Diastasis Rectus Abdominal Muscle Separation (DRAM)
What is the Diastasis Rectus Abdominal Muscle Separation (DRAM) that people refer to post-delivery?
DRAM separation is primarily caused due to the separation of the connective tissue that joins the anterior abdominal muscles, primarily the Rectus Abdominis muscles, along the central line of the abdomen. The anterior abdominal wall provides a supportive brace for the back muscles. Together the back and abdominal muscles work synergistically together to protect the spine and allow for pain free and functional movements.
What is considered ‘a normal in DRAM separation? ‘
A DRAM separation is considered within normal range if the separation is between 1-2 fingers wide in gap. The depth of the DRAM separation should also be considered, as well as the abdominal muscle action can be felt with ease. Real Time Ultrasound (RTUS) can also be used to show images of the DRAM separation.
What are some of the complications that can develop due to a DRAM separation?
When there is a break down in this central front wall the following may occur:
Hernia- a hernia is when an organ or part of an organ such as the intestine pushes through the gap in the anterior abdominal wall. A lump is felt just below the skins surface or can be seen and felt on the surface both at rest and or with movements. Umbilical “belly button” hernias are common in pregnancy and in most cases do not require any surgical repair.
Lower back pain- is a common symptom described by clients. Clients often describe: the feeling of their “back just isn’t supported or is going to “give way”. Pain with moving in and out of bed or while sleeping, or a sudden lower back pain, whenever they go to lift their baby, car seat or pram. This may occur immediately post birth or for years after giving birth.
Pelvic Floor Dysfunctions (PFMs) such as: Incontinence (the leakage of urine, gas, or faeces) that continues more than eight weeks postpartum. Constipation, painful intercourse, or vaginal pain at rest and or this any activity. A mummy belly that looks like a 4-month pregnancy belly, even after the mother has given birth.
Digestive changes – commonly described as either constipation and or Irritable Bowel symptoms. Increase in abdominal gas or a distended abdomen for unknown reasons. Typically, mums will notice a bloated belly later in the day / evening and or with any exercises. They diet, change their diet and still their belly persists months, to years after giving birth.
If mums are experiencing or noticing any of the above signs or symptoms, I would encourage them to seek a trained professional diagnosis.
What can women do during pregnancy to help prevent DRAM from occurring?
During pregnancy there are a few key considerations pregnant women needs to put in place in their daily functional life. They are:
To always aim to breathe rhythmically and in their natural breathing pattern. To avoid breath holding or even a minor “Valsalva” manoeuvre. That is closing off the epiglottis, at the back of the throat and bearing down. This is a similar action to straining, when constipated. This sort of action may cause a change of pressure in the internal system, forcing pressure down on the PFMs and strain on the abdominal muscles.
In any action such as lifting a toddler, a car seat or pram, aim to always breathe well and not breathe hold and or bear down! If you think you do or may breathe hold sing whistle, hum, and chat away. You cannot breathe hold and do this at the same time!!
If you feel you are going to do this the “load” is too heavy – stop!
I do not recommend doing sit ups when pregnant, as this action may cause separation of the abdominal muscles.
When is surgery an option to close the DRAM separation?
In cases where the DRAM separation is both deep and wider than 2 fingers, it may be recommended to have a Diagnostic Ultrasound conducted with a Sonographer or trained Clinician. That way the depth, width and quality of the underlying and surrounding muscles and tissues can be determined.
In cases where a tear in the connective tissue, the abdominal walls or muscles is detected and is possibly likely to hinder safe actions of the muscles, surgery may be an option.
DRAM surgical repair is widely done with General and Plastic Surgeons here in Singapore. No surgery should ever be taken “lightly”, and I believe should always be the second option to conservative management, with exercise and rehabilitation being the first action taken with a trained Physiotherapist in this area. If you decide on surgery you should always aim to strengthen your abdominal muscles beforehand, as doing so will help support the sutures and surgery.