There is a scientific reason for the tummy that hangs around months after childbirth – no matter how much you diet and exercise.
Got a mummy tummy? Suffering from postnatal incontinence or back pain? Before resigning yourself to fate, check if you have diastasis recti.
While pregnancy and birth are life-changing – and most times, wonderful experiences for women – the female body also goes through a lot of physical changes and stress.
One of the biggest physical changes is a sustained abdominal separation, known as diastasis recti (DR). This condition can lead to other issues such as back pain, hernia, constipation and digestive issues, and pelvic dysfunction. While some mothers won’t experience any symptoms, they may retain a pouch, which is commonly dismissed as extra weight or “mummy tummy”.
Mum-of-two Naazrina Kokholm, 37, recalls her experience: “I first realised that I had DR when it was pointed out to me by my pilates instructor. At that time, I was just starting to embark on a healthy lifestyle and an exercise regimen after a hectic five years caring for my two children.”
Others, such as communications manager Penny Hoo, who also has two children, simply could not “get back in shape after delivery” even though she was back to her pre-pregnancy weight. “My abdominals were not flattening out and I felt generally weak at my core,” she shares. “I had read about DR in a mummy’s group online and I realised I may have had it.”
Pregnancy is the leading cause of diastasis recti
According to aesthetics doctor Dr Rohan Mendis, who treated Naazrina and eventually helped her close her DR gap, “anything that causes excessive pressure on the abdominals can cause DR”. These, he says, include weightlifting, frequent or rapid changes in weight, fluid build-up in the abdomen, and advanced age. For women though, pregnancy is one of the common causes.
The linea alba – the connective tissue that holds the left and right sides of the rectus abdominis muscle (what we know as the abs) – is about 1cm wide, and runs from the bottom of the sternum to the top of the pubic bone. During pregnancy, hormones cause the linea alba to weaken and stretch so that the muscles can give way and separate to accommodate the growing baby.
After childbirth, the condition normally corrects itself as hormonal signals change and the tissue (mainly made of collagen) regains its tensile strength, Dr Mendis says. “Sometimes, the condition persists, where two sides of the abdominals remain separated by more than 1cm. The bulge is caused by organs pressing against the weakened connective tissues.”
Having a gap in the core is not uncommon for postnatal women, as up to 40 per cent of women in Singapore have DR. However, awareness of DR is considered low among local women, especially when compared to some Western women who hail from countries where postnatal physio assessments are de rigueur. In Europe and Scandinavia, for instance, women are usually provided with consultations and a 12-week post-partum rehabilitation programme to ensure optimal recovery, and as a preventive measure against future complications.
The good news, though, is that more local women here are getting educated about their post-partum core and pelvic health, including DR. Female health physiotherapist Danielle Barratt, who practises at Physio Asia Therapy Centre, recalls: “Five years ago, two out of 10 of my local patients knew about DR. Now, I would say seven out of 10 of them are aware of DR and taking active steps to resolve it. This is a very good development as it shows that women are empowering themselves with knowledge and action.”
Check before you resume training
If you suspect you have DR, perhaps through a self-check (more on that below), the first step, Danielle says, should be to go for a physiotherapy assessment by a female health physiotherapist.
“As the techniques and measurements may vary between people, a further assessment with RTUS (Real Time Ultrasound) may be a better choice to view the DR gap. At the same time, RTUS can be used to view the client’s pelvic floor muscle function, and other primary core muscles,” Danielle says. “Observing a client’s breathing pattern is also extremely important in supporting closure of the DR gap and function of the core muscles. Once a thorough physiotherapy assessment has been carried out, only then can an individualised muscle strength training programme be tailored.”
A gap that is one- to two-finger’s width may be considered a healthy and functional DR gap, says Danielle. “It is not just about the width of the DR gap, but equally as important is the depth of it and the feel of the connective tissue and muscles on either side of the gap as a client lifts her head and moves,” she explains. Other factors to consider are the age of the client, quality of the skin and connective tissue, the hormonal stage a woman may be in or entering, her fitness level and posture, and any pain factors.
From a physio’s perspective, the aim is to bring optimal functionality back to a client. This means that she should be able to go about daily life effectively, without pain.
Surgery – via an abdominoplasty, which is also known as a tummy tuck – is an option as well. As it is considered a major operation, with a considerable recovery and rehabilitation time (you’re not allowed to lift anything for weeks!), it’s something that women should think carefully and seriously about.
New therapies are also being researched. For example, after over a year of trying other means, Naazrina has managed to close her DR gap with BTL EMSCULPT treatments. The treatment uses High Intensity Focused Electromagnetic technology to induce muscle contractions wherever it is applied on the body.
For Naazrina, the sessions, which were targeted at her abdominal area, helped her narrow the DR gap and strengthen her core, she says.
Should you DIY?
So, can you heal your DR through simple exercises at home? The answer isn’t a black-and-white yes or no. Rather, it’s a “see first”.
Just as each pregnancy is different, each case of DR is also different, with many personal factors coming into play. Thus, it’s important to get yourself checked by a physiotherapist trained in female health.
Further along, when your physio gives you the go-ahead to take part in more strenuous physical exercises, make sure to train under a qualified instructor who knows about DR and postnatal women’s health.
One of them is pilates instructor and founder of The Moving Body, Audrey D’Cotta. Audrey, who is trained in diastasis recovery techniques, says: “It is extremely important for all fitness trainers in Singapore to get trained in postnatal conditions, especially when it comes to the core of the body. Having DR would mean that there is weakness in the support structure of the body and that other muscles would likely be compensating for the lack of integrity in the abdominal wall.”
Kareen Lai, a fitness trainer who founded Mums In Sync, and who holds several prenatal and postnatal training certifications, agrees: “Postnatal mums should not be too eager to start a vigorous fitness regime. Ideally, seek advice from a trainer who understands the mechanics of a postnatal body.”
A knowledgeable trainer would be able to guide you on simple dos and don’ts, to prevent you from inadvertently making the DR condition worse.
For instance, postnatal women with DR should “avoid HIIT routines, sit-ups and planks unless they have been coached and guided by trained professionals”. In fact, Kareen says: “The most fundamental technique to healing diastasis is breathwork. You must get your breathing right to start the basis of training.”
Seemingly simple actions such as getting out of bed need to be relooked as well. Says Linda Tang, a postnatal-trained barre instructor and co-founder of WeBarre: “I always advise my clients who have DR to get up from a lying position by rolling from the side, instead of a typical sit-up position. Abrupt core exercises will traumatise the DR area even more.”
Ultimately, Linda says, postnatal women with a sustained DR should prioritise “breathing deeply and taking things at a slower, more controlled pace”.
In short, take it slow in order to go fast in the future!
How to do a self-check for diastasis recti
Female health physiotherapist Danielle Barratt of Physio Asia Therapy Centre advises.
- Lie on your back with your knees bent, and the soles of your feet on the floor. Remove any pillow or head support.
- Place the tips of the fingers horizontally across the DR gap, about 5-6cm above the belly button, with fingertips facing downwards.
- Lift your head off the floor very gently, breathing out as you do this. You will be able to feel your abdominal muscles contract towards the midline on either side of your fingertips. The distance where the muscles do not close is the DR gap.
- Repeat the above action at the level of the belly button and at 5cm below the belly button. The widest measurement will be considered the DR gap.