Diastasis of the Rectus Abdominus Muscle (DRAM) Cork University Maternity Hospital

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1 Diastasis of the Rectus Abdominus Muscle (DRAM) Cork University Maternity Hospital What is diastasis of the rectus abdominus muscle? The rectus abdominus muscle sits on top of all the other muscles of your abdomen. It has a left and right muscle belly, which are connected in the middle. DRAM is simply a thinning and widening of the tissue connecting the left and right sides of the muscle. Doming of the muscles when going from lying to sitting Is it common? A certain amount of separation in pregnancy is normal as it allows your abdomen to expand and make room for the growing baby. Consequentially, doming, or bulging forwards of the abdominal muscles may have been noted during pregnancy while trying to come to sitting from lying, or getting out of the couch or bath Over a third of women will have a gap of two fingers or more after their first baby. Factors that make a DRAM more likely to occur are: Multiple Pregnancies Large sized babies Increased weight size of the mother Poor collagen make-up in the skin Chronic constipation Persistent heavy lifting Self-check for DRAM Can be checked from 2 days to 1 week post natal This is a test, not an exercise Lie on your back with your knees bent and your feet flat on the floor. Place one hand behind your head, and the other on your abdomen, with your fingertips across your midline parallel with your waistline at the level of your belly button.

2 With your abdominal muscles relaxed, gently press your fingertips into your abdomen at the level of your belly button. Use the hand behind your head to help you do a sit up like action. Roll your upper body off the floor into a crunch, to bring your ribcage closer to your pelvis. You should feel the gap narrowing above your belly button around your fingers as you lift your head off the bed. If the gap is greater than 2 fingers in width, you need to follow the advice on the following pages to help reduce the DRAM. Repeat this test at 6-8 weeks postnatal. Ideally this gap would be less than 2 fingers. If the gap is greater than 2 fingers and there is obvious doming of your abdominal muscles with day to day activities, a review with a Chartered Physiotherapist is advisable. How can I help my DRAM heal? 1.Use an abdominal support if the gap is greater than 2 fingers Tubigrip provided by your physiotherapist and/or elastic supportive underwear which comes over your belly button should be worn as often as possible for the first 6-8 weeks especially when you are active during the day. 2. Abdominal Exercises for the first 6-8 weeks postnatal: You can start these exercises immediately after the birth of your baby or when you feel well enough. Exercise 1: Transversus Abdominus This is your deepest abdominal muscle. It is like the body s natural corset. It works gently all day long to support your abdomen. By doing this it gives support to your back and pelvis. The easiest position to start this exercise is in side lying as in the picture below. Once it becomes stronger in this position you can also practice it in sitting and standing. Take the above given position. Let your tummy sag. Breathe in gently. As you breathe out, draw your lower tummy in gently towards your back as if you are pulling up the zipper of your pants. It may also make it easier to feel the muscle work if you place your hand on your lower tummy below your belly button. As you breathe out and draw the lower tummy in gently, you should feel it move away from your hand. Aim to start holding for 3 seconds and progress to holding for 10 seconds.

3 You should be able to breathe and talk while doing this exercise. Try and increase the number of times you do this in a row, start with 4-5 times, gradually increase to 10 times Little and often during the day i.e.4-5 times is good to practice this exercise, particularly in the first few weeks after your baby is born. This will help build up the stamina of this muscle quickly for you. You may notice your pelvic floor muscles working while doing this exercise. This is quite normal as both muscles work together to support your pelvis and back. If you have had a c-section and are having difficulty doing this exercise, you may in fact find it easier to do this exercise by first drawing up your pelvic floor and then draw your tummy in gently. Exercise 2: Pelvic tilting Lie on your back with your knees bent and your feet flat on the bed/floor. You will feel a small gap between your lower back and the bed/floor. Gently draw in your lower tummy muscle as in Exercise 1 and then roll your pelvis back to flatten your back completely onto the bed/floor. If you find your abdominal muscles are doming or bulging forward go more gently with this exercise to avoid this. Aim to start holding for 3 seconds and progress to holding for 10 seconds. Start off doing as many repetitions as you can comfortably. Gradually aim to build that you could do 10 repetitions in a row. Aim to do this exercise 1-2 times daily 3.Back care to protect the abdominal muscles: Getting in/out of bed: Use the following technique for getting in and out of bed particularly in the first 6-8 weeks postnatal Getting out of bed: Engage and draw in your lower tummy as shown in exercise 1. If you feel your tummy muscles are weak, also engage the pelvic floor muscles

