Initial Management of Postpartum Diastasis Recti
Women with postpartum diastasis recti should be referred to physiotherapy for core stabilization exercises and counseled to avoid traditional abdominal curls, while continuing aerobic activities like walking. 1
First-Line Conservative Management
Physiotherapy Referral and Exercise Prescription
- Refer immediately to a physiotherapist specializing in pelvic floor dysfunction for supervised core stabilization exercises. 1
- Core stabilization exercises combined with an abdominal corset for 8 weeks produces superior outcomes compared to either intervention alone, improving inter-rectus distance, trunk muscle strength, endurance, balance, and disability scores. 2
- Neuromuscular electrical stimulation (NMES) combined with abdominal exercises three times weekly for 8 weeks significantly improves abdominal muscle strength (peak torque, total work, average power) and reduces inter-rectus distance more effectively than exercises alone. 3
Exercise Modifications and Safety
- Avoid traditional abdominal strengthening exercises (abdominal curls, sit-ups) during pregnancy and early postpartum as these may worsen the separation. 1
- However, recent evidence demonstrates that supervised curl-up exercises starting 6-12 months postpartum do not worsen inter-rectus distance and actually increase rectus abdominis thickness (0.7 mm improvement) and strength (9 Nm improvement at 10 degrees). 4
- Continue aerobic exercise such as walking throughout pregnancy and postpartum, as this is associated with decreased odds of developing diastasis recti. 1
Assessment Parameters to Monitor
Clinical Examination
- Measure inter-rectus distance using ultrasound at rest and during curl-up maneuver (normal: ≤28 mm at rest, ≤25 mm during curl-up). 4
- Assess for midline abdominal bulge without fascial defect on physical examination. 5
- Evaluate trunk flexion strength, endurance, and balance as functional outcome measures. 2
Risk Stratification
- Identify high-risk patients: multiparous women, obese patients, those with multiple previous abdominal operations. 5
- Assess severity using classification systems based on degree of separation between paired midline rectus muscles and myofascial deformity. 5
Treatment Duration and Expected Outcomes
- Prescribe an 8-week supervised physiotherapy program as the standard treatment duration. 2, 3
- Antenatal exercise reduces the presence of diastasis recti by 35% (RR 0.65,95% CI 0.46 to 0.92). 6
- Both antenatal and postnatal exercise programs reduce inter-rectus distance width, though evidence quality remains limited. 6
When Conservative Management Fails
- Surgical intervention (midline plication, extensive anterior abdominal wall plication, or mesh reinforcement) is reserved for severe cases unresponsive to 8+ weeks of conservative therapy. 5
- Optimal surgical management depends on degree of severity and extent of myofascial deformity. 5
Critical Pitfall to Avoid
The traditional teaching to avoid all abdominal exercises may be overly restrictive—while avoiding curls during pregnancy and early postpartum (0-6 months) is prudent 1, supervised curl-up exercises starting 6-12 months postpartum are safe and beneficial for strength without worsening separation. 4