Diastasis Recti Abdominus (DRA or diastasis) is common during pregnancy and in the postnatal period. Many trainers have heard of diastasis, but don’t understand its complications or how to effectively train women who have it. If you are training pregnant women in the pre or postnatal period you should be aware of the contraindications that can occur when DRA is present, and the implications this will have on your exercise and load selection.
DIASTASIS RECTI ABDOMINUS (AB SEPERATION DURING PREGNANCY)
DRA occurs when the two sections of the rectus abdominis (abs) separate at the linea alba or midline, causing a gap of 2 finger-breadths or more. Boissonnault and Blaschak noted that 66% of women in their third trimester of pregnancy have DRA - so this affects a significant portion of the population. Bursch noted that all women had some degree of diastasis in the post-partum period, with at least 85% having a gap of more than 2 finger-breadths, which is considered the standard for diagnosis.
Diastasis is a normal response to pregnancy, most commonly occurring at some point during the second trimester. The gap between the rectus abdominis muscles gets larger as the baby continues to grow and more pressure is put on the abdominal wall. Diastasis is a result of the hormones relaxin, progesterone, and estrogen softening the connective tissue of the linea alba, combined with the extra load on the abdominal muscles from the growing baby; this weakens the abdominals and they in turn separate. As pregnancy progresses, the abdominal muscles become stretched and lengthened as the uterus stretches to make room for the baby. Gilleard and Brown noted a 115% increase in the length of the rectus abdominis during pregnancy; the angle of the muscle inserted was also changed, which reduces the muscles’ ability to stay taught and results in a loss of strength.
DRA is typically measured up to 4.5cm above and below the belly button. When the gap between the two abdominal sections is more then 2 finger-breadths apart the woman is considered to have a mild diastasis; 2-3 finger-breadths is moderate, and if the gap is more than 4 finger-breadths apart the diastasis is considered severe. Clients who have moderate or severe diastasis should be referred to a women’s health physio for clearance before beginning training. If you do not have pre/post-natal certifications, you should refer your client to a women’s health physio or qualified PT to diagnose whether DRA is present in your client before training them.
Diastasis alters a client’s posture and abdominal stability. It may also cause lower back pain and pelvic floor dysfunction, all of which can potentially lead to injury. These changes affect the way you should be training pregnant and postnatal women.
Pregnant women should avoid abdominal strain, to reduce the risk of bringing on DRA or making an existing diastasis gap larger. Abdominal strain can be caused by:
- Heavy loading
- Being in a plank position (such as push-ups, planks, renegade rows)
- Any exercise that requires a strong core contraction, such as sit-ups
- Using the Valsalva manoeuvre (holding your breath whilst lifting)
Take note when training your pregnant clients and be on the lookout for ‘doming’, where a bulge appears at the linea alba during exertion. If your client is experiencing doming whilst training or otherwise, it would be best to refer her to a women’s health physio who will perform an assessment and prescribe strengthening work (and potentially some added support, such as a pelvic belt or tubi grip). You should avoid using the Valsalva manoeuvre as this increases intraabdominal pressure. Instead, when your client is training, ask them to inhale on the eccentric portion of the lift and exhale on the concentric/ exertion. Modified planks (with hands raised), side planks and palof presses are all safe exercises to use until the third trimester, as long as your client does not need to hold her breath to complete the exercise and isn’t feeling added pressure on her pelvic floor.
During the post-natal period, some women’s diastasis will naturally return to a separation of less than two finger breadths apart, being considered non-DRA. But after 12 months, 32% of women still have at least a mild form of diastasis. The linea alba provides strength, support, and stability to the abdominal muscles and internal organs - so when it is separated clients may feel weak and not be able to lift as much as before, and/or have back pain and pelvic floor issues. It is important to remind our clients that for most women, it takes about a year for the body to recover from birth and for pelvic floor and abdominal health to return to normal. Some women with severe DRA (4 finger-breadths or more) will opt for a surgical fix called an abdominoplasty, but your client should make this decision in conjunction with her physio and specialists. For postnatal clients with DRA, we take a similar approach to exercise as with pregnant women; avoid heavy loading, abdominal strain such as push-ups, burpees and planks, and anything that causes doming, discomfort, or pelvic floor leakage or heaviness.
- Start with core/pelvic floor connection exercises, until your client can do these without leakage or pain.
- Progress onto light weight resistance movements with pelvic floor/core engagement, such as lat pulldowns, glute bridges, or bicep curls. Advise your client to avoid holding her breath and instead exhale on exertion.
- Once your client can comfortably achieve these exercises with pelvic floor and core connection integrated, she can move onto more complex movements such as squats, lunges, push-ups and planks.
- Add load slowly over time if there are no abdominal or pelvic floor issues.
- Always refer out when necessary.
With most pregnant and postnatal women developing diastasis recti at some point of their pregnancy journey, it is important to understand how load and exercise selection can make things worse. Once the baby is born, the DRA may not just disappear on its own - so it is crucial to either assess the client (if you have the skills to do so), or refer out to a women’s health physio who can advise you on what you should avoid with each client. Avoiding abdominal strain is just as important during the postnatal period as it is during pregnancy; however, women try to get rid of their ‘mum tums’ with excessive amounts of burpees, sit-ups and planks... which only make the issue worse and lead to injury. We can step in as fitness professionals by educating clients on the changes that have occurred and reminding them that they need to heal before returning to heavy loads and complex movements.
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Written by tutor - Libby Searle