Postpartum Exercise: What You Need To Know From A Women's Health Physio - Part 2: Abdominal Separation & Prolapse
This blog is Part 2 in the "Postpartum Exercise: What You Need To Know From A Women's Health Physio" series. If you haven't read Part 1 yet, I'd recommend jumping to that blog and reading it first before getting into this post :) Click here to read part 1.
Prolapse
4 in 10 women are affected by pelvic organ prolapse at some stage in their life.
What Is Prolapse?
The bladder, uterusand rectum are pelvic organs, supported in the pelvic cavity by connectivetissue (ligaments and fascia). The pelvic floor muscles also support the pelvicorgans from underneath.
Look at the image of the child on a trampoline below. The child represents your pelvic organs i.e. your bladder, uterus and bowel and the trampoline represents the connective tissue structures that sling up and support your pelvic organs. The hands pushing up from the underside of the trampoline are your pelvic floor muscles when they contract!
If thesesupportive tissues are weakened or stretched, the pelvic organs are not asstrongly supported and can push down into the vaginal wall. Thisbulgingor sagging of the pelvic organs into the vagina is called prolapse.
Weakness inthe pelvic floor muscles means there is also less upward support for the pelvicorgans. So if the supportive tissues are stretched or weakened AND there isless support from the pelvic floor muscles underneath this may allow theprolapse to worsen.
What Causes Prolapse?
Some of thefactors that increase your likelihood of having prolapse are:
- Having a baby
- Family history
- Lifestyle factors like excessive heavy lifting or manual labour
- Medical conditions like chronic constipation or chronic coughing (in peoplewith emphysema or asthma)
What Are The Signs & Symptoms of Prolapse?
Some signs or symptoms that may point towards prolapse:
- A feeling of dragging,bulging or heavy sensation in the vagina.
- You may be able tosee or feel a small lump or bulging inside the vagina or at the entrance toyour vagina
- You may noticesome changes or difficulty with completely emptying your bladder or bowel
- You may notice adifference during sex
How Can You Prevent & Treat Prolapse?
When lookingat what you can do to prevent or treat prolapse, we need to remember thefactors above that increase your likelihood of prolapse – and not all of thesecan be changed or avoided!
But here aresome things to address if you have some degree of prolapse or that you are ableto change for good pelvic health even if you don’t have any prolapse…
- Avoid straining on the toilet when trying to pass a bowel motion: If you are prone to constipation you should take steps to address this, for some women this means increasing fluid intake or fibre intake or using stool softeners for a period. When you are on the toilet the following position (see across) may make it easier to pass a bowel motion, simply use a small step stool to elevate your knees higher than your hips and lean forward resting your elbows on your knees and relax your stomach, avoid straining/pushing down!
- Strengthening your pelvic floor will provide more support to your pelvic organs and the supporting connective tissues: Imagine that those hands (pelvic floor muscles) are really pushing upwards to support the child (pelvic organs) on the trampoline (connective tissues), there would be less strain or downward pull on the trampoline (connective tissues). This is where your pelvic floor physiotherapist can work with you to start a strengthening program which may reduce your symptoms of prolapse
- Be fitted with a pessary: There are also other treatment options that may reduce the symptoms of your prolapse e.g. your pelvic floor physiotherapist may be able to fit you with a pessary. A pessary is a flexible plastic device that is inserted into the vagina and thus supports the vaginal walls from the inside helping to “hold up” any prolapse. It has been found to be as effective at reducing prolapse symptoms as surgery!
Whenyou are assessed by a pelvic floor physiotherapist, they will be able todiscuss all your management options and find the best plan that reduces yoursymptoms and gives you the freedom and confidence to return to the activitiesthat you love!
“Abdominal Separation” (Rectus Abdominus Diastasis)
By the third trimester of pregnancy, around 60-100% of women experience a stretching or widening in the connective tissue between their abdominal muscles, this is called rectus abdominus diastasis.
There is a lot of attention on “abdominal separation” in the postpartum period. Numerous internet sites and exercise blogs focus on exercises to “close the gap” and “fix” abdominal separation. These articles and exercise blogs are misleading and are providing women with the wrong focus when they are looking to rehabilitate their abdominals after pregnancy! Let’s first of all talk about abdominal “separation” in more detail and then discuss exercise.
What Is Rectus Abdominus Diastasis?
Rectus abdominus diastasis (also known as abdominal separation) is the stretching or widening in the connective tissue between their abdominal muscles.
If you picture your abdominal muscles youhave four layers:
- On the surface is your“six-pack muscles” rectus diastasis then
- External obliques then
- Internal obliques and then
- The deepest layer is your transversusabdominus.
