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The abdominal muscles | The Royal Women's Hospital

Because your abdominal muscles stretch over the growing baby and uterus, they can become less effective.

The abdominal muscles support your abdominal organs and spine. When the abdominal muscles contract they produce spinal movement so you can bend and twist, or hold the spine stable so you can stand upright. This is called ‘core stability’. Because your abdominal muscles stretch over the growing baby and uterus, they can become less effective at doing their normal support and movement tasks. If they are not exercised at all, they can overstretch as the uterus rests forward onto them. Then they maybe unable to return to their original length and shape after birth.

Sit-ups, or ‘crunches’ are the usual exercises associated with abdominal training. These are inappropriate and ineffective during pregnancy – ineffective because the stretch on your abdominal muscles means they cannot work the way they did before you were pregnant; and inappropriate because the exercise is done lying on your back. In this position the baby rests on major blood vessels and may block blood flow, causing dizziness.

Tummy exercises in pregnancy

The best way to exercise the abdominals and gain core stability is to draw them in without moving your spine. Think of cuddling you baby with your abdominal muscles or sucking your bellybutton towards your backbone.

• Get on your hands and knees. Let your tummy relax.
• Breathe in gently. As you breathe out, gently draw in the lower part of your stomach firmly, lifting your baby as you draw in. Hold for the count of three or more if you can. Let go.
• Repeat this movement up to 10 times with a few seconds rest between each one.
• Build up gradually until you can hold the muscles strongly for 10 seconds and repeat the exercise 10 times, and can also do a 60-second-long hold.
• When this exercise becomes easy, challenge yourself by lifting one arm alternately while keeping you abdominals ‘switched on’, then one leg, then opposite arm and leg, then same side arm and leg. With each of these variations, build up your hold time as you did with the initial exercise.

Hint: Don’t move your back at any time during the exercise. You should be able to breathe and talk as you do this exercise. You can also squeeze your pelvic floor muscles at the same time.

Group exercise during pregnancy

If you are exercising in a group or at a gym, choose to do clinical pilates, a fitball class, boxercise, aquarobics, or a ‘Pump’ class (with light weights) for the best abdominal workout.

The Women’s does not accept any liability to any person for the information or advice (or use of such information or advice) which is provided on the Website or incorporated into it by reference. The Women’s provide this information on the understanding that all persons accessing it take responsibility for assessing its relevance and accuracy. Women are encouraged to discuss their health needs with a health practitioner. If you have concerns about your health, you should seek advice from your health care provider or if you require urgent care you should go to the nearest Emergency Dept.

what is it, what is dangerous, how to treat

Alexander Natroshvili

Chief Surgeon and Medical Director of GMS Hospital

Some women after childbirth may not know that they had such a problem as diastasis, because sometimes it is invisible and goes away on its own. However, in another part, the disease manifests itself more strongly - and it would be better to recognize it in the first stages and cure it.

About what diastasis is, why it appears and what to do about it, we talked with the chief surgeon and medical director of GMS Hospital Alexander Natroshvili.

What is diastasis and why does it occur?

Diastasis (from the Greek diastasis - separation) is a divergence of the rectus abdominis muscles to the sides with stretching of the connective tissue between them - it is called the white line. This happens at the level of the navel, above or below. Recall that the rectus muscles are those that form the press cubes.

Diastasis occurs with prolonged stretching of the anterior abdominal wall. Often appears from the 28th week of pregnancy (in the third trimester). After all, the uterus begins to grow rapidly and stretch the abdominal muscles to the sides.

Such changes in the anterior abdominal wall are physiological, that is, normal. Without them, the baby would not fit in the mother's belly. Stretching is also enhanced by hormonal changes and the preparation of the body for childbirth.

After the baby is born, the anterior abdominal wall begins to rebuild its structure. After 6 months, diastasis can be detected in 60% of women, and after 12 - already in 33%. If after six months the problem has not gone away and is not treated, it will be noticeable and can lead to the formation of an umbilical hernia.

Another cause of diastasis is excess weight, when excess adipose tissue stretches the anterior abdominal wall. Therefore, men can also have this problem.

Why is diastasis dangerous?

We have already found out that diastasis after pregnancy is a normal, physiological phenomenon. By itself, it does not pose a danger to life.

