One year ago I gave birth by C-section to twins Natalia and Alex, who were healthy and relatively big: a combined 12 pounds, 3 ounces. Six weeks after their birth, I was eager to begin exercising again. Once I got the okay from my doctor, I'd jog a few times a week and go to a weekly postpartum exercise class, but even after I'd lost most of the baby weight, I was left with a bulging belly that felt weak and flimsy. My ob-gyn told me that these issues were just a part of motherhood (I also had a 2-year-old). After comparing notes with other moms, I came to see my compromised state as normal. But as months passed and my midsection remained unchanged, I trusted that inner voice telling me something wasn't right and started researching what might be going on.
I spoke to personal trainers and physical therapists specializing in postpartum women and learned that a stomach like mine is not normal, though it is common. I have diastasis recti abdominus (DRA), an increased separation of the most superficial layers of the abdominal muscle and weakening of the connective tissue that holds it together. While this condition isn't specific to postpartum women and may run in families, carrying a child can make it more likely. So can pregnancies close together, twin or triplet pregnancies, a major weight gain, or being 35 or older.
DRA can be linked to incontinence, lower back pain, and hernia. It's hard to know precisely how many women are affected, though one small but oft-cited study found that two thirds of women in the third trimester and about one third of moms at five to seven weeks after delivery have an abdominal separation. Along with excess fat between the muscles and organs, stretched-out skin, and weakened muscles, this separation may be one of the reasons that some women have a pooch long after they give birth. And with the right core-strengthening exercises, lifestyle changes, and physical therapy, diastasis recti is often correctable, although in extreme cases, surgery may be necessary.
To understand how diastasis recti abdominus forms, you need to visualize the all-important core, a complex muscular system that supports most of the body's movements, including sitting, walking, and picking up your child. The rectus abdominus is a muscle in two parts that run side by side from the sternum to the pubic bone. The sections come together at the midline in a network of connective tissue and lay atop the other core muscles, while the obliques and the transverse abdominus wrap around the sides of the body and provide a sort of internal corset.
When a woman is pregnant, the weight of the child pushes downward on the pelvic floor and outward against these muscles, says physical therapist Fatima Hakeem, director of rehabilitation services at the Woman's Hospital of Texas, in Houston. DRA occurs when a stretched midsection further separates the rectus muscle, like "a zipper that's undone," says Hakeem.
A separation that's less than three-quarters of an inch wide in a postpartum woman is considered normal. Anything greater classifies as diastasis recti, although the focus shouldn't be entirely on the size of the separation, says Cynthia Chiarello, Ph.D., assistant professor of rehabilitation and regenerative medicine at Columbia University Medical Center, in New York City, who has been studying the condition for ten years: "It also depends on how your abdominal wall is functioning." In a small percentage of women, DRA is associated with the bladder, uterus, rectum, or other pelvic organ slipping down (known as a prolapse), or with an umbilical or abdominal hernia, in which the midline connective tissue actually rips or tears, potentially causing organs to breach that hole.
If you're concerned that you have DRA, talk to a professional. While an ob-gyn doesn't specialize in the musculoskeletal system, she should still be your first stop, especially if you've recently given birth or have pelvic-floor issues, says Isa Herrera, clinical director of Renew Physical Therapy, in New York City, and the author of Ending Pain in Pregnancy. She, or your primary-care physician, can refer you to a physical therapist specializing in women's health, who can develop a program tailored for you.
Online and in-person programs including the MuTu System and the Tupler Technique employ moves that are frequently used by physical therapists. While they've each been endorsed by PTs and fitness professionals, and have thousands of devotees, Hakeem still recommends that women start a new specialized exercise program under the supervision of a professional, if possible. "I'm always worried that they're not going to do it right," she says. "And accuracy is everything."
Try this move that may help improve core strength and close an abdominal gap: Take a deep breath, and on the exhale, move your belly back toward your spine. (Or pretend to zip up a pair of pants that no longer fit, Hakeem suggests.) You can lie down with a neutral spine and your knees bent, feet flat on the floor, or sit up with good posture while repeating this exercise 10 times three times per day.
