TWIN PREGNANCY & ABDOMINAL SEPARATION CASE STUDY
Here is a case study about a lovely patient from a few years ago – let’s call her Mollie. In celebration of multiple births week, I thought a case study on Rectus Abdominis Diastasis (RAD) would be appropriate. RAD, otherwise known as DRAM, diastasis recti, abdominal separation or “the tummy gap” is a normal part of pregnancy. The tissue between the ‘6-pack’ muscles stretches and thins to make space for the growing pregnant belly, and the muscles on either side get further apart. I have only seen 2 women in my whole career who did NOT develop RAD with pregnancy, one of which had extenuating circumstances. It is often larger after twins, triplets etc, because the belly needs to stretch more. Even though RAD is normal, we aim to minimize it, and rehab it well after birth.
Mollie came to see me 6 weeks after delivering twins. She described that her belly “felt like an empty bag without a speck of muscle.” Her belly was not sore, but the look of it was highly bothersome to Mollie. She had always been a naturally slim build with minimal effort. After giving birth, this was still the case and when she lay on her back, her tummy appeared very slim. However, when Mollie stood up, she looked at least 5 months pregnant. Trying to hold her belly in made very little difference.
She told me that a midwife or physio on the postnatal ward had assessed her diastasis and said it wasn’t too bad: only 2cm. I often hear this, but I find reassessment worthwhile. Most quick RAD assessments entail a crunch while someone feels the width of the gap between the muscles at the level of the belly button. This distance is the “active” measure because it is done while the lady actively crunches. The active measure is useful information, but only a small part of the picture. It’s not enough to determine whether your RAD is minor or severe.
As we lift into a crunch, the muscles narrow together. There is often a point where they will re-widen if we lift too high. The amount that they narrow depends on the many factors including the strategy used for the crunch. If someone’s muscles shut to 2cm at the belly button, that’s nice… but where did they start from at rest? How narrow are they above and below the belly button? How firm and supportive is the tissue between the muscles? If you only measure the active width at the belly button, both ladies in this diagram below have a 2cm diastasis. Clearly, one of them is far more significant than the other.
Assessment
When we are standing, we are not doing a crunch, so the active measure is irrelevant. If the muscles are wide apart, the organs move forwards into the stretched tissue more easily. This explains why Mollie’s belly was so different when she stood up and gravity wasn’t holding her organs in as much. Her muscles were like the more severe picture. Mollie had a 21cm gap at rest. This was one of the most severe diastasis I have come across. However, Mollie was very committed to her rehab and genetically blessed in some of the factors that are harder to influence, like the skin’s ability to bounce back from a large stretch.
Treatment & Outcome
We went through a progressive regimen of home exercises. Over a period of only 3 months, Mollie’s muscles toned up to the point where they were less than 5cm apart at rest at the belly button. They were only 2.5cm apart at rest above and below the belly button. They all shut to 1cm actively. This was enough to enable Mollie to hold her belly in normally when standing. Even when she relaxed in standing, she no longer looked pregnant – just like someone who has had a baby. She felt her strength returning and was no longer bothered by her belly.
This was a faster than average improvement because of:
- Mollie’s commitment to her exercises
- Her luck in having a good support network and a fairly ‘easy run’ as far as postnatal phases go. E.g. her baby slept better than average, breastfeeding went smoothly…
- Genetic luck in great adaptability of her connective tissue
I was pleasantly surprised that she didn’t end in surgery. I didn’t know that such severe diastasis could improve so much and so quickly. The muscles always improve quickly if people manage to do their exercises. Improvement in the quality of the tissue between the muscles is much more variable. Sometimes RAD continues to improve for over a year of progressive exercises!
When to see a physio?
Come and talk to one of the pelvic floor physios at Alchemy in Motion about minimizing RAD in pregnancy, especially if you’re having twins or more! Use a tubigrip or similar for the first 2 weeks after giving birth. Some women benefit from tubigrip in pregnancy too. We strongly recommend that you come back to see us 2 weeks after giving birth if possible as we can usually start abdominal assessment and rehab at this time.