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Abdominal separation. Those two words can bring up a lot of fear and confusion for new mothers. Whilst it is a normal part of pregnancy and is the body’s way of creating space for your baby to grow and develop, abdominal separation or rectus diastasis has become a source of a lot of conflicting (and simply incorrect) information. If you are feeling overwhelmed and unsure of how to properly heal your abdominal wall after birth, co-founders of the Empowered Motherhood Program (link: https://www.empoweredmother.com.au/) Lyz Evans and Kimberley Smith are here to guide you through the process step-by-step.
In the above video, Titled Pelvic Health Physiotherapist Lyz Evans shares the four simple steps that you can take to heal abdominal separation after birth - all backed by the latest research and clinical developments.
Before you begin your healing journey, it is essential to understand what abdominal separation is and the physiological changes that have contributed to your rectus diastasis. Understanding the physiological changes that have occurred will enable you to appreciate the healing process and focus on your recovery with confidence.
Were you surprised to see that your tummy still looked 6 months pregnant after birth? We know it is a shock for most women.
One of the factors that causes this distension of the abdominal wall is the fact that the uterus remains in an expanded state for up to 6-8 weeks after birth. Pre-pregnancy, your uterus typically weighs around 70 grams and is the size of a fist. During the nine months of pregnancy, the uterus expands up to 14 times its normal size and can weigh up to 1 kilogram and be around the size of a watermelon! Involution is the process in which the uterus retracts back to its normal size, taking 6-8 weeks. This heavier and larger uterus can cause the abdominal wall to distend, particularly when this extra weight rests on weakened muscles and connective tissue.
A second factor is that during pregnancy, the collagen fibres that make up the linea alba change from a Type 1 to a Type 3. So what does this actually mean? The linea alba is a super strong band of connective tissue that runs down the midline of your abdomen from your breastbone to your pubic bone. One of the roles of the linea alba is to provide an anchor point for your abdominal wall muscles.
Normally the linea alba is strong, thick and fairly rigid. So pre-pregnancy, your six pack muscles, or rectus abdominis sit close together (note that they are still separated by the linea alba so there is always some degree of separation of the abdominal muscles).
Due to the increase in oestrogen in pregnancy, there is a change of the collagen fibres from thick and rigid (Type 1) to thin and stretchy (Type 3). As your pregnancy progresses and the uterus expands, the linea alba grows thinner and wider and the inter-recti distance between the two sides of your rectus abdominis increases.
The thinning and weakening of the abdominal wall combined with the changes to the linea alba and an expanding uterus all contribute to the degree and depth of abdominal separation you will experience.
Now with all these changes it’s no wonder women are left confused as to what they should be doing to heal their abdomen wall in the postnatal period. The great news is there is a lot you can do. And we are going to break it down for you below with our ABCD’s of abdominal wall rehab.
We mentioned above that the abdominal wall thins and weakens and the collagen fibres change from thick and rigid to thin and stretchy. Your early postnatal recovery is optimised when you can work with your body’s natural healing process to enhance collagen synthesis and re-modelling and muscle growth.
Collagen synthesis refers to the process of producing new collagen in the body. This is important for maintaining the health and integrity of tissues that contain collagen.
Collagen remodelling refers to the process of breaking down old collagen and replacing it with new collagen. This is a natural process that occurs in the body over time, and it helps to keep tissues strong and healthy.
Muscle growth, on the other hand, refers to the process of increasing the size and strength of muscle tissue. This is typically achieved through resistance training or other forms of exercise that place stress on the muscles. When muscles are stressed, they experience small tears or damage, which then triggers the body to repair and rebuild the muscle tissue, resulting in increased strength and size over time.
In short, you have to ‘use it or lose it’. The ability of your body to synthesis collage and lay down new muscle is an essential part of abdominal wall recovery and is dependent on the abdominal wall being mechanically loaded.
Studies show that 4-8 weeks of non-loading (not using a muscle group) can result in a 20-30% loss of muscle mass. During the early postnatal period, the abdominal muscles can become sluggish and require gentle activations to help rebuild its strength.
One effective exercise shown in the video above is core activation in four-point kneel. Once you become comfortable with this exercise, it's important to incorporate it into your everyday life to ensure that you're engaging your abdominal muscles in your daily movements.