Another exercise also involves lying on the floor with your knees bent and feet flat. Crisscross your hands over your belly and exhale, raising your head slightly off the ground as you push together your recti muscles, recommends Herrera. Hold for a few seconds while you exhale and inhale, then lower your head back to the ground. Repeat 10 times, working up to 30 reps daily.
Kegels, which involve raising and gently drawing up the pelvic-floor muscles and then relaxing them, are also essential. Be sure to do them properly and allow time to feel your muscles relax between contractions. This move doesn't focus on the abdomen, but the transverse will automatically engage along with the pelvic floor because these muscles work in harmony, says Herrera.
In addition to doing these core exercises, you can make small lifestyle adjustments, like rolling instead of sitting straight up out of bed, bending at the knees instead of the waist when you pick up your child, and keeping good posture when you sit. By holding your body in correct alignment, you avoid putting too much weight on the weakened front side or causing a crunch in the recti muscles, says Wendy Powell, an English expert on postpartum restoration, who developed the MuTu (short for mummy tummy) System in 2010.
Whichever method you choose to heal your body, be consistent. Do the main core exercises daily for at least ten to 15 minutes for as many weeks as needed. Once you've mastered doing some of the moves accurately, they can be done while you're doing another mindless activity, such as brushing your teeth.
With a doctor's approval, these core exercises can be done during pregnancy and as soon as you feel ready after giving birth. But it's never too late to strengthen these core muscles and start seeing results, Herrera says. She worked with a mother of five who had a 5-cm. abdominal separation and was finally able to close her gap.
Crunches or traditional ab moves, like Pilates 100s, may exacerbate the problem, says Powell. It's best to also avoid planks and push-ups or any activity that puts the bulk of the body's weight on the weak front side, she says, as well as yoga poses including standing forward bend and boat pose, which strains your trunk. If you run, Powell's rules are simple: You're ready if, while exercising, you don't leak urine, don't experience pelvic or lower-back pain, don't feel unstable in your core, and don't bulge anywhere on or from within your abdomen or pelvic floor.
Women with DRA can certainly improve with exercise and lifestyle changes, although Hakeem recalls a former petite patient whose muscles had separated dramatically after having twins. For this woman -- and others whose separation is extreme, likely exceeding 2 inches -- surgery is the only option for true recovery.
The procedure, often referred to as a tummy tuck, involves removing excess skin and fat, plus sewing together the recti muscle if necessary, and it can vary widely depending on the patient, says Gregory Dumanian, M.D., chief of the division of plastic surgery at the Northwestern Feinberg School of Medicine, in Chicago. Recovery is said to be a little tougher than it is with a C-section, and you can generally go back to work in two weeks and exercise after four to eight weeks. To ensure a lifetime fix, it's best to have the procedure done after you've had your last child. There's always a small chance that stitches will unravel or pull through the tissue during a subsequent pregnancy, requiring another surgery. The average cost is between $10,000 and $15,000. Unless you have a hernia, in which case a portion of the procedure will likely be covered, the surgery is viewed as cosmetic and is not paid for by insurance.
Despite the cost, Leslie Hewitt, a mom of two from Brooklyn, recently had a tummy tuck for her DRA. One year after giving birth to her second son, Louis, now 3, Hewitt still looked pregnant despite running, hitting the gym regularly, and doing "thousands of crunches." After much research, she found information on DRA, promptly did an at-home check, and diagnosed herself with the condition. "When I realized this is what I had, I was devastated," Hewitt recalls. "And then I realized I was too young to go around looking like this."
Hewitt's incision goes from hip to hip, and her procedure, which also included a breast lift, lasted seven hours and cost $20,350. Little things, like being able to wear a T-shirt with confidence, have made her happiest. On a recent shopping trip, "everything fit," she says, and for the first time in years she didn't have to worry about camouflaging a problem area. "That disfigurement is gone," she says. "And I just look completely different."
I'm willing to exhaust every other mode of treatment before I consider surgery. Now that I know what to do for my belly, I finally feel mentally and physically up to the task. I'll try to be realistic about results and easy on myself in the process. This body did create three beautiful lives in the past five years, after all.
Originally published in the August 2015 issue of Parents magazine.
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