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Prevention and Treatment of Pregnancy-Induced Diastasis Recti


A woman’s abdomen expands significantly over the course of the 40 weeks of pregnancy—it stretches and widens to make space for a growing baby, the placenta, and the fluids that will nourish and carry the baby to term. 

In the last trimester alone, babies will grow from about two pounds to between six and nine pounds by the time they are ready to be born! 

Logically, as the body transforms to nourish and protect a growing baby, big changes will take place. While most women’s bodies will change a great deal after pregnancy, some women may experience changes that can affect their muscular health. Diastasis recti is a common condition that can occur in full-term pregnancies that can destabilize the core and may lead to other health problems. 

This article answers important questions about diastasis recti, and it provides information to coaches about the prevention and management of diastasis recti.

 

What Is Diastasis Recti?

Diastasis recti abdominis, often called diastasis recti, rectus diastasis, or DRA, is a separation of the rectus abdominis, the two abdominal muscles that run down each side of the abdomen next to the belly button. Clinically, diastasis recti is traditionally defined by a separation between the rectus abdominis muscles. Traditionally, the “two-finger method” was used to determine whether diastasis recti was present, but it is possible to have diastasis recti with a smaller muscle separation. 

It is usually observed during or shortly after giving birth, but it can also develop due to non-pregnancy factors as we age. 

It is diagnosed by physical examination where physicians identify a midline abdominal bulge while sitting or standing. The bulge may indicate a hernia, which presents a health risk, or it may indicate a divarication, which is a bulge that results from the physical separation of the muscles and shifting of tissue. 

For a more exact diagnosis, the physician may use a caliper to measure the separation. If a patient is considering surgical measures to correct the diastasis recti, physicians may also request an ultrasound, MRI, or CT. 

Contrary to popular belief, diastasis recti doesn’t always result in protrusion. According to research, abdominal wall protrusion and muscle stretching can occur without diastasis recti, and there are people who have diastasis recti but have minimal protrusion. 

Diastasis recti is not generally routinely screened for in the doctor’s office. Women will often approach their physicians with concerns about their abdominal appearance after pregnancy or due to discomfort related to the loss of abdominal muscle function. 

How Common Is Diastasis Recti?

Conditions like diastasis recti are generally referred to as a pathology or a health problem. However, it is a very common condition in pregnancy. In fact, some researchers estimate it occurs in two of every three women, while others report that all women have some degree of diastasis recti in their last trimester of pregnancy. 

Classifications of Diastasis Recti 

The degree of abdominal muscle separation, the location of the separation, and the degree of bulging (fascial defects) lead to different classifications of diastasis recti. Classifications may be beneficial for identifying treatment and management options and for explaining discomfort and related symptoms. 

Below are the classifications of diastasis recti proposed by the German Hernia Society and the International Endohernia Society based on width, length, and location of the diastasis recti and clinical observation of bulging. 

Width of Diastasis Recti

The width of diastasis recti can be measured by caliper, MRI, CT, or ultrasound. 

  • <3 cm separation: mild diastasis 
  • 3-5 cm separation: moderate diastasis
  • >5 cm separation: severe diastasis

Location and Length of Diastasis Recti

From the beginning of the rectus abdominis (the top of the solar plexus) to the top of the pubic bone, there are five anatomical sectors along the abdominal midline that are useful for classification. The sectors, from top to bottom, are named:

  • Subxiphoidal (from the top of the solar plexus area to above the stomach)
  • Epigastric (from above the stomach to 3 cm above the belly button)
  • Umbilical (the 3 cm above and below the belly button)
  • Intraumbilical (from 3 cm below the belly button to 3 cm above the pubic bone)
  • Suprapubic (from 3 cm above the pubic bone to the pubic bone)

Physicians will normally also make note of bulged skin folds.

What Are the Health and Wellness Effects of Diastasis Recti? 

Some of the negative effects on health and wellness that are caused by diastasis recti include, but are not limited to: 

  • Discomfort in the abdomen 
  • Pelvic instability
  • Pelvic organ prolapse 
  • Bloating
  • Incontinence
  • Constipation
  • Diarrhea
  • Hemorrhoids
  • Pain during intercourse
  • Instability
  • Lumbar back pain
  • Negative body image
  • Lower quality of life
  • Body dysmorphic disorder (BMD), when a preoccupation with perceived defects or flaws leads to repetitive behaviors like mirror checking, excessive grooming, running hands over the abdomen, or reassurance-seeking, or mental acts like comparing their appearance with that of others. BMD can cause significant distress or impairments in functioning. 

