Abdominal Separation During and After Pregnancy: “DRAM” Explained

Steph Peisker (Physiotherapist – Burnie)

What is “DRAM?”

Diastasis of Recti Abdominis Muscles (DRAM) is the separation of the two rectus abdominis muscles along the linea alba [1], (See figure 1). In other words – it’s a separation and thinning of the connective tissue between the ‘six pack’ muscles. Sometimes it can be seen when changing positions i.e. straining to get out of bed, or sitting up … it is unlikely to be baby’s arm or head poking out of your belly, that is the DRAM with bulging (see Figure 3).

It is measured and recorded in clinic using a tape measure (some use fingers) at the umbilicus, above and below whilst doing a mini sit up/crunch (see figure 2). A widening >2.7cm is considered to need attention [2]

Image result for diastasis rectus abdominis

Figure 1. DRAM representation. Pic sourced from: https://www.babycenter.com

Why does it happen during pregnancy?

DRAM occurs due to hormonal elastic changes of the connective tissue, mechanical stresses placed on the abdominal wall by the growing fetus and displacement of the abdominal organs [3]. It is super common, it usually appears in the second trimester of pregnancy and usually worsens until delivery; studies [4] and [5] have reported 100% prevalence at gestation week 35! There isn’t a huge consensus about the factors that may lead to DRAM, but there have been some risk factors reported such as multiple pregnancies, baby size and importantly heavy lifting as this places more strain on the stretched tissue [6].

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Figure 2. Georgie Palmer (patient, with permission) and myself (Steph Peisker) assessing DRAM.

Why it is so important anyway?

The abdominal wall has important functions in posture, trunk and pelvic stability, respiration, trunk movement and support of the abdominal viscera. An increase in the inter-recti distance can put these functions in jeopardy and can lead to a change in posture and subsequently place the lumbar spine and pelvis more vulnerable to injury [7].

Does it resolve?

Natural resolution and greatest recovery of DRAM occurs between 1 day and 8 weeks after delivery, after which time, recovery plateaus [8]. It has been reported that DRAM does not spontaneously resolve for many postpartum women, at 6 months post 39-45% may be affected and for some it may persist for many years [9].

Figure 3. Bulging of the abdominal wall in DRAM, a 26-year-old patient, 14 months postpartum [12].

Is it really as cute as “I’ve Popped Early’’ in the next pregnancy?

Multiparity (multiple pregnancies) without recovery of abdominal tone between successive pregnancies places a woman at risk for developing DRAM due to repeated and prolonged stretch on the abdominal wall [3]. Due to the stretched connective tissue, it is likely that popping early just means that there is essentially less muscle tone of the six pack and can’t support the growing uterus quite so well, so… erm… that’s weakness, dear.

It is important to retrain the abdominal wall to recover function in between pregnancies, not only for cosmetic purposes but to support the growing uterus, minimize associated musculoskeletal discomforts and prevent a worsening DRAM.

Finally – What to do about it!

Our Women’s health Physiotherapists at Coastal Physiotherapy can help you!

Image result for pregnant belly During pregnancy, we want to minimize the strain through the DRAM. Changing the way you get out of bed is a start, i.e through side lie and also… avoid heavy lifting… which is particularly important for mums carrying toddlers.

We want to keep you exercising, probably not in a heavy deadlift kind of way – but regular exercise prior to pregnancy and during the antenatal period seems to reduce the risk of developing DRAM and reduce the size of DRAM, respectively… as exercise helps to maintain tone, strength and control of the abdominal muscles [10]. More-over, Tubi-grip has its role in some cases too, some ladies like the support and it reduces the strain from the growing uterus.

Out with the old… in with the NEW:

Remember trainers saying that Crunches were bad news after pregnancy and the transverse abdominis i.e. Planking / “drawing in” exercises were best? Well, guess what…

CRUNCHES are IN! We now have evidence to back us up… CRUNCHES and better than planking for recovery of the DRAM! … (see [6] and [11])

Let’s think about this logically; when lying down (supine) the DRAM is at its widest point, but when you crunch, it comes together slightly – which is used to assess and standardise the width of the DRAM.

Abdominal exercises work in the longer term because it strengthens and controls abdominal muscles, improving their tone which reduces the stress on the line alba and thus facilitates the reduction of DRAM [11]. In the early phases it won’t be Cross fit style crunching, it will be supported and a controlled “mini crunch”. There is no point heaving yourself up, losing control, bulging and hurting your neck… that’s not good for anything.

So essentially, any strength or perhaps cardio exercise that you do that is in control, reduces the DRAM with no bulging (figure 3), you’ve got the green light… (Perhaps, get some help in the initial phases and ensure your technique is tip top).

Oh! and don’t forget about the pelvic floor … But more about that later 😊

Want some advice? I’d be happy to help

Coastal Physiotherapy

Phone: 64314586.

Email: info@coastphysio.com.au

 

References

[1] Venes D. Taber’s cyclopedic medical dictionary. 20th ed. Philadelphia: F.A Davis; 2005

[2] Rath AM, Attali P, Dumas JL, Goldlust D, Zhang J, Chevre JP. The abdominal Linea alba: an anatomo-radiologic and biomechanical study. Surg Radiol Anat 1996; 18:282-8.

[3] Lo T, Candido G, Janssen P. Diastasis of the recti abdominis muscles in pregnancy: risk factors and treatment. Pysiother Canada 1999; 51: 32-37, 44

[4] Hannaford R, Tozer, J. An investigation of the incidence, degree and possible predisposing factors of rectus diastasis in the immediate post-partum period. J Nal Obstet Gynecol Speical Group of the Australian Physiotherapy Association. 1985;4:29-32

[5] Fernandes da Mota PG, Pascoal AG, Carita AI, BO K. Prevalence and risk factors of diastasis rectus abdominis from late pregnancy to 6 months post partum, and relationship with lumbo-pelvic pain. Man Ther 2015; 20:200-5

[6] Kamel, D and Yousif, M. Neuromuscular Electrical Stimulation and Strength recovery of Postnatal diastasis Recti Abdominis Muscles. Ann Rehabil Med 2017; 41 (3): 465-474

[7] Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: the role of fascia following pregnancy and delivery. J Bodyw Mov Thera 2008: 12: 333-48

[8] Coldron Y, Stokes MJ, Newham DJ, Cook K. Postpartum characteristics of rectus abdominis on ultrasound imaging. Man Therapy 2008: 13: 112-21

[9] Chiarello CM, Falzone LA, McCalsin KE, Patel MN, Ulery KR. The effects of an exercise program on diastasis recti abdominis in Pregnant women. Journal of Womens Health Phys Therapy. 2005;29:11-6

[10] Benjamin DR, Van de Water AT, Peiris CL. Effects of Exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy 2014; 100: 1-8

[11] Mota P, Pascoal AG, Carita AL, et al. The immediate effects on inter-rectus distance of abdominal crunch and drawing in exercise during pregnancy and the postpartum period. J Orthop Sports Phys Ther. 2015; 45 (10);781-788

[12] Michalska A, Rokita W, Wolder D, et al. Diastasis recti abdominis – a review of treatment methods. Ginekologia Polska. 2018; 89 (2); 97-101