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Introduction

In my recent postpartum experience as an orthopedic physical therapist, I have come across many triumphs and trials in recovering from childbirth. I thought it would be helpful to discuss the anatomical changes that happen during/after pregnancy and provide some tips that may be helpful for any other women currently in their fourth trimester. One of the most prevalent conditions that many pregnant women encounter (including myself) is diastasis recti abdominis.

What is Diastasis Recti Abdominis?

Diastasis recti adbdominis (DRA) is the thinning and widening of the connective tissue called the linea alba that lies in between the two muscle bellies of the rectus abdominis. The reason this increased distance of the linea alba is so common during pregnancy is that it physically has to occur to allow for expansion of the belly as the baby grows in the second and third trimesters of pregnancy.

For most women, once the baby is delivered the linea alba can heal and retract back together within 8 weeks due to its high elasticity. This can be facilitated strengthening exercises (see below). However, some cases of DRA can be pathological, meaning that DRA may not be a problem needing treatment unless you are experiencing related pain, bulging in the abdomen, incontinence, bleeding, or functional limitations due to the abdominal separation.

These symptoms may be indicative of umbilical hernia or severe separation. Seek out advice from your doctor or pelvic floor PT who specialize in treating postpartum recovery if think you may be experiencing DRA that is pathological.

How do I know if I have Diastasis Recti Abdominis?

The gold standard for diagnosing DRA is ultrasound, however there is a self test that can be used at home and in the clinic. To perform this test, simply lie on your back with your knees bent and feet flat on the ground. Then lift your shoulders slightly off the ground as if doing a crunch.

While in this position, put your fingers just above your belly button and feel for a gap between the abdominal muscles. If you feel a gap of two or more finger widths, discuss these findings with your doctor or pelvic floor PT.

The classification of DRA is as follows: 5 cm separation is severe DRA. In my case, I used this test at 6 weeks postpartum and found I had a 1 finger width gap just above my belly button. Once my doctor cleared me for exercise after my 6-week postpartum check up, I slowly began to integrate specific core exercises into my daily routine to help decrease my linea alba distance and safely regain strength in my core.

How do I treat Diastasis Recti Abdominis?

Outlined below are several basic core exercises that may be done in the fourth trimester in order to strengthen the abdominals in a way that does not increase the linea alba distance. These exercises are specifically designed to engage the entire abdominal complex to facilitate control with regulating intra-abdominal pressure and breathing. Many women wonder – is it okay to do crunches postpartum or during pregnancy? A common misconception is that you cannot perform crunches or forward flexion of the trunk in order to avoid increasing DRA.

However, recent research has shown it actually is important to load the rectus abdominis to strengthen it and therefore decrease the distance of the linea alba. The key is that you must avoid any coning or doming of the abdomen when doing forward flexion or crunches. The way to help control this is by engaging the deep core muscles, or the transverse abdominis, with appropriate breathwork (TA) and then introducing rectus abdominis strengthening.

If you are having trouble with this concept, reach out to PT to ensure correct TA activation, breathing techniques, rectus abdominis activation, and appropriate exercise progressions. Discontinue any of these exercises if you experience pain, leakage, coning/doming, bleeding, or pelvic heaviness.

Exercise 1: TA Isometric Contractions

1. Begin lying on your back with your legs bent and feet resting on the ground.

2. Place your fingers just inside the bones on the front of your pelvis.

3. Exhale through pursed lips, and gently pull the muscles under your fingers in (this is the transverse abdominus).

4. Hold for 10 seconds.

5. Relax and repeat for 10 repetitions.

Note: Make sure to draw in rather than push out your muscles. Watch for any coning/doming. This should be a subtle movement.

Exercise 2: TA Fallouts

1. Begin lying on your back with your knees bent and feet resting on the floor.

2. Engage your abdominals as outlined in the previous exercise and slowly lower one knee towards the ground.

3. Return to the starting position and repeat with the other leg.

Note: Make sure to exhale with the movement through pursed lips and do not allow your hips or trunk to rotate during the exercise.

Exercise 3: TA Marches

1. Begin lying on your back with your knees bent.

2. Engage your abdominals as outlined in Exercise 1.

3. Slowly alternate marching one leg off the ground at a time to a 90-degree angle.

4. Do not allow your back to arch as you lift your legs.

5. Watch for any coning/doming.

Note: You may progress this exercise by starting with both legs off the ground at a 90-degree angle, then slowly lower one leg at a time touching your toes to the floor.

Exercise 4: Mini crunch with towel

1. Begin lying on your back on top of a long sheet or towel with your knees bent, feet resting flat on the floor.

2. Pull the sheet across your abdomen, crossing the sheet over the middle of your belly.

3. As you exhale gently draw in your TA as described in Exercise 1 and slowly lift your head and upper back off the floor as you also pull gently on the towel to tighten around your abdomen.

4. You are now engaging the rectus abdominus and using the towel to reinforce the closure of the two rectus muscle bellies.

5. Hold as you inhale, then exhale as you slowly roll back down to the starting position and repeat for 2 sets of 10 repetitions.

Note: Watch for any coning/doming and do not hold your breath during the exercise.

Resources

1. Gluppe, S. B., Ellström Engh, M., & Bø, K. (2023). Curl-up exercises improve abdominal muscle strength without worsening inter-recti distance in women with diastasis recti abdominis postpartum: A randomised controlled trial. Journal of Physiotherapy, 69(3), 160–167. https://doi.org/10.1016/j.jphys.2023.05.017 

2. Hall, H. (2023, August 8). Diastasis Recti Rehabilitation. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK573063

3. Laframboise, F. C., Schlaff, R. A., & Baruth, M. (2021). Postpartum Exercise Intervention Targeting Diastasis Recti Abdominis. International journal of exercise science, 14(3), 400–409.

4. Theodorsen, N.-M., Bø, K., Fersum, K. V., Haukenes, I., & Moe-Nilssen, R. (2024). Pregnant women may exercise both abdominal and pelvic floor muscles during pregnancy without increasing the diastasis recti abdominis: A randomised trial. Journal of Physiotherapy, 70(2), 142–148. https://doi.org/10.1016/j.jphys.2024.02.002 

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