Diastasis Recti Prevention Strategies

The risk factors that increase the chance of developing diastasis recti during pregnancy include pregnancies with multiples, diabetes, and overweight. If appropriate, general healthy lifestyle strategies, like a balanced diet and regular health screening, may help lower the risk of diastasis recti. 

Exercise including isometric contractions of the transverse abdominis (tummy tucks) during pregnancy combined with resistance training and cardiovascular exercise with certified prenatal trainers may help to prevent the development of diastasis recti. 

It is important to note, however, that diastasis recti is not preventable in all women. The multiple factors involved in diastasis recti, from genetics to the growth dynamics of the fetus, may all have a greater influence on the condition developing than other prevention factors. 

Top 3 Diastasis Recti Treatment Strategies

There are three main lines of treatment for women who wish to correct their diastasis recti for functional or cosmetic reasons. Success rates are variable and poorly documented, and complications can develop for more invasive surgical options. Additionally, relapse is always a possibility, especially if the woman with diastasis recti becomes pregnant following treatment.

Below is a breakdown of the different lines of treatment for women with diastasis recti after pregnancy. 

Physiotherapy

The first line of corrective treatment for women with diastasis recti is physiotherapy. 

It is important to note, however, that there isn’t a consensus on which regimen to use and there is limited evidence on success rates of physiotherapy for diastasis recti correction. Physiotherapy programs may vary significantly depending on the symptoms of diastasis recti and the goals of treatment. 

Some common physiotherapy lines of treatment include: 

  • Rectus abdominis “re-education” programs including exercises
  • Antenatal and postnatal elastic bandages
  • Intensive physiotherapy focused on pelvic floor muscles
  • Neuromuscular electrostimulation of the rectus abdominis muscles 

Exercise

There is conflicting literature on the accepted exercises for diastasis recti treatment. Some studies report that women with diastasis recti should avoid abdominal exercises since the intense contraction of the abdominal muscles may increase muscle separation rather than reduce it. 

Other researchers have examined the effectiveness of abdominal exercises with success in increasing strength but not for reducing pain and discomfort. 

Many accepted diastasis recti exercise regimens focus on exercises that strengthen the core, such as dynamic core stability plank exercises or supine core stability strengthening programs to strengthen all core muscles at once, rather than just the rectus abdominis. This patient information guide published by Oxford University Hospitals summarizes some of the recommended exercises for people with diastasis recti. 

Some research shows that postpartum exercise doesn’t correct diastasis recti, but it can help to improve abdominal function through muscle strengthening. Other research, however, shows that engaging in specialized exercise programs can reverse diastasis recti. 

If you are not trained in prenatal and postnatal fitness, it is important to refer clients to specialists before making recommendations. 

Corrective Surgery

For some women who experience significant pain or loss of function due to their diastasis recti and haven’t seen significant improvement after physiotherapy and exercise regimens, surgery may be an option. Surgical options include: 

  • Plication, which is a folding, tucking, and suturing of the excess weakened muscles. This is most effective for mild to moderate diastasis.
  • Insertion of resorbable or non-resorbable mesh pieces over the separation. This may be effective for moderate to severe diastasis. 
  • The use of laparoscopic or endoscopic techniques assisted by robots, which leave minimal scarring. However, these techniques are still in the testing phase and are not widely used. 

Note that women who have experienced abdominal wall weakness but do not have the muscle separation that is indicative of diastasis recti may also be candidates for corrective surgery. 

4 Things Health Fitness Coaches Should Know About Diastasis Recti Prevention and Management Strategies 

Everyone Experiences and Sees Their Diastasis Recti Differently

One of the reasons diastasis recti has been so difficult to classify is that women’s bodies are so unique. Not only can proportions vary significantly, so can their anatomy. Additionally, the way a body holds pregnancy and the growth factors that are specific to the fetus all affect how a woman’s body stretches and changes. 

The experiences of diastasis recti can be as diverse as women’s bodies. Some women may not even notice they have diastasis recti or not feel any symptoms besides changes in how their abdomens look. 

