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21 Alterations oftheAbdominal Wall During Pregnancy
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Fig. 21.2 Increasing of abdominal circumference from rst month to ninth month of pregnancy
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21.4 Inter-rectus Distance
andDiastasis Recti
Abdominis
One of the muscles thought to undergo change in
pregnancy is the rectus abdominis. As the fetus
grows, the two muscle bellies of the rectus
abdominis, connected by the linea alba, elongates
and curves around as the abdominal wall expands,
with most separation occurring at the umbilicus
[8, 19, 21]. The augmented inter-rectus distance
(IRD), often referred to as diastasis rectus
abdominis (DRA), is described as a change in the
abdominal musculature, specically in the linea
alba and rectus abdominis sheath, with onset in
the last trimester of pregnancy and whose peak of
incidence occurs immediately after birth and the
rst weeks following childbirth [8, 10, 21, 22].
Although some studies suggested that an augmented IRD could reduce the abdominal integrity and functional strength, contributing to
pelvic instability and back pain [20, 23, 24], no
scientic evidence exists about the functional
implications of an augmented inter-rectus distance or even about the effect of the exercise on
prevention and/or reduction of IRD.
21.4.1 Classication andPrevalence
ofDiastasis Recti
Criteria and IRD cut-off value for the diagnosis
of DRA vary in the literature [2, 6, 8, 9, 25–28],
and to date there is no international consensus on
the measurement location. In a cadaver study,
Rath etal. (1996) dened a widening of the IRD
more than 10mm above the umbilicus, 27mm at
the level of the umbilicus, and 9mm below the
umbilicus, as pathological DRA [6]. Others
dened DRA as a widening of the IRD more than
2.5 cm at one or more assessment points using
digital calipers [29]. In a more recent ultrasound
study, Beer etal. (2009) suggest that in nulliparous women, the linea alba should be considered
“normal” when the IRD width is less than 15mm,
at the xiphoid level, 22mm at 3 cm above the
umbilicus, and 16mm at 2cm below the umbilicus [2]. Lately, Mota etal. (2018) found that in
primiparous women, the IRD may be considered
“normal” up to values wider than in nulliparous
[30] using the same methodology of Beer etal.
(2009) [2].
This way, Mota etal. (2018) suggest that during pregnancy, the linea alba can be considered
normal up to 79 mm when measured at 2 cm
below the umbilicus, 86mm at 2cm above the
umbilicus and 79mm, at 5cm above the umbilicus [30]. At 6months postpartum, the linea alba
can be considered normal up to 21 mm when
measured at 2 cm below the umbilicus, up to
28mm at 2 cm above the umbilicus, and up to
24mm at 5cm above the umbilicus [30]. Use of
normative IRD values in primiparous women
may be found in the diagnosis of the condition
and in the decision of treatment strategies
(Table21.1).
Studies have found that DRA may affect
between 30 and 100% of pregnant women [8,
21], and that it may remain separated in the
immediate postpartum period in 35–60% of
women [21, 25]. However, the condition has also
been found in 39% of older, parous women
undergoing abdominal hysterectomy [26] and in
52% of urogynecological menopausal patients
[28]. Reported prevalence of DRA or increased
IRD varies and may be inaccurate due to different
IRD cut-off values for the diagnosis [2, 6, 8, 25,
28, 29, 31] and use of different measurement
assessment methods.
Table 21.1 Quantitative classications of diastasis using
different location measurements on the linea alba and
women background variables. Rath etal. on a study with
cadavers [6]; Beer etal. on a study with nulliparous [2];
Mota etal. on a study with primiparous [30] (maximum
inter-rectus distance values in mm)
Rath
etal.
Beer
etal.
Mota
etal.
