As a women’s health physiotherapist and a new mum myself, the words mummy tummy are no strangers to me. When pregnant myself last year, I recall my major concerns with my future postnatal body were stretch marks and the dreaded ‘tummy gap’, also known as a diastasis of the rectus abdominis muscles when I am wearing my professional hat.
Despite all my knowledge about pelvic floor dysfunctions and the havoc it can cause to us mums, mummy tummy was something I felt more out of control of being able to address myself. During pregnancy and prenatally I did my pelvic floor exercises religiously and whilst practising them I was gaining feedback all the while on how my pelvic floor was holding up by how they felt, how many I could do, how long I could hold them for. However, with a growing bump all I could see was more stretched and itchy skin and less feet! It wasn’t until having my little girl could I then assess how my tummy muscles had truly coped.
This is something I feel many ladies can relate to, not necessarily for the same reasons, but I feel that the number one bodily concern for mums to be besides the birth itself is loosing their tummy and waistline. I feel this is probably partly due to the fact we have a long way to go with education and awareness on other health and musculoskeletal issues related to childbearing such as pelvic floor muscle dysfunction, pregnancy related pelvic girdle pain, and life changing issues such as gestational diabetes.
I also relate this ‘mummy tummy’ fixation to social media today often portraying that your body should just ‘ping back’ after having your baby. What posts and Instagram pictures of famous celebs showing off their perfect wash board postnatal tummies doesn’t show is the 30 minutes it may have taken to set up the perfect light, angle and filter needed for that picture and the team of health and fitness experts providing her with advice and supervised daily exercises, and a nanny to help them whilst they are exercising! This is when social media is not always good for the body and mind and postnatal depression.
So my aim today is to provide some clarification and support on:
The 2nd part of this blog will then help you to understand;
The abdominal wall
Your abdominal wall is cleverly designed to act as a well designed corset, with horizontal, diagonal and vertical layers, which join at the front via a fibrous connective tissue strip. The muscles act together to support your abdominal organs, protect your spine and provide movement.
What is a diastasis rectus abdominis?
During pregnancy, the abdominal wall has to expand to accommodate your growing baby and all that comes with it, the Rectus Abdominis muscles commonly do this by stretching and widening the fibrous strip in the centre of your tummy causing the two abdominal walls to separate apart. This fibrous strip that connects the left and the right abdominal muscles is called the linea alba and it is not as elastic as the muscles it connects together and so it takes time for it to recoil back if at all once you have had your baby. It can thin and become weaker.
Diastasis of the rectus abdominis muscles (DRAM for short) can start around 14 weeks of pregnancy, and can continue to increase until delivery. Studies have found the average increase in the distance of the gap to be around a centimetre from the navel to the pubic bone and just under 3cm above the navel, with 1cm found in the upper abdomen. Research has also found though that in ladies who have not had babies that there is a great variation in the inter-abdominal muscle gap distance so what can be normal for one lady may not be for another. So classification of a diastasis is generally termed as having over 2 cm gap between the abdominal muscles. However....recent research by pioneering women's health physiotherapists such as Diane Lee and Julie Wiebe have highlighted it is not just the width of the gap that is relevant but the DEPTH and TENSION you can create across it.
What is the likelihood of having a diastasis of the rectus abdominis muscle?
Valid and reliable research is minimal in this field but what is available suggests that all new mums will have a degree of widening of the gap between the rectus abdominal muscles immediately after delivery and have a reduction in tension of the abdomen, 53% will have a true diastasis at this time, and 36% remain to have a diastasis at 7 weeks postnatally Boissonnault & Blaschak (1988). Coldron et all (2008) measured the inter-recti distance from day 1 to 1 year and found that the distance markedly decreased up to 8 weeks postnatally but little to no change after that when no exercises or advice was provided to the lady.
So my take on this was that it would be likely I would have one and so I started being proactive in my own pregnancy to prevent and minimise compromise to my abdominal muscles. Professionally it means that I now focus on DRA with all women in their Mummy MOT appointments as soon as possible and even make sure they feel it and know how to assess it themselves so they can be practical and hands on with improving the situation and being aware of what to do and what not to do….notice how I didn’t say how to reduce the gap….keep reading.
What does it mean to my body?
The abdominal wall and the tension it provides have important roles in posture, trunk and pelvic stability and movement, respiration, and support of the abdominal viscera.
An increase in the inter-recti distance and a reduction in tension and support across the abdomen put these functions in jeopardy. This may result in altered trunk mechanics, impaired pelvic stability and changed posture, which could leave the lumbar spine and pelvis susceptible to injury, and evidence is still questionable whether this results in increased chances of experiencing pelvic girdle pain, urinary incontinence, pelvic organ prolapse and back pain. Some research has found incidental findings of the above symptoms and DRA but if they are cause and effect is still questionable to date. More research is needed.
What is known is that the abdominal wall works in synergy with the pelvic floor, deep back stabilisers and diaphragm, otherwise known as your breathing muscle. Together all these muscles form the ‘abdominal canister’. If one of these muscles is not working up to scratch then it can affect how they all function. The following diagram from Burrell Education highlights this perfectly so knowing how to regain activation and support in your abdominal wall in conjunction with the pelvic floor and breath is so important in the postnatal period.
Research now tells us that the main issue with diastasis that can create changes to the contour of the tummy and possible links to symptoms is not necessarily how wide the gap is but the lack of tension and therefore support it creates across the abdominal wall. So therefore do not get hung up on purely how wide it is. This was a previous school of thought but not up to date with available research.
Therefore when assessing ladies I would then repeat the above test whilst getting them to activate the deep abdominals called transversus abdominis and the aim is to feel more tension across the gap. To do this I cue ladies to exhale as they lift their head meanwhile hollow their lower abdomen in towards them from their pubic bone to navel, imagining they are trying to fit into a tight pair of jeans. The exhale is very important to prevent you holding your breath and creating an increase in the intra abdominal pressure. If there is more tension across the gap this is good! However if someone still has a gap after recruiting their deep abdominal muscles this is a true diastasis. So in order to address it we start with activating all the core muscles of the abdominal canister in synergy to help give stability to the abdominal wall. Therefore working the deep abdominals, pelvic floor and diaphragm together can improve it!
That is a very quick insight into where to start when trying to address it, but more to come next time on that. For now, get practising assessing your tummy. If you haven't yet dared put your hands on your tummy, if it all feels a bit icky and jiggily reassure yourself that this is where to start to help addressing it. I remember how horrible it felt to touch my tummy for the first time after having our little girl but it helped me know the situation my abdominals were in after so many months of being unsure how they had coped, and this helped me get on the path to recovery sooner.
Any questions at all please just ask. If you want support at assessing this further then please get in touch for a Mummy MOT where we can go through this in detail with you and develop a bespoke programme for you.
For all you fitness and health professionals out there here are some references: