnancy, especially as we age and go through the childbearing years, it’s important to remember that a certain degree of separation is to be expected. The key message here is: we need to stop fearing the separation and start focusing on the functional recovery of the abdominal wall.
The Role of Sit-Ups in Postpartum Recovery
Previously, the common belief was that doing sit-ups could exacerbate diastasis recti postpartum. The rationale was that engaging the abdominal muscles in this way could increase the separation. This led to recommendations that pregnant women should only use a log roll technique to get out of bed and avoid exercises that involve flexing the spine, like sit-ups, in an effort to protect the abdominal wall.
However, recent research is challenging this previous thinking. A study titled Pregnant women may exercise both abdominal and pelvic floor muscles during pregnancy without increasing the diastasis recti abdominis: a randomised trial (Theodorsen et al., 2022) has shown that it is possible for women to engage in abdominal exercises during pregnancy without increasing the severity of diastasis recti. This research challenges the long-held belief that strengthening the abdominal wall could make diastasis worse. In fact, the findings suggest that strengthening the abdominal muscles may be beneficial for overall pregnancy and postpartum recovery.
If I've previously recommended that you avoid sit-ups or only use a log roll during pregnancy, it’s time to update that guidance. The abdominal wall becomes weak over the course of nine months, and avoiding all abdominal exercises could potentially delay recovery postpartum. Instead, a more balanced approach to abdominal strengthening, when appropriate, could support recovery and reduce the risk of complications, such as pelvic girdle pain or more severe diastasis recti.
The Multifactorial Nature of Diastasis
It’s important to recognize that diastasis can be multifactorial. While abdominal separation is a normal part of pregnancy, certain factors might make some individuals more prone to larger separations. One such factor is hypermobility, where the body’s connective tissue, including collagen, is more elastic. Those with hypermobility might be more predisposed to having a higher proportion of type 3 collagen fibers, which are more stretchy and have less recoil ability compared to type 1 collagen fibers. This could result in a greater propensity for more pronounced abdominal separation or difficulty in healing.
Type 1 vs. Type 3 Collagen Fibers
Type 1 collagen fibers are the strongest and most abundant type of collagen in the body. They provide structure and support to tissues, such as skin, tendons, and bones. In contrast, type 3 collagen fibers are more elastic and less robust, contributing to tissues that require flexibility. During pregnancy, a surge in hormones like estrogen and progesterone—especially during the second trimester—can cause the body to produce more type 3 collagen fibers to accommodate the growing baby. This increased distensibility of the abdominal wall can lead to a protruding abdomen, and in some cases, increased pain in the symphysis pubis and sacroiliac joint (the joint at the front and back of the pelvis).
Hormonal Shifts and Collagen Postpartum
After childbirth, particularly for breastfeeding mothers, there is a hormonal shift that increases the production of type 1 collagen fibers. This shift helps to stiffen the connective tissue and improves its ability to recoil, which can aid in the recovery of diastasis. This is another reason why strengthening the abdominal muscles and supporting the body through proper exercise is essential for postpartum healing. As the body moves through these hormonal changes, providing adequate tension and stability through core exercises can help improve the function and stability of the pelvis and abdominal muscles.
The takeaway message here is that we need to stop catastrophizing normal abdominal separation and embrace a more functional, evidence-based approach to diastasis recti recovery. Strengthening the abdominal wall, including the rectus abdominis, can lead to significant benefits not just for diastasis, but for overall postpartum recovery. The key is to balance exercise, hormonal changes, and the body's natural healing process as we move through pregnancy, childbirth, and the postpartum period.
As we continue to learn more about diastasis and recovery, it's important to remember that a strong abdominal wall can support a faster, more efficient recovery and may even reduce pain and discomfort associated with childbirth. So, let’s shift the narrative from fear to empowerment, and focus on strengthening the body in ways that support healing and recovery.
Reference:
Theodorsen, N.-M., Bø, K., Fersum, K. V., Haukenes, I., & Moe-Nilssen, R. (2022). Pregnant women may exercise both abdominal and pelvic floor muscles during pregnancy without increasing the diastasis recti abdominis: a randomised trial. Journal of Physiotherapy, 68(4), 274-280.
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