Why Every Mum is Talking About Diastasis Recti?

I still remember standing in front of the mirror, weeks and months after giving birth, gently pressing my tummy and wondering, why does it still look like I’m pregnant?

If you have felt that soft bulge or gap down the centre of your tummy after pregnancy, you are definitely not alone.

Many mums have asked, “Is this Diastasis Recti?” and “How do I even check for it or prevent it from getting worse?”

Today, we asked Dr Pearlie Tan, a senior plastic surgeon in Singapore and former Head of Plastic, Reconstructive and Aesthetic Surgery Service at Sengkang General Hospital, who now runs her own private practice to share her insights on what Diastasis Recti really is, how you can check for it, and what you can do to prevent it from happening or worsening.

Meet Dr Pearlie Tan

Q: What inspired you to specialise in plastic surgery, particularly in treating Diastasis Recti and hernias?

A: I have always been keenly aware of how appearance can affect how one feels.

I remember my mother telling me that when I was much younger, a mother pulled her child away from me and said, “Do not go near her, she is diseased.” My mother replied, “She is not diseased, she has eczema.” That was back in the 1980s.

We had a book at home with black-and-white pictures of the “Elephant Man” and “Werewolf Boy” which always fascinated me, yet I remember feeling sad that the way they looked made them objects of curiosity and shame.

Image: Dr Pearlie Tan and her brother in their younger days.

As a medical student, I went to India for an elective. That was the first time I saw cleft lips, cleft palates, burn victims, and more. I believe my early awareness of how physical appearance affects emotional wellbeing inspired me to help others feel better in their own skin.

I have several focused interests in plastic surgery. As a trainee, I went through the full rigour of plastic, reconstructive, and aesthetic surgery.

However, after becoming a mother myself, I gained a more personal perspective on post-childbirth body contouring. In a way, I also felt a certain kinship with my mummy patients.

One of the rewarding parts of what I do is to make mothers realize that it is not their fault or lack of effort. Some things are just going to happen. I hope more women gain access to proper information and professionals to choose the right treatment for themselves.

Q: What is Diastasis Recti? 

Image provided by Pearl Plastic Clinic.

A: The word “diastasis” comes from the Greek word diástasis, meaning “separation.”

“Recti” refers to the two rectus