Postpartum Abdominal Separation…Is this Normal?

If you or someone you know still has a protruding belly several months after giving birth, chances are that you (or she) has diastasis recti.  To be clear, we are not talking about the flabby, loose skinned belly that plagues us all after pregnancy.  The bulge I am speaking of is most evident when the abdominal muscles are contracted, such as when coughing or sneezing and becomes more obvious once a woman returns to normal exercise.  Sometimes, it may even look like a hernia.

Diastasis recti is a separation of the two sides of the outermost abdominal muscle, called rectis abdominis.  During pregnancy, the same hormones that allow the pelvis to expand in preparation for delivery also sometimes allow other tissues to expand beyond their normal threshold.  This combined with the increased pressure (ie. a growing baby inside) on the connective tissue that binds the two sides of rectis abdominis, can lead to the separation.

The literature is still unclear as to who is at risk for diastasis recti and the prevalence of it.  What I can tell you is that in the last 6 months I have seen five women– at various points of postpartum– for diastasis recti.  In addition, I have been involved in three separate facebook threads of women seeking more information about it.  Of those five women I saw in my office, only one of them was referred to me by her healthcare provider.  The other four women– and actually the 3 women on facebook as well– had very similar stories of recognizing the symptoms on their own and being somewhat brushed off by their providers.

So, when is it time to seek treatment?  To some degree, a separation is a normal part of pregnancy and most often will return to normal within the first several weeks of healing after delivery.  First and foremost, you should seek treatment if you have symptoms associated with the separation.  Symptoms might include low back pain, pelvic pain or an overall sense of decreased stability throughout the mid-section.  Without the presence of symptoms, you should seek treatment if you still have a 2+ finger width separation 2-3 months postpartum.  If left untreated, the lack of core stabilization may lead to back and pelvic pain down the road and the most severe cases may in fact lead to an abdominal hernia.

Despite what you may think, the goal of treatment isn’t actually to close the separation completely; in fact, many women will continue to have a 1-2 finger width separation and that’s perfectly normal.  The main goal is actually to create improved activation of the deeper abdominals– most specifically Transverse Abdominus.  This muscle acts like a corset.   Imagine that corset pulling everything in… allowing the top muscles to move closer to midline.

It is critical to learn how to recruit the appropriate core muscles.  Some traditional “core” exercises can in fact make it worse.  These include– but are not limited to– crunches, planks and torso twisting exercises.  The benefit of a physical therapy consult is that the exercise program will be tailored to your strengths and weaknesses and will provide very clear guidelines for exercise progression.

The assessment is simple.  While lying on your back, place your fingers at your belly button.  Perform a small crunch and if your fingers sink in between the two sides of the abdominal muscles, then you have a separation.  This same assessment is repeated both above and below the belly button.  The degree of separation is often measured by how many fingers fit into the separation.

Unfortunately, not many OBs and midwives are including this assessment in their routine 6 week postpartum check-up.  If you have recently given birth, I urge you to ask your healthcare provider to check you.  If you are past that 6 week check up and believe you might have a separation, I would highly recommend calling your physical therapist to assess it.


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