However, you should not start the problem, it can lead to unpleasant symptoms. For example, 20% of patients experience chronic low back or pelvic pain. An aesthetic defect also appears, often it is he who leads the majority of patients to the doctor. Also, the functions of the pelvic floor are sometimes violated - up to urinary incontinence during physical exertion. A more serious threat to health is represented by hernias of the white line of the abdomen, including umbilical ones. With diastasis, the risk of their formation increases many times over.

How likely is diastasis?

Factors that increase the risk of developing diastasis:

• multiple pregnancies, especially if less than a year has elapsed between them;
• over 35 years of age;
• birth of twins;
• high birth weight of the baby;
• natural childbirth - attempts to increase intra-abdominal pressure;
• asthenic (thin) body type.

Everyone will experience some degree of muscle strain after childbirth. Approximately 65% ​​of the abdominal wall is restored on its own and the white line is reduced. Normally, in a woman giving birth, its width should be no more than 23 mm.

Approximately one third of the widening of the white line will remain: this will be visually noticeable and may lead to the above symptoms.

How to reduce the risk of diastasis?

Prevent excess weight gain during pregnancy through moderate physical activity and proper nutrition. Also, don't lift heavy things. Remember that any straining and increase in intra-abdominal pressure increases the likelihood of developing diastasis. Do not get out of bed abruptly and straight, it is better to turn on your side and lean on your hands to gently sit up and then stand up.

Avoid dynamic abdominal exercises from the 12th week of pregnancy and in the postpartum period - classic exercises like crunches, leg raises and torso can aggravate the situation.

Is it possible to independently determine if there is diastasis?

Yes, it's easy to do. Lie on your back, raise your head and shoulders, look at your stomach, if you see a “roller” in the middle or, conversely, a “failure”, you have diastasis. You can feel it - press just above the navel: if the fingers fell through, then there is a problem. How pronounced it is, and what to do about it, the doctor will answer.

Which doctor should I contact?

Diastasis problems are mainly dealt with by surgeons. You need to find a specialist with extensive experience in this topic. Ideally, he should do an ultrasound and determine the exact degree of muscle separation, and then prescribe treatment.

Can diastasis go away on its own?

If more than 12 months have passed since the birth of the baby - no, the white line will no longer be able to return to normal by itself. But sometimes women do not even know that they had diastasis, since it was mild and disappeared on its own within 6–12 months. We recommend that you consult a doctor after giving birth to check the condition of the muscles, and if necessary, you can immediately begin treatment.

How to cure diastasis?

With a wide diastasis, it will be possible to restore the structure of the abdominal wall and the white line only with the help of an operation.

Complexes of physical exercises are performed at the first stages. They will not do anything with the white line itself, because it is a connective tissue that is unable to increase in size in order to return to its previous state. But training will help improve the shape of the abdomen, make it fit by bringing the muscles into tone.

What physical exercises can be done?

Let's start with the things you can't do. These are all variants of basic exercises with additional weight, for example, deadlifts or Romanian deadlifts, squats. You also need to carefully approach the training of the abdominal muscles. We do not recommend doing crunches, classic planks, hanging leg raises, etc.

Instead, you need to strengthen your deep core muscles. Choose exercises such as side plank, "vacuum", "cat", Kegel gymnastics (training the muscles of the pelvic floor). They will help with recovery and strengthening.

The simplest exercise is "vacuum". Take a deep breath, then exhale and contract your abdominal muscles, pressing your navel against your spine. Lock in this position for 5-10 seconds, and then relax. Repeat 3-4 times. It is best to do the "vacuum" in the morning on an empty stomach, and when there is no menstruation.

The "cat" exercise will help strengthen the abdominals and tighten the stomach. To perform it, get on all fours, make sure that your palms are shoulder-width apart. While inhaling, round your back, neck, lower your head and pull your stomach in as close to the spine as possible. On the exhale, bend in the back, stretch the back of the head to the coccyx. Do about 8 reps.

When is surgery necessary?

Surgical treatment is planned if, in addition to diastasis, a hernia has also appeared. In this case, the exercises are powerless and only increase the risk of complications.

Diastasis greater than 4 cm leads to an aesthetic and functional defect, it can also be corrected only by surgery. Another indication for surgery is the lack of effect from training for 6 months.

How difficult will the operation be?

Not easy for a surgeon, because it is a thorough reconstruction of the anterior abdominal wall. How easily it will be tolerated by the patient depends on the type of operation. There are two types:

1. "Open" in combination with abdominoplasty (removal of excess skin in the abdominal wall). After the operation, the woman will have a tightened aesthetic belly. However, a fairly wide cosmetic suture will be visible, usually surgeons "hide" it in the bikini area.
2. Laparoscopic diastasis repair. In modern clinics, a variant of "endoscopic" surgery is used, that is, they work in the layers of the anterior abdominal wall. Although this is more difficult for the surgeon, it is safer for the patient. In this case, you can achieve a better cosmetic result - there will be three small scars in the bikini area or along the scar from a cesarean section. After six months, they will be almost invisible.

Modern low-impact techniques make the rehabilitation period short. In good clinics, the hospital stay rarely exceeds two days, after which patients return to their daily activities. After 3-4 weeks, you can do aerobic sports, and after 3 months, almost all restrictions on physical activity are removed.

Will the operation get rid of diastasis permanently? Or can there be relapses?

There is no 100% guarantee in surgery. However, with the correct selection of the variant of the operation and its proper execution, the risk of recurrence is low. In the practice of modern clinics, it does not exceed 0.5%.

With a simple "suturing" of a wide diastasis, without strengthening the white line with a special implant, the risk of recurrence reaches 18-25% (according to world literature).

If diastasis is cured, will it appear after the next birth?

Optional, but the risk of recurrence during pregnancy is greatly increased. We recommend doing an operation to restore the anterior abdominal wall after all planned births.

Diastasis of the rectus abdominis muscles and diastasis of the womb. Solvable problems of pregnancy. Interview with Doctor of Medical Sciences, Professor M.A. Chechnyova

— What is muscle diastasis and what is pubic diastasis?

— Pregnancy is an amazing and wonderful time, but it is also a period of additional loads, which undoubtedly becomes a test of strength for the female body.

The previously existing everyday point of view that pregnancy rejuvenates and gives strength is not confirmed by anything. During the bearing of a child, significant additional loads are placed on the mother's body, which often lead to the manifestation of problems that were invisible before pregnancy.

Diastasis of the rectus abdominis muscles is a divergence of the inner edges of the muscles along the white line of the abdomen (connective tissue structure) at a distance of more than 27 mm. Pubic diastasis is one of the manifestations of pregnancy-associated pelvic girdle pain. This pathology affects the entire pelvic ring, sacroiliac joints and symphysis. And they certainly have common causes for the appearance.

The formation of such problems is facilitated by a decrease in the strength of collagen in the connective tissue. One of the reasons is an innate predisposition, the so-called connective tissue dysplasia, when the tissues are very elastic, extensible. During pregnancy, the body of a woman increases the production of the hormone relaxin, which reduces the synthesis of collagen and enhances its breakdown. This is provided by nature to create maximum elasticity of the birth canal. However, other structures, such as the anterior abdominal wall and the pubic symphysis, also fall under the action of relaxin.

— How does diastasis of the muscles and diastasis of the pubis affect pregnancy and childbirth?

— Divergence of the rectus abdominis occurs in about 40% of pregnant women. During pregnancy, it does not give serious complications that threaten the life of the mother or the condition of the fetus. However, the inferiority of the work of the rectus abdominis muscles forces the redistribution of the load on the back muscles, which can lead to lumbar-pelvic pain and, accordingly, discomfort in the back. During childbirth, the abdominal muscles are involved in attempts, and the violation of their anatomy and function can affect the birth act.

With diastasis of the pubis, things are more complicated. As already mentioned, this is only one of the manifestations of a violation of the structure and function of the pubic joint (symphysiopathy) during pregnancy. It occurs in about 50% of pregnant women in varying degrees of severity: in 25% of cases it leads to restriction of the mobility of the pregnant woman, in 8% - to severe disorders up to disability.

With symphysiopathy, the ligaments of the pubic articulation and cartilage that connect the pubic bones suffer. All this leads to severe pain in the pubic joint, pelvic bones, lower back, as well as to a violation of gait and the inability to stand up or lie down without outside help. Women with pelvic girdle pain syndrome experience significant levels of discomfort, disability, and depression, with associated social and economic problems. These include impaired sexual activity during pregnancy, chronic pain syndrome, risk of venous thromboembolism due to prolonged immobility, and even seeking early induction of labor or caesarean section to stop pain.

During childbirth, this patient may experience a rupture of the pubic symphysis and may require surgery to repair it.

— How to prevent the development of muscle and pelvic diastasis during pregnancy and childbirth? What factors increase the likelihood of its development?