4 1. Bend your knees up and roll over onto your side. 2. Bring your hands across to grip the edge of the bed for support. 3. Drop both your legs over the edge of the bed. 4. Use your elbow and hands to push yourself into a sitting position. Getting into bed: Reverse the above process. Support your tummy when opening your bowels: Try and avoid being constipated by maintaining a high fibre diet and ensure you have an adequate fluid intake (1.5-2 litres/day). To support your abdomen when opening your bowels. Sit on toilet with your feet flat on the floor. Cross your arms across your abdomen as shown in the pictures below to add support. Lean forwards, this makes it easier for your back passage to widen and open Give yourself plenty of time, 5-10 minutes, to allow your bowels time to work. Try and avoid straining on the toilet as this will increase pressure on the abdominal muscles. If you need to strain, breathe out and give support to your abdomen with your hands while giving pressure down towards your back passage. Lifting and heavy work: Engage and draw in the lower abdomen as shown in exercise 1 before lifting. If you feel the abdomen muscle is weak, also engage the pelvic floor muscles. Know the maximum weight you can lift with ease. Minimise the amount of heavy lifting or heavy housework you do, as it strains the abdominal muscles.

5 Tips for lifting toddlers and children: Before lifting a small child, bend your knees, keep your back straight and engage your abdominal muscles (Exercise 1). Lift only for the minimum amount of time and distance. Instead of lifting: Kneel down to comfort them or sit and let them climb up to you Let them climb into and out of the car seat by themselves if possible. Get them to stand up in the cot when taking them out and put them back into the cot in a standing position. Posture when sitting and standing: Your abdominal or tummy muscles support your middle when you are sitting or standing. To encourage the muscles to continue doing this and to help strengthen them at the same time, take care with your posture when sitting or standing Sitting Slouching while sitting will stop your tummy muscles working. Sitting very tall will put them under strain along with your back and pelvis. Aim for halfway between these two positions. Ensure your feet are well supported on the ground and if the back of the chair doesn t support you to sit in this halfway position use a pillow/cushion behind you This is particularly important when you are feeding your baby. Standing Poor Posture Good For the first few weeks after your baby is born try not to stand for long periods. Because your tummy muscles are weak, they will tire quickly causing you to slouch when you stand. Use your tubigrip or support underwear for the first 6-8 weeks after your baby is born. Using the support, try and stand tall, drawing in your lower tummy muscle as given in Exercise 1. This is particularly important when holding your baby. The extra load of carrying your baby will challenge the tummy muscles more and will make you more likely to slouch

6 Return to exercise gradually: You can commence gentle walking as soon as you feel comfortable. Start with 5-10 minutes on a flat surface and increase as you feel comfortable Swimming (usually after your 6 week post natal check) Cycling, 6 weeks post natal (once you can sit comfortably) Post natal modified Pilates at 8-10 weeks postnatal. General Pilates can be too difficult for the first 6 months postnatal High impact exercise should be avoided before weeks postnatal and until your abdominal separation has reduced to 2 fingers. This includes running, step aerobics, tennis and yoga. Progression after 8 weeks postnatal: The Physiotherapy Department, CUMH does not provide a postnatal service for DRAM. It is advisable to seek an assessment with a Chartered Physiotherapist in Women s Health and/or attend postnatal Pilates classes: When progressing to higher level abdominal exercise regime. If there is doming of your abdominal muscles when doing higher levels of exercise. If exercise causes discomfort in your tummy, back or your pelvic floor muscles. If there is a gap of greater than 2 fingers at your 8 weeks postnatal selfcheck of your DRAM. For details Physiotherapy Department Cork University Maternity Hospital Tel no