Now the surface muscle rectus abdominus hastwo muscles running vertically and parallel to each other with a band ofconnective tissue (the linea alba), in between. During pregnancy in order foryour body to make room for a growing baby, the band of connective tissue,called the linea alba, will stretch or widen. This is a NORMAL process, thatneeds to occur for your body to accommodate your growing baby!
Imagine the linea alba is like a piece ofglad wrap, as your stomach grows the glad wrap keeps getting stretched and ispulled taut by your stomach. Then after giving birth, the glad wrap won’talways go back to it’s original shape right away and it will be a bit thinner andless taut.
* With abdominal separation there is no tearing or hole in the abdominals that needs to rejoin or heal after pregnancy. Your abdominal muscle layers as still intact, albeit weaker and still lengthened after the pregnancy, and your connective tissue is stretched and wider/thinner.
Assessing The Gap
Women will often notice a “gap” or a“bulging” in the centre of their stomach when sitting up from lying or doingother tasks that load the abdominal wall. For many women there will be normalrecovery that happens after they give birth.
* Studies have found that this “gap” willgenerally remain slightly larger in women who have had a baby compared withthose who haven’t had a baby. For around 60% of women, the separation won’tpersist past 6-months postpartum.
In the past there has been a large focus onthe inter-recti distance i.e. the “gap” between the abdominal muscles. Womenwould often be told that their separation was “2-fingers wide” or “4-fingerswide” when assessed by healthcare professional. Unfortunately, this then meantthat women became focused on “closing the gap” rather than on rehabilitatingtheir abdominal wall as a whole!
Remember that there are four layers ofmuscle in the abdominal wall. Ideally these four layers should work together ina coordinated fashion, so that your trunk can accommodate loads well andfunction to transfer loads from upper body to lower body and vice versa!
Rather than just assessing the “gap”, yourphysiotherapist will also assess how your abdominal wall works when put underload. If your abdominal wall is working in a coordinated way when taking load,we shouldn’t see obvious bulging (or doming) in the centre of your abdomen orobvious overuse of some abdominal muscles and underactivity in other abdominalmuscles!
If you notice an obvious “gap” or “bulging”when your abdominal wall is under load, you may benefit from physiotherapy.Your physiotherapist will provide you with individualised exercises likestretches, activation or strengthening exercises to rehabilitate how youactivate your abdominal muscles.
Exercises For Abdominal Separation
Alot of your questions are asking for exercises to do or avoid for abdominal separation. This is difficult because you will need to be assessed by a physiotherapist to see which muscles you overuse or do not activate when doing abdominal exercises and what positions you can achieve a coordinated abdominal activation! But here are some pointers when choosing abdominal exercises:
- Monitor your abdominal wall to begin with when trialling abdominal exercises and if the centre of your abdominal wall is “bulging”/”doming” (see below picture) then the exercise is either too difficult or not the right exercise for you currently and needs to be changed to another exercise!
- You do not need to avoid all abdominal exercises when you have abdominal separation, but you do need to choose the appropriate level of difficulty for what your abdominal muscles can achieve a coordinated activation!
- You need to gradually increase the difficulty of your abdominal exercises to load your abdominal muscles and allow them to get stronger too!
- Activating pelvic floor muscles will provide some women with an activation in the deepest layer of their abdominal wall (transversus abdominus). This transversus abdominus activation is often an important part of achieving a coordinated activation of the abdominal wall and thus reducing the bulging. So, doing your pelvic floor exercises may also help your abdominal rehabilitation!
- If you haven’t yet been assessed by a physiotherapist, the best start for your abdominal rehabilitation is to start some deep breathing and pelvic floor exercises (again remember that many women need to be assessed to achieve the correct pelvic floor activation too!). Check that you can achieve a slow deep breath into the sides of your rib cage and check if you can squeeze your pelvic floor as if you are drawing a tampon or straw up inside yourself. Can you activate your pelvic floor and do a deep breath as the same time?
About Ciaran
Ciaran Fox (nee Williams) is a physiotherapist based in Caringbah, Sydney. Ciaran has a strong background in musculoskeletal, sports and women’s health physiotherapy.
Having started her career working on thesidelines of women’s sports fields and within private practice locations, shedeveloped an interest in helping women with both musculoskeletal and pelvicfloor issues! She has completed postgraduate courses in pregnancyphysiotherapy, hip, pelvis and rib pain and women’s health management ofincontinence, prolapse and return to sport screening!
She is passionate about working with womenthrough their pregnancies and into the postpartum period, to help them remainactive or return to the activities that they love!
Outside of the clinic, Ciaran has her handsfull with 8-month old Owen. She is also a keen runner and loves a goodsandhills session or more recently a run with Owen in the running pram!
Contact Details and to book an appointment with Ciaran:
Ph: (02) 8544 3680
6/345 Kingsway Caringbah, NSW 2229
Editor's Note: This post is for information purposes only. Always consult your health care professional for personalised advice.