Women Location of measurement on
<45years
old
>45years
old
Nulliparous 15 22 16
Primiparous 24 28 21
the linea alba
Superior Middle Inferior
10 27 9
15 27 17
21 Alterations oftheAbdominal Wall During Pregnancy
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361
Warning
c
functional implications of an augmented
inter- rectus distance
distance may be considered “normal” up to
values wider than in nulliparous
of the exercise on prevention and/or reduction
of inter-rectus distance
No scientific evidence exists on the
In primiparous women, the inter-rectus
No scientific evidence exists on the effect
21.5 Risk Factors forDiastasis
Eecti Abdominis
There is scant knowledge about the risk factors
for DRA.Two studies analyzed several variables
such as, age, ethnicity, body mass index, height,
weight gain during pregnancy, pre-pregnancy
weight, gestational age at delivery, type, and
duration of birth [21, 27]. An association of DRA
during pregnancy with Caucasian ethnicity and
lack of regular exercise during pregnancy was
suggested [27]. It is considered that women with
DRA have a greater number of pregnancies and
deliveries [28, 32], and among multiparous
women, it is suggested that there is a strong association between provision of childcare and DRA
during pregnancy [27]. However, these studies
were limited by the sample size, reliability of the
instruments used, and were not denitive in its
ability to delineate risk factors. Additionally,
Mota etal. (2015) [21] found that in primiparous
women, there were no risk factors associated
with DRA (Table21.2), and women with DRA
were not more likely to have lumbo-pelvic pain
than women without DRA at 6months postpartum [21].
However, it may be interesting to study women
with severe DRA, for example, with more than
one child, to understand the risk factors and the
impact of severe DRA in women’s body.
Warning Women with severe DRA should be
c
studied to understand the risk factors and the
impact of severe DRA in women’s body
Table 21.2 Possible risk factors for diastasis recti in
postpartum women
Variables
Mean age (years) 31.6
Pre-pregnancy BMI 21.7
Weight gain during
pregnancy (kg)
BMI at 6month postpartum 22.3
Hypermobility (positive ≥4
out of 9 on Beignton)
Mean baby weight birth
(kg)
Abdominal circumference
in late pregnancy at 2cm
below the umbilicus
a
No risk factors were associated with DRA in 6months
postpartum [21]
With
DRA
(2.2)
(3.5)
12.8
(3.3)
(3.7)
3.2
(2.5)
3.2
(0.3)
105.5
(7.2)
Without
DRAP value
32.5
(2.9)
22.2
(3.0)
12.4
(3.5)
22.5
(3.2)
2.9
(2.5)
3.1
(0.3)
104.7
(7.1)
0.4
0.2
0.7
0.8
0.6
0.1
0.1
a
21.6 Procedures andInstruments
toAssess theInter Rectus
Distance
The most common methods to assess IRD are palpation [8, 25, 33, 34] and calipers [35, 36]
(Fig.21.3). However, the reported prevalence of
DRA (or augmented IRD) may be inaccurate
because of the lack of reliability, the low responsiveness (ability of a tool to detect small differences or small changes), and lack of validity
(ability of an instrument to measure what it is supposed to measure) [37] in the methods and instruments used to measure the IRD. Recently,
ultrasound imaging has been suggested as a useful
method to assess muscular geometry and as an
indirect measure of muscle activation via changes
in muscle thickness during contraction [38].
Coldron etal. (2008) used ultrasound to characterize RA changes during the rst year postpartum [10] and Mendes (2007) et al. claimed
ultrasonography to be an accurate method to
measure diastasis recti when compared with surgical compass during abdominoplasty [39].
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Fig. 21.3 Palpation of the linea alba versus ultrasound imaging
P. Mota
Across-days reliability may be of interest to
physiotherapists who perform repeated assessments of abdominal muscle function over time
[38]. Factors such as relocation of the original
imaging site, reproduction of the same transducer
pressure and orientation, as well as maintenance
of a relatively stationary transducer position during muscle contraction could adversely affect
reliability [38] and accurate interpretation of
ultrasound imaging and lead to erroneous conclusions [40].
The reliability of ultrasound imaging to measure IRD at rest and during contraction was tested
and showed good reliability to measure women
[31]. The authors recommend it to be used for
studying DRA and its recovery in postpartum
women.