In the first 8 – 10 weeks postpartum whilst the remodeling process is underway the abdomen is still incredibly weak and distended. Whilst the collagen fibres are changing from Type 3 to Type 1, and excess hormones are still present in your body, it is important that we provide some rigid support to the abdominal wall to help reduce distension and also provide a form of sensory feedback for the abdominal wall.
This is where abdominal support garments such as SRC recovery tights become so important to your postnatal recovery and the research backs this up.
There a number of research papers that show that core exercises combined with wearing abdominal wall support garments from an average of 8 hours per day results in:
compared to just doing core exercises alone.*
Interestingly, an SRC lab study that showed that when wearing the tights that under ultrasound myography that the inter-recti gap decreased and the rectus abdominis muscle thickness and tone increased!
From around 6 weeks postpartum, you need to start to load the abdominal wall. One of the key ways the abdomen is designed to move is to flex the trunk in a curl up action!
For a long time, there was a lot of confusion about whether crunching was safe or not. However if we want to load the connective tissue and rebuild the muscle bulk doing curl ups or crunches in the right way can help rather than hinder.
Our daily life require us to flex the trunk such as when getting up out of bed to getting out of a chair, this curl up movement pattern is repeated hundreds of times a day. In the EMP, it is really important to us that you not only heal your body safely, but that you also prepare your body for all the movements you need for daily life.
The research also backs this up. When we compare a group of women who do foundational core exercises combined with crunching, against another group that do foundational core exercises combined with planking - the group that has far greater improvements in inter-recti distance is the in fact the group that do crunches as apart fo the program.**
This is one mistake we see so often. Women fail to progress beyond early postnatal exercises and so they feel stuck feeling perpetually postnatal.
The abdominal wall needs to flex, stabilise, rotate and extend – and if we never get off the ground or challenge the muscles then it will never regain its full strength. Progressive overload is the primary principle of muscle growth, so its important that we continue to challenge the muscle with respect to movement patterns, endurance and power if we want it to continue to grow.
All of your body’s natural healing is finished by 8 – 10 weeks after birth, so any additional improvements are going to take a bit of work. Ensuring you are continuing to safely progress and challenge your abdominal wall will ensure you continue to heal and return to your pre-pregnancy strength (or beyond!).
References
Antonio ( 2017) SRC Recovery shorts, research Laboratory analysis of the functional effect: Single case study. Cuesta- Vargus, Catedra de Fisiotherapia, Universidad de Malaga, Andalucia, Spain.
Depledge J, McNair P, Ellis R. ( 2021 )Exercises, Tubigrip and taping: can they reduce rectus abdominus diastsis measured at three weeks post partum? Musculoskeletal Sci Prac; 53:102
Keshwani et al 2019. The impact of execrsie therapy and abdominal binding in the management of diastasis recti abdominus in the early post partum period: a pilot randomized controlled trial. Physiotherapy Thoery and Practice 25:1-6
Lee ( 2017) Diastasis Rectus Abdominus: A clinical guide for those who are split down the middle. Learn Publishing. Surrey BC Canada.
Saleem, Khann, Farooqui, Yasmeen, Rizvi ( 2021) Effect of exercise on IR distance and associated Low Back Pain among Post- partum Females: A randomized Control Trial. J Family Reprod Health Sep: 15 ( 3) 202 – 209
Szkwara, M., Egwuagu, C., Topping, M., & Schutt-Aine, J. (2020). A prospective quasi-experimental controlled study evaluating the use of dynamic elastomeric fabric orthoses to manage common postpartum ailments during postnatal care. Journal of Women's Health Physical Therapy, 44(1), 24-34.
Walton, Costa, Lavanture, McLarth and Stebbins 2016 The effects of a 6 week dynamic core ability plank exercise program compared to a traditional supine core stability strengthening program on diastasis recti abdomen in closure, pain, Owestry disability index ( ODI) and pelvic floor disability index scores. Physical Therapy and rehabilitation Vol 3: 3.
Lyz Evans and Kimberley Smith are the co-founders of the the Empowered Motherhood Program (link: https://www.empoweredmother.com.au/), the award-winning online program and mobile app that combines physio-led exercise with expert education for every stage of pregnancy, birth and postpartum. Lyz is a Titled Pelvic Health Physiotherapist and mum to 3 and Kimberley is a pregnancy and postnatal exercise specialist and mum to 3.
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