Working with pregnant and post-natal women is a privilege and something that’s close to my heart.
Diastasis Recti [DR] (also known as abdominal separation) can occur as the abdomen stretches to accommodate the growing baby. The linea albea (the connective tissue between the two parts of the RA muscles) stretches causing the left and right rectis abdominus (RA) to move away from each other creating a gap.
The DR is assessed and measured by having your client lying supine with knees bent at 90degrees and feet flat on the floor. Locate her naval and place your fingertips (gently and only after explaining and gaining permission of course) just above the naval. Have her lift her head, aiming chin to chest. If there is separation you will feel the finger fall between the abdominals (you do not need to press hard). In some women the separation may be very obvious even before they lay down. Repeat the process with your fingertips just below the naval as the separation can be above and or below. Note that the area over the naval itself is likely to feel quite open and broad, what you’re looking for is the state of the abdominals above and below this point when it comes to establishing severity.
Many women may come in stating that their doctor, physiotherapist or midwife has advised that they have a separation of ‘x’ number of fingers width. They may even have referred them to you. Explain that you’d still like to assess for yourself so that you can perform a repeat examination to track her progress. Often when asking women about their birth experience and if you ask about separation, they may shrug and not know if they suffered any at all. It has either missed being checked, or they’ve been checked and since it was insignificant it wasn’t mentioned to them. Although they say all pregnant women have some level of separation, it is only an issue when it is two or more finger widths in size.
When the separation is less than two fingers wide it tends to repair without much intervention. As long as a women engages deep abdominals correctly, creating the flattening effect on the belly, pulling the RA towards each other and firming the linea alba.
So why do some women suffer greatly with separation and others not? They say older mothers, multiple pregnancies (due to repeated stretching), large weight babies and performing strenuous lifting or strenuous abdominal exercises after the first trimester, are all contributing factors.
I’ve given it a lot of thought and hands on application over the years having worked with hundreds of pregnant women in my fourteen years of teaching. As a naturopath, I cannot help but look at everything holistically, especially during my own pregnancies. I sit in the multiparous category, I’ve had four babies and would be considered therefore at greater risk of DR especially with the third and forth pregnancy.
I had our two girls in my twenties (before I started my pilates journey) and then we welcomed our two boys in my early thirties, with pilates under my belt prior to our third, during and post-natal through both. So I have a good idea of how it all feels with and without pilates. Before becoming pregnant with my fourth baby, I would have been at my leanest and strongest (especially abdominals) of any of my other pregnancies. Yet, I still managed to avoid abdominal separation of any concern. I believe my pilates practice and self awareness is the reason.
I have also been blessed enough to be our family doula (birth assistant) and have done so for seven of my nieces and nephews births. All natural births, as were my own, which of course requires the abdominals to work hard. Watching and assisting a birthing woman gives a totally different view to add to my personal and very internal experience of birthing babies. Observing adds another layer of perspective on what a woman’s body actually goes through during labour and those abdominals work hard! It is intense and visible. It is thoroughly amazing what they do while pushing out those babies…. Watching my own abdominals during birth was not a priority!
The way I see it, a woman has a greater risk of developing a problematic DR if she is lacking in nutrients and if she hasn’t learnt to ‘zip it all up’ i.e. she has a weakened and compromised core.
If a woman, for whatever the reasons, has what I’ll call a ‘lazy center’ (poor pelvic floor and an inability to sufficiently engage transverse abdominals) she would seem to be at greater risk.
Such women may be overweight and generally lacking condition or conversely, they may be women who have very strong abdominals and strong global muscles, but lack sufficient control of the deeper stabilisers. They may be small in stature, so that carrying a baby of even normal size will mean that the abdominals will need to stretch further than for a taller woman, and since the abdominals are tight to begin with in the absence of efficient connection via TA & Pelvic floor, this group of women can suffer the same complication.
As a naturopath, I would also like to suggest other co-contributing factors such as nutritional deficiencies that can inhibit collagen strength and resilience, healing and repair. Think vitamin C, magnesium and essential fatty acids just for starters. Fodder for another article, but food for thought, when it comes to cross referral opportunities with your local allied health practitioners!
This article is specifically to share my thoughts on the topic of DR, based on what I’ve learned and contemplated throughout my own pregnancy experiences and with my many clients. I’ve not had a separation greater than 1 finger despite four pregnancies and none of my clients whom I worked with through pregnancy has either… So it begs the question. Why? Is that a coincidence?
As mentioned, I’ve had four children. When I was pregnant with my fourth baby and undergoing further study in pilates and learning new repertoire, I noticed that when I tried to perform certain exercises (especially if I didn’t engage properly) I could see my rectis abdominus doming (that triangular shape you see when someone is displaying RA dominance with a lack of TA activation). Being my fourth pregnancy, I was aware of abdominal separation and wanted to avoid it. Logic to me said that if I continue to do exercises where doming resulted I would be at a greater risk of a troublesome degree of DR. So I commenced, immediately, to change how I moved, avoided anything that loaded the abdominals too greatly causing doming, made sure I mindfully ‘zipped up’ before performing any exercise and when picking up my toddler or getting out of bed. My belly was the biggest it had ever been with this baby due to the shape, due in part to Samuel’s posterior presentation, which meant he loved to push out on my abs with his feet while I attempted to pull him back toward me with my abs. I looked like the front end of a jumbo compared to my other babies’ shape, which were carried naturally closer to my center.