Recent studies have suggested alternative
methods to study the biomechanical implications
of DRA [41]. However, these methods should be
interpreted with caution, as they were not yet
tested for its reliability [42].
Warning
c
method to assess inter-rectus distance in
postpartum women.
diastasis, but they should be first tested for
reliability.
Ultrasound imaging is a reliable
Other methods are suggested to study
21.7 The Eect ofExercise
onDiastasis Rectis
Abdominis
It has been suggested that antepartum activity
level may have a protective effect on DRA and
exercise may improve post-partum symptoms of
DRA [9]. Postnatal women are encouraged to
resume abdominal exercises shortly after delivery to restore their abdominal shape and tness
[6, 18, 32]. To date, there is scant knowledge on
the most effective abdominal exercises both during pregnancy and after childbirth. In particular,
there is little evidence on which exercises are
most effective in reduction of the rectus diastasis.
The rationale behind the abdominal strengthening programs is the assumption that the contraction of all abdominal muscles will reduce the
horizontal abdomen diameter in such a way that a
horizontal force will be generated producing the
approximation of both rectus abdominis, particularly at the umbilicus level [43]. However, there
is no evidence that this horizontal tension will
produce an approximation of the rectus abdominis muscles. The horizontal force is the result of
the overall action of the deep abdominal muscles
(oblique’s and transversus abdominis muscles)
which are anteriorly attached to the lateral side of
each rectus abdominis muscles [44] and posteri-
21 Alterations oftheAbdominal Wall During Pregnancy
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363
orly connected to the lumbar vertebral column.
Thus, the horizontal tension produced by these
deep abdominal muscles could pull the rectus
abdominis muscle laterally toward the xed sites
on the vertebral column, increasing the inter-rectus distance.
The abdominal crunch is one of the most used
exercises in abdominal strengthening programs.
However, the abdominal crunch has been considered a risk exercise for development of rectus
diastasis [8], and lately core training with the
drawing-in exercise has been recommended both
in the general population [45, 46] and during
pregnancy and even after childbirth [11]. It has
been proposed that the activation and training of
the transversus abdominis draws the bellies of the
rectus abdominis muscle together [32], which
improves the integrity of the linea alba and
increases fascial tension, allowing efcient load
transference and torque production [11, 47].
However, due to the low number and quality of
the studies, there is insufcient evidence to support this statement. Additionally, there are studies
suggesting that the activation of the transversus
muscle has a widening effect of the linea alba,
and the abdominal crunch produces a narrowing
of the IRD [48]. A recent RCT found that curl-up
exercises improve abdominal muscle strength
without worsening inter-recti distance in women
with diastasis recti abdominis postpartum. https://
doi.org/10.1016/j.jphys.2023.05.017.
Warning
c
of exercise in diastasis recti
widening effect on the linea alba.
No scientific evidence on the effect
Transversus muscle activation has a
21.8 Conclusions andFuture
Directions
Ultrasound measures the IRD in mm and such
levels of assessment are difcult to detect by
palpation.
The ultrasound imaging is recommended to
access IRD and the evolution of DRA in postpartum women.
The IRD cut-off value for categorizing DRA
needs to be further studied. Further studies are
needed to evaluate the effect of different abdominal exercises in the reduction of the IRD during
the postpartum period. Given the high prevalence
and the concern, many women experience with
this condition, further high- quality randomized
controlled trials on the effect of different abdominal exercises on the DRA are warranted.
Measurements of other structures (muscle
length, thickness), comparison with multiparous
women, and longer follow-up studies than 6months
postpartum could be of value in future studies.
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Physiotherapy Treatment
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fortheAbdominal Wall
RafaelVicettoMartinez
22
22.1 Foreword
DRA is a complication of the abdominal wall,
generally underestimated by health professionals
that should be taken into account for its associated problems.
The linea alba is the anatomical structure on
which this lesion is based, and the evolution of
the patient will largely depend on the degree of
its distension.
