Core Dysfunction Series Part III: Treatment of Diastasis Recti in the Postpartum

Continuing our core dysfunction series with diastasis recti.  In part 1 of this series, we defined diastasis recti as the separation of the two halves of the rectus abdominus (six pack muscles) and noted that nearly 100% of pregnant women will have diastasis.  It is a normal part of pregnancy, as our abdominal cavity needs to make room for a growing baby!  In part 2, we discussed the three main controllable factors of diastasis during pregnancy and what may be preventing healing in the postpartum: Posture, Breathing, and Activity.  

As a reminder, these blog posts are not medical advice and are for educational purposes only.  We recommend that you consult your medical practitioner or pelvic floor physical therapist for any concerns that you may have. 

Steps Towards Healing Diastasis Recti in the Postpartum

In our previous post in this series, we discussed how posture, breathing, and activity can all contribute towards diastasis and then prevent healing if; non-optimal positioning; poor pressure management strategies; and inappropriate movements were utilized by prenatal or postpartum mothers.

However, if we utilized optimal positioning, a great pressure management strategy, and appropriate movements, we would contribute towards the healing of diastasis recti in the postpartum!  While nearly 100% of pregnant women will have diastasis, not 100% of us need to maintain it during the postpartum, nor is it something we must live with as mothers. 

There are other factors that may contributes towards the prevention of healing in the postpartum that Mama may not have control over, such as genetics or physical and emotional support in the postpartum, but we will not touch upon those in this post. 

1. Posture

As discussed in the previous blog post, as pregnancy progresses, there is an increased weight on our front side (belly & breasts).  This increased front load tends to contribute towards less effective posture (rounded upper back, forward head position, sway back position, and/or increases curve in the low back) and could potentially be forcing your body to compensate to remain upright.  These compensations can prevent proper healing and may encourage poor pressure management strategies for the abdominal cavity. 

Let’s discuss how to use posture as a tool to help us minimize diastasis in pregnancy and then heal in the postpartum! 

When we talk posture in our small group training, we usually give the cue: stack ribs over pelvis in the relative position you are in.  If the ribs are generally stacked over the pelvis, then we most likely are in a neutral spine range. 

A neutral spine (and this is relative to each Mama) is the midrange position for your core.  Muscles optimally operate in midrange position, so deviation from this range will force your muscles to work a little bit harder and may compensate in order to meet the demand. 

Now, our spines are meant to move: it rotates, extends, and flexes both forward and side to side!  We are not meant to live in one set position!  By all means, please move!  Movement is sooo key for health and healing (see the activity section below). 

However, when Mama is standing there (or sitting, squatting, running, etc) with poor posture, her core is having to work overtime in order to stabilize which might result in increased pain, decreased function, and more issues later on.

Now, some of these postural adaptations (increased curvature of the lumbar spine, for example) will happen to accommodate for a growing baby and a constantly changing pregnant body!  So, what can you do?  Focus on posture as best as you can during pregnancy, and then reestablish the mind-body connection to stabilize during the postpartum.

When it comes to finding neutral, there is a posture progression we can take!  We will walk you through each position starting from the head and working our way down the body. 

From each of these positions you can conduct various exercises with the spine in neutral.  For example, in the supine position, you could do dead-bug walks or glute bridges.  Most load bearing movements require the spine to be in neutral to safely accomplish.  While there is much debate on this in certain fitness groups, in general we want the spine to be neutral when we squat, deadlift, bench press, and move weight around.

The Progression: Supine -> Side Lying -> Table Top -> Seated -> Standing

Supine:

In supine, we can use the ground to help us find and support a neutral spine. 

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Starting from the head, think about pulling your pony tail upwards to lengthen in the back of the neck.  There will be a slight tuck of the chin, but not so much that we create a few double chins!  This is neutral for your neck. 

The back should be relatively flat against the ground.  Sometimes there is a tendency for the low back to lift off the ground.

Legs can be bent 90 degrees, or they can be up in a dead bug position.  Think as if you were holding a stability ball between your legs. 

Side Lying

In side lying, we are starting to introduce gravity and working on stabilizing and finding neutral in this new plane and resisting lateral flexion (side bending). 

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Line up the elbow, hip, and ankle in a relatively straight line. 

Starting at the head, think about that length in the back of the neck, with the slight tuck of the chin.

Stack the elbow underneath the shoulder; if you are feeling tension in the shoulder, the elbow may not be stacked properly under the shoulder.  Square the shoulders so that the ribs are stacked in line with the pelvis.

Now, focus on engaging in the core so that the side body doesn’t sag towards the ground. 

Legs can be bent at a 90-degree angle. 

Table Top

Table top is an advancement from supine, but we no longer have the floor to support and stabilize our spine.  We now have gravity working against us.

Starting from the head again, think about lengthening in the back of the neck with a slight tuck of the chin.

Wrists stacked under shoulders, and knees stacked under hips. 

Focus on engaging the core so that the belly isn’t sagging towards the ground.  The belly sagging towards the ground will cause: an increased curve in the lumbar spine; the pelvis to tilt forward (anteriorly tilt); and stretching of the linea alba.  Remember to focus on aligning the ribs with the pelvis.

Seated

In seated, we don’t have to worry about the legs just yet but can start to find that upright posture.

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Starting from the head again, think about lengthening in the back of the neck with a slight tuck of the chin.

Let the palms of the hands open, to allow for the shoulders to externally rotate.  There is a tendency to live in this huddle position due to pregnancy, then holding our babies on the outside, nursing, looking at our phones, etc. 