I believe that had I not applied the principles of pilates at that time, I was most likely going to end up with some level of separation greater than I did.
This is not to suggest anything conclusive, but given the method of engaging core stabilisers is beneficial all round, it stands to reason that we encourage all pregnant women to learn the technique in the hopes that my logic is right and it assists in the prevention of problematic DR.
This is my theory and I’m sticking with it!
In my opinion and experience, the very nature of what is required to heal and repair a DR, is the same mechanism by which we can prevent it!
Remember that diastasis recti is a result of increased intra abdominal pressure but, more so when in addition to inappropriate or ineffective loading on a compromised and weakened core! Solving the compromised and weakened core seems the obvious solution to me.
The Pilates Method addresses the condition of the environment and increases our resistance to suffering under the increased intra abdominal pressure. Pilates works to decrease the chances of a large problematic gap, if applied well (properly), before and during pregnancy, whilst at the same time serving to repair the compromised core and close the gap should the method not be sort until after delivery, or should the prevention efforts have failed for any reason. A small gap remaining isn’t significant, provided you have addressed the core and the space in between, the ‘mid-line’, is shallow and firm.
To assist other pregnant mums in preventing DR, I show them what doming looks like, how to avoid it by reducing strain through the abdominals and engaging TA correctly before all moving and lifting activities and I encourage various nutritional supplements for pregnancy.
As pilates teachers we have a golden opportunity with our pregnant clients (and ourselves if it is relevant) to empower the way they move, giving them the necessary feedback to learn to engage correctly thought pelvic floor and TA, so that they carry the baby close to their center, thus reducing the forward load on their spine and reducing back pain. Teaching them to ‘zip up’ and encouraging them (with education and feedback) to not overload abdominals while pregnant or in the early post natal stages (i.e. until repair is obvious) also allows them to learn to move without bearing down on the pelvic floor. By encouraging a healthy strength and awareness in both pelvic floor and TA, correcting alignment and teaching diaphragmatic breathing allows a healthy strong pregnancy with better core support, potential reductions in back pain and hopefully avoiding ongoing incontinence issues and other problems.
Here’s a lovely way to have your pregnant clients learn to engage. Ask your pregnant client to lift her baby up with her pelvic floor and use her abdominals to hug her baby, literally moving her pregnant belly up and down with no hands. Its quite the trick and provides wonderful visual feedback that she is working in the right direction. I also believe that the feedback the baby gets with those belly hugs is highly beneficial.
Supporting these muscles not only supports her growing belly, but also has them ready to kick into gear to birth her baby! If she has performed these movements during pregnancy it becomes easier to guide her back to them once postnatal. ‘Imagine bub is still in there, lift and hug’.
If the TA and pelvic floor are well cared for during the pre-natal phase and a woman has developed good awareness, it becomes so much easier to help her recover quickly from the birth (regardless of natural or C-section delivery) and flatten her tummy while restoring strength and function. If a woman finds that her tummy is still a ‘pouch’ and months later people are asking when her baby is due, it is emotionally tough. It is also indicative that she has not restored function (or perhaps didn’t develop good function prior to bub or during pregnancy) thereby becoming further weakened during pregnancy and birth. This pouch is not to be accepted as normal. I’m not talking about overweight here, I’m talking about a lack of tone and function to the deeper muscles, which therefore are not working as they should to pull the rectis abdominus in towards the spine, thereby flattening the belly and providing support. Instead the pressure is outward and often a bearing down further stressing the pelvic floor. It can be accompanied by stress incontinence, back pain, sexual dysfunction and the stress of ‘not returning to their normal belly size’. No woman should have to accept that as ok when there are clearly things that make a significant difference.
This is why our work is so important. It’s a game changer.
When my post-natal mums come back in they all start the same way. Slowly, specifically and mindfully.
We lay them down, do the checks, commencing simply (and oh so importantly) with alignment and breathing.
Learning or remembering how to breathe so that the exhale collects those abdominals and contracts them to the center. Trying to lift and engage pelvic floor until finally it answers us. We need to give them feedback (hands on and verbal), but in order to do this effectively you need to be able to see and feel when things are working, or not working. That’s your goal, if you don’t already know how to spot it, find a mentor to have hands on demonstrations.
It is so important to let your women know (some may need encouraging) that this process is not to be rushed. This is an important time to honour what your body has been through and repair properly by reactivating all the deep muscles that switch off with birth. Like any injury, we need to rehabilitate the area properly to avoid potential future problems, like stress incontinence, which may be normal in the first weeks post natal, but months and years later is problematic and awful.