- There is no recipe that will be one hundred percent. There is a wonderful term in the medical literature called "lifestyle modification". Whatever diseases we study, be it symphysiopathy, diabetes mellitus or preeclampsia, the risk group for pathology is always overweight women. You need to prepare for pregnancy, you need to be in good physical shape. During pregnancy, weight gain should be monitored. The recommendation to "eat for two" is not just wrong, but extremely harmful. Pregnant women should maintain reasonable physical activity. Weak and flabby abdominal muscles, combined with the large size of the fetus, undoubtedly increase the risk of diastasis.

The risk factors for symphysiopathy in numerous studies are hard physical labor and previous injuries of the pelvic bones. Factors such as time elapsed from previous pregnancies, smoking, use of hormonal contraception, epidural anesthesia, mother's ethnicity, number of previous pregnancies, bone density, weight and gestational age of the fetus (post-term fetus) are not associated with an increased risk of symphysiopathy.

— How to diagnose diastasis recti and diastasis pubis?

— In most cases, diastasis rectus abdominis can be diagnosed clinically. It happens that inspection, palpation and simple measurements are enough.

In the standing position, you can see the divergence of the muscles when the woman does not have subcutaneous fat. In this case, diastasis is defined as a vertical defect between the rectus muscles.

With tension of the abdominal press, a longitudinal protrusion is observed in the diastasis zone. Such a protrusion is especially noticeable if the patient in the supine position is asked to raise her head and legs. If necessary, you can measure the width of the defect simply with a ruler.

Ultrasound may be the most accurate diagnostic method. With ultrasound, the inner edges of the rectus muscles are clearly visible and the distance between them at different levels can be measured.

Computed tomography is used in the diagnosis of diastasis extremely rarely, mainly in scientific research.

For the diagnosis of symphysiopathy and diastasis pubis there is no one test as a "gold standard".

The first place, of course, is the questioning and examination of the patient. We pay attention to the gait of the pregnant woman, to how she sits down, lies down and how she gets up. Symphysiopathy is characterized by a “duck gait”, when a pregnant woman rolls from foot to foot. On palpation in the area of ​​the womb, pain and swelling are noted. The so-called pain provocative tests are used, for example, a mat-test (pulling up an imaginary rug, mat with your foot towards you).

The following questionnaires are used to assess quality of life, pain and disability: Health-Related Quality of Life (HRQL), Oswestry Disability Index (ODI), Disability Rating Index (DRI), Edinburgh Postpartum Depression Scale (EPDS), Pregnancy Mobility Index (PMI), and Pelvic Ring Score (PGQ).

Of the instrumental methods, ultrasound is the most widely used, less often computed or magnetic resonance imaging. Ultrasound allows you to assess the condition of the ligaments of the pubic joint and the interpubic disc, the severity of the changes and the risk of natural childbirth.

— What is the treatment for diastasis recti or pubis?

— Primary prevention: when planning and during pregnancy, it is necessary to strengthen all muscle groups of the pelvic girdle, as well as the pelvic diaphragm.

More often, diastasis of the rectus muscles disappears on its own during the first months after childbirth. Special physical exercises to correct the work of muscles, to tone them and restore their basic functions should be performed under the guidance of a competent instructor. There are types of physical exercises that can, on the contrary, worsen the situation with diastasis of the rectus abdominis muscles. In some cases, when there is no effect from physiotherapy exercises, it is necessary to resort to surgical correction of the defect. Currently, both endoscopic and open surgery are practiced. The choice of method depends on the size and localization of the defect.

With symphysiopathy, therapeutic exercises reduce lumbar and pelvic pain. Acupuncture and wearing a pelvic bandage have a positive effect on symphysiopathy.

Initial treatment for pubic symphysis should be conservative even if symptoms are severe. Treatment includes bed rest and the use of a pelvic brace or corset that tightens the pelvis. Early appointment of physiotherapy with dosed therapeutic exercises will help to avoid complications associated with prolonged immobilization. Walking should be done with assistive devices such as walkers.

In most cases (up to 93%), the symptoms of dysfunction of the pelvic ring, including the pubic joint, progressively subside and completely disappear six months after birth. In other cases, it persists, becoming chronic. However, if the diastasis exceeds 40 mm, then surgical treatment may be required. Most studies recommend surgery only after failure of conservative treatment, inadequate enlargement of diastasis, or its recurrence. Several procedures have been described, including external fixation and open reduction of the pubic bones with internal fixation.

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