Focus on aligning the ribs over the pelvis, you may need to lean farther back than you would be accustomed to.  Option to lean back into a wall to use the wall as a support and guide.

Pay attention to how your pelvis is sitting; are you rocking forward or backwards on your booty? Do you feel tension in your low back, if so does it feel compressed or overstretched?

Standing

Finally, in standing we can incorporate what we have learned in previous positions to find neutral while completely upright. 

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Starting from the head again, think about lengthening in the back of the neck with a slight tuck of the chin.

Let the palms of the hands open, allowing the shoulders to externally rotate. 

Focus on stacking ribs over pelvis.  Pay attention to the position of your rib cage; is it thrusting upwards towards the sky?  Is it pushed backwards? 

Now pay attention to your pelvis.  Is it tilted forward?  If you’re not sure, try to stick your booty out.  Can you do it?  If not, you may already be in a forward tilt.  Now for the opposite, is your booty clenched and pelvis tucked under?  If you’re not sure, poke your booty to see if it’s clenched, or try to tuck your booty under without using your legs.  Can do you do?  If not, you may already be tucked under. 

Moving down the legs, stack ankles under knees and hips.  Feet pressing into the ground at three points: the big toe ball mound, the pinky toe ball bound, and the middle of the heel.  Your feet should form a triangle with the ground. 

2. Breathing

When we breathe, we want to focus on a 360 expansion of the abdomen as we inhale and then as we exhale everything returns to its initial position.  We’re talking the front, sides, back, and bottom of the abdominal canister expanding. 

It helps to place the hands on the sides of the ribs in any of the above posture positions.  Usually starting in supine or seated will allow you to focus on the breath. 

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As you inhale:

  • Feel your hands being pushed outwards as your ribs laterally expand (Sides)

  • Feel your belly rise in unison with your sides (Front)

  • Feel your pelvic floor expand downwards (Bottom)

  • Feel your back push into the ground (if you are supine or against a wall in seated) (Back)

As you can see (and hopefully feel) every side of the abdominal canister expands during the inhale in unison.

Now, we use breath as a tool to manage the pressure within our abdominal cavity.  A great pressure management strategy will result in optimal function, while a poor strategy will contribute towards dysfunction.

During an inhale, the increased pressure in the abdomen stabilizes the spine.  During an exhale, muscular force stabilizes the spine. 

The amount of muscular force being utilized during an exhale depends on the demands of a situation.  If we are in a low demand situation, such as sitting or standing, the exhale will be relatively relaxed.  If we are in a high demand situation, such as squatting a barbell or picking up heavy child, the exhale will require more muscle activation and tension.

There are a few breathing strategies that you can utilize during exercise, but for our early postpartum mothers we typically go with exhale on exertion.  During the “easier” part of the movement, Mama will inhale fully, focusing on a 360 expansion of her abdominal canister to include the pelvic floor.  As she reaches the more difficult portion of the movement, she exhales, focusing on a slight abdominal contraction and pelvic floor contraction and lift.  The strength of exhale will be determined by the demand of the exercise; we always try to meet tension to task. 

For example, if a Mama was doing a squat, she would inhale as she lowered down in the squat.  At the bottom of the squat, as she began to lift out of it, she would exhale the entire way up focusing on contracting her abdomen and contracting and lifting her pelvic floor. 

There is some debate as to which comes first, posture or breathing, depending on someone’s educational background, but there is no debate that both posture and breathing work together for optimal function.

3. Activity

During pregnancy and the postpartum, not every movement is appropriate.  The phrase, “Just because you can doesn’t mean you should,” is so appropriate for this phase of life for women. 

Movements during pregnancy that will help you adapt to postural changes involve movements that increase mobility on the front side (chest openers, hip openers) and increase strength on the back side (upper/mid back, glutes, hamstrings). 

These same movements are great during the postpartum, as we still have a load on the front with a baby on the outside now in our arms or in our carriers, and if we are breastfeeding, our breasts are a few sizes larger than normal.   

As always, positioning and breath during movement is more important than the movement itself.  It doesn’t matter if you did the top 5 movements for pregnancy or the postpartum if you did them all poorly.

If you are doing a movement and you find that you are resorting to poor form, poor pressure management, or it causes pain/discomfort, take a step back and reevaluate the movement. 

Steps towards resolving the movement issue can involve:

  • Focus on positioning; can an external cue help you, such as a visual cue such as looking in a mirror, a verbal cue from a coach, a tactile cue from a coach, a resistance band, or yourself?

  • Focus on your breathing; are you getting a true 360 expansion during your inhale? Are you contracting and lifting the pelvic floor/abdomen during your exhale? Are you exhaling during exertion?

  • Decrease the resistance; if the resistance is too difficult or the weight it just too heavy, you may not be ready to lift it without compensating. There is no shame in the Mama workout game. I can’t say I have ever been to the gym where someone judged me for having great form, but I can say that I have been to a gym where someone lifted way too much weight with shit form, and maybe one other dude was impressed, and then said lifter walked away with some serious pain.

  • Ditch the movement. If none of the above work, we may need to just ditch the movement for now. Remember what the intention of the movement is, and then find a movement that meets that intention.

When it comes to healing diastasis (and really any other type of pregnancy related dysfunction), we need to remember that diastasis is usually not the problem it’s the symptom of an underlying problem that typically resides in three areas that we discussed in this post: posture, breathing, and activity. 

If we can move with optimal positioning, engage in a great pressure management strategy, and utilize those principles in movement, we can work towards healing in the postpartum.

 

The mama in me honors the mama in you.  Mamaste

-Gina