We need to reconnect the mind to the body, slowly wake up pelvic floor and TA.
Alignment, Breath, Engage then move.
We remain in neutral spine until we are sure the connections are holding and then slowly add more challenge. If we are repairing a DR of two or more fingers width, the application is the same, teach them to activate TA to draw the RA together, but importantly DO NOT load them with flexion until you are sure they can perform the movement without separation.
Inspire and motivate them to understand that if they start properly, with your feedback, they’ll quickly return to full strength and function, or like many of my clients, a better body (form and function) than they had pre-bub!
We must not underestimate the importance of alignment and breathing. Placement of the rib cage and shoulder girdle must be correct or they will fail to properly engage and sustain contraction in pelvic floor and TA. Remember that the core must include both the pelvis and the shoulder girdle.
A new mum will be locked up through the upper back and shoulders, since the repetitive feeding and baby holding wreaks havoc. The posterior muscles weaken due to the feeding posture and the pectoral muscles tighten. So addressing these issues along the way for them will be equally important.
After the alignment and breathing is underway nicely, we will add challenge to the abdominals with leg lifts. Look at supine work and prone work (where the floor provides lovely feedback as to the position of the abdominals), side lying and quadruped work. All the while, cueing the same things. Alignment, breath and moving without losing the connection. Think about utilising small apparatus, like using a fit ball under their feet and establishing hip function without them having to carry the weight of their legs until you can see that they can hold both legs up without doming.
Some will resume this position almost immediately (especially if you worked with them pre pregnancy and during pregnancy) but nothing is a given. Use your observations to make the appropriate modifications. Worst case scenario they keep breathing and working on getting those abdominals to fire in a neutral unloaded position (front, back, sides, quadruped, sitting and standing). If this is all they can manage, then trust me it will feel like work! When everything switches off after the birth, it literally feels like a black hole down there, you don’t even know what you can’t feel. Give them time, they will have to concentrate specifically, talking to the area until it finally says hello again.
Remember a C-section client may take quite a while to have feeling come back around the incision. Give them feedback and encourage them to massage the area to encourage circulation for healing.
Don’t forget to give all your postnatal mums a little ‘dessert’ with assisted stretches to help them relax and completely release tension. It will be challenging for many of them just concentrating on getting things activated again. In addition, they can feel quite vulnerable at times with the hormones racing and sleep deprivation on top, so it’s just lovely to give them some extra hands on attention.
The roll back becomes the next thing I add to the repertoire. It’s less loaded than a chest lift as you work with gravity not against it. They can see their own abdominals to make sure they are not doming. They can even do this with baby in arms holding close to their body while strength is building then as they get stronger challenge by holding baby further away. Always checking those abs!
Regardless of how you decide to program, it’s all about HOW they perform the movements and it is our job to provide that feedback and not allow them to progress until we can see that they can do it while maintaining the connection.
If you venture beyond what the abs are ready for, you will increase abdominal separation and the RA will shorten and buckle in the wrong position and cause greater issues.
In regards to a DR (and to avoid it) be sure and have the discussion with women about how they move at home, especially when moving from lying down to sitting up and also engaging properly (pulling abs in, not pushing them out or bearing down) and especially while picking up other children. This day to day awareness and practice is important so as not to undo all the good work done in the studio and will fast track their results.
I have had women attend the studio as new clients, where it is six and even twelve years since their youngest child and they still have abdominal dysfunction due to unresolved abdominal separation. So while it may seem absurd to them, you need to treat them as if 6-8 weeks post partum and try to retrain the compensatory patterns that will have kicked in, but trust me it is worth the effort.
My approach in summary:
Assessment, alignment, diaphragmatic breathing – engaging pelvic floor and transverse abdominals – with ribs drawing down towards hips without moving the pelvis out of neutral. Then add to the challenge with leg movements. Perform these in supine, prone, side lying, quadruped, sitting and then standing work, in that order, is what I find best. Whatever doesn’t overload their abdominals. Once you start progressing to support work (planks, elephant etc.) be sure and apply a hand to make sure they are maintaining their connections. If not, peel it back, or perhaps they just need more direction to get the zip up!
Remember endurance in any of the work will come later. Monitor and provide feedback. It’s all based on the body in front of you.
In the case of preventing or healing a DR the principals of Pilates are priceless.
The cure is the prevention.
Remember it’s all about returning someone to life and what a gift that is to a new mumma!
Melissa Barry
ND Adv Dip Pilates
*Disclaimer: I use the term ‘cure’ loosely here of course, no exercise program can or should claim to ‘cure’ or ‘fix’ every situation. In some cases women require surgery to correct function and stability when the linea alba is severely compromised, stretched and weakened. Pilates still has value for these women pre and post surgery. I have worked with women post-surgical correction. In these cases I wasn’t privy to working with them pre-surgery, so can’t say whether our system could have made improvements in these cases. I suggest that it certainly won’t harm and would have been beneficial if approached with adequate supervision and feedback and would serve to further support their overall wellness and healing of the lumbopelvic region.
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