Other women may experience debilitating symptoms caused by diastasis recti, including a loss of strength and movement. In some cases, these symptoms may even prevent them from doing their job, caring for their families, or performing physical activities as they’d like.

Some women may also experience body dysmorphic disorder following pregnancy, which can have a significant effect on how they view their bodies. The physical changes that diastasis recti can cause, regardless of the level of functional changes, can be traumatic for some women. They may no longer recognize themselves in the mirror. The relationship women have with their bodies is an equally important part of wellness as physical health. 

If your client knows they have diastasis recti and they want to speak about it with you, lend an ear. Be open to understanding how they feel.

Your Client with Diastasis Recti May Have Been Gaslighted by Their Physician

Unfortunately, many physicians consider diastasis recti to be primarily a cosmetic problem. Women with diastasis recti may have approached their physicians due to loss of function or pain related to the condition but are dismissed by physicians who understand diastasis recti to be a problem of “unsightliness” over loss of function. 

Your client may feel devalued when they try to explain how the diastasis recti has affected their strength, movement, or stability. 

If appropriate, offer support to your client, and let them know you believe them. 

Most Insurance Doesn’t Cover Diastasis Recti Corrective Surgery

After having undergone physical therapy and completed fitness programs, diastasis recti may not be fully corrected. In these instances, women may want to consider corrective surgery. However, most insurance companies will not cover corrective surgeries due to diastasis recti because it may be classified as cosmetic surgery. 

For women who have experienced a loss of function and pain, the classification may be devastating, knowing they have limited options for treatment. 

In this case, you may choose to work with your client’s healthcare team to identify the best course of action for symptoms management. 

Women with Diastasis Recti May Benefit from Mental Health Programs

Unrealistic body standards and a potentially overwhelming pressure for women to recuperate their pre-pregnancy bodies can take a toll on their mental health. Additionally, women who have diastasis recti may develop body dysmorphic disorder, a psychiatric condition that can be treated. 

If the effects of diastasis recti on your client’s wellbeing are emotional and psychological, you can be an important support for them. If you don’t feel equipped to speak with your client about this, or if your client requires specialized mental health support, consider supporting your client in finding a mental health specialist. 

Main Takeaways

Diastasis recti is a common condition that develops during pregnancy where the expansion of the abdominal area causes the abdominal muscles to separate in the middle. The classification and severity of the separation varies as do the symptoms of diastasis recti. Some women may not even notice the separation, while others may have debilitating symptoms such as incontinence, lower back pain, and body dysmorphic disorder. 

There are some methods for helping to prevent diastasis recti, including minimizing risk factors and engaging core muscles before and during pregnancy. However, it is unclear if and how diastasis recti is fully preventable. Treatment for diastasis recti includes physiotherapy and exercise as a first measure and potentially diastasis recti corrective surgeries. 

Fitness and health coaches can support clients by acknowledging the many ways that diastasis recti may affect their wellness, by offering to help them understand the condition, and by helping them navigate the health system and identify resources that may help them manage symptoms and seek specialized treatment. 

 

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References

  1. https://www.tandfonline.com/doi/abs/10.1080/09593985.2020.1849476
  2. https://pubmed.ncbi.nlm.nih.gov/30046291/
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  4. https://pubmed.ncbi.nlm.nih.gov/2968609/
  5. https://journals.lww.com/jwhpt/Fulltext/2005/29010/The_Effects_of_an_Exercise_Program_on_Diastasis.3.aspx?bid=AMCampaignWKHJ 
  6. https://doi.org/10.3389/fsurg.2019.00001 
  7. http://dx.doi.org/10.5281/zenodo.3228938 
  8. https://doi.org/10.3389/fsurg.2019.00065
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  10. https://journals.lww.com/greenjournal/Abstract/2014/05001/Postnatal_Exercise_Can_Reverse_Diastasis_Recti.352.aspx 
  11. https://www.tandfonline.com/doi/abs/10.1080/09593985.2020.1849476 
  12. https://europepmc.org/article/med/26204339
  13. https://doi.org/10.3389/fsurg.2019.00065 
  14.  https://doi.org/10.1016/j.surg.2016.05.035 
  15. https://www.ouh.nhs.uk/patient-guide/leaflets/files/11749Precti.pdf 
  16. https://doi.org/10.1007/978-3-319-27470-6_31





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