The importance of raising patients’ awareness
of their daily activities is to enable them to make
correct management of pressures which will prevent worsening of diastasis. This will be crucial
to the recovery process of the abdomen, as gentle
training motions in hyperpresion will cause an
increase in pressure that may harm the abdomen.
Prior to any treatment based on abdominal
surgery, it is vital to strengthen the abdominal
wall. A specic program of exercises will result
in an approximation of the recti and an increase
in abdominal tone (within existing functional
limitations).
Supplementary Information The online version contains
supplementary material available at https://doi.org/
10.1007/978- 3- 030- 43840- 1_22.
R. V. Martinez (*)
Physical Therapy Clinic Vicetto, Madrid, Spain
e-mail: rafa@siovicetto.com
It is necessary to always perform an abdominal untrasonography as well as a manual examination of the area for a correct differential
diagnosis. Information must also be gathered
about existing pelvic oor status, lumbar pathologies, or digestive disorders.
22.2 Introduction
The disparity found in the prevalence of Diastasis
rectus abdomini (DRA) is due to differences in
the inter-rectus distance (IRD) considered normal or pathological, in the location of the point of
measurement (supraumbilical, umbilical or infraumbilical), in the measurement protocol (in rest
or in contraction of the lower abdomen), and in
the measuring instrument employed.
There is no international consensus as to the
degree of separation that should be considered
pathological, but not as to the location of the
measurement.
In a study with cadavers, Ratz etal. [1] found
that the width of the linea alba increases with age
and after 45years of age, mostly at the supraumbilical level.
These authors considered that, below 45years
of age, diastasis is pathological if the IRD is
greater than 10 mm in the supraumbilical area,
27mm at the level of the umbilicus, and 9mm
below it. Beer etal. [2], based on ultrasonography measures, suggest that in nulliparae, the IRD
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_22
367
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R. V. Martinez
should be considered normal if it is less than
22mm at 3cm above the umbilicus and 16mm at
2cm below.
Other authors, based on palpation, consider
that there is diastasis when the separation between
the recti of the abdomen is wider than two ngers
[3], or 2.5cm measuring with calipers and ultrasound scanner [4].
22.3 Patient Selection
We must take into account different points that
we explain below.
1. Importance of the Anatomy and Action in the
DRA
2. Pregnancy and Postpartum
3. Obesity/Overweight
4. Pelvic Floor
5. Musculoskeletal Problems (Low Back Pain
and Diaphragm)
6. Postures that Increase Intra-abdominal
Pressure and Worsen Diastasis
7. Evaluation of the Abdominal Muscle
22.3.1 Importance oftheAnatomy
andAction intheDRA
Previous studies have pointed out the important
role of the abdominal muscles on the stabilization of the pelvis, especially the transverse
abdominal, which acts as a corset [5, 6].
An association has been found between the
weakness of the abdominal muscles and the ability to stabilize the pelvis, both in pregnancy and
in the postpartum period, as a result of structural
adaptations of these muscles during gestation [7]
and may cause, among other problems, back pain
and pelvic oor dysfunction [8–11].
Studies with electromyography and ultrasonography have demonstrated a synergic coactivation of the abdominal muscles and the muscles of
the pelvic oor that would help to increase intravaginal pressure in situations of increased intraabdominal pressure, helping to maintain urinary
continence [12–15].
Given the importance of the abdominal muscles in the management of intra-abdominal pressures [15, 16], we consider it important to assess
the degree of diastasis present in the postpartum
period, to address adequately the recovery of the
webbing of the abdomen, and to avoid exercises
that may increase the damage (all those that
require the action of the rectus abdominis muscles, exors of the trunk, and hyperpressive
abdominal movements).
During the postpartum period, many women
resort to programs of abdominal strengthening in
an attempt to recover their gure as quickly as
possible, but the effectiveness of these programs
is not evidence-based and often prove to be
counterproductive.
It has been observed that IRD decreases during the isometric contraction of the abdominal
muscles [17] and that the decrease of the IRD in
the postpartum period was correlated with
improvements in the isometric strengthening of
the exors of the trunk; not to be confused with
the isometry which requires a shortening of the
muscle bers, from which the former differs
greatly [18].
On the other hand, the use of an abdominal
supportive belt immediately after birth seems to
be effective to decrease diastasis [19], as it
increases lumbo-pelvic stability and redirects
intra-abdominal pressure, unloading the lumbar
rachis [16].
22.3.2 Pregnancy andPostpartum
It has been shown that the IRD increases as pregnancy progresses, with prevalence in the third
trimester between 66.6 [3] and 100% [20].
Greater weight gain in pregnancy and parity
are factors associated with IRD [8, 9]. The prevalence of IRD remains high in the immediate
postpartum, being important enough in 53.3–
62.5% of women so as to require protection
exercises [3, 21].
This prevalence decreases in the postpartum
period, but it is not spontaneously resolved in
many women [3, 22]: 36–52.4% at 2 months
postpartum [3, 20] still show IRD, up to 39% at
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6months postpartum, and even a year after giving birth differences can be found with respect to
control groups [23].
It will be therefore important to design, during pregnancy, a correct exercise plan that
strengthens the abdominal area and prevents
abdominal hyperpressure, as well as to provide
general care of the abdomen in the postpartum
recovery period [11].
22.3.3 Obesity/Overweight
Overweight is one of the main parameters that
affect the linea alba via an increase of pressure in
the central line of the abdomen, which coupled
with eventual movements that require an activation of the rectus abdominis, increasing abdominal hyperpressure and with it abdominal
distension. Overweight women will show greater
diastasis, as visceral containment by the anterior
musculature of the abdomen becomes anatomically impeded because of the increased pressure
in the central line of the abdomen.
Overweight in the postpartum period is a decisive factor in both the establishment of abdominal diastasis and in its subsequent treatment, as
the excessive abdominal volume further complicates recovery in these cases.
22.3.4 Pelvic Floor
The key reason why we have to take into account
the structures of the pelvic oor in our assessment of the abdominal diastasis is that visceral
contents in pregnancy cause a considerable
weight increase in the urogenital area, so pregnant women are more prone to being affected.
Urinary incontinence will be more common in
patients who have increased abdominal distension, as the abdominal wall is weakened and cannot correctly manage pressure [16].
Abdominal diastases are often accompanied
by musculature weakening, which in turn causes
in many cases loss of urine, rectal dysfunctions
which hinder evacuation because of the change in
the ano-rectal angle (constipation, hemorrhoids),
low back pain because of a structural imbalance,
and changes to body biomechanics.
Recovery should be focused on postural control, avoiding positions that increase intraabdominal pressure, which may cause discomfort
and further problems to the pelvic oor.
The control of the exercises by the physiotherapist will be the key to a successful recovery of
the abdomen.
22.3.5 Musculoskeletal Problems
(Low Back Pain
andDiaphragm)
The abdominal space is delimited by the diaphragm in its superior part, by the perineal muscles in the inferior part, by the lumbar spine in
the posterior area, and by abdominal muscles in
the anterior area (transverse abdominis, internal
obliques, external obliques, and rectus
abdominis).
In ideal conditions of equilibrium, any variation in pressure should be equally distributed
throughout the entire abdominal space, affecting
all visceral except the urethra. This balance is
broken by diastasis.
Variations in abdominal pressure can be
brought about by performing physical activity
requiring trunk exing movements (classic “situps”) or by brusque reactions of the organism
such as sneezing.
Back injuries are one of the leading causes
associated to bad abdominal balance and IRD
dysfunction [5]. Lumbar spine re-education and
motor control are the bases for recovery in physical therapy.
Breathing itself implies a pressure variation in
the abdomen, as the descent of the diaphragm to
facilitate the entry of air to the lungs reduces
space and increases pressure.
A bad distribution of this pressure can cause
various physical problems (hernias, lower back
pathologies, lower extremities injuries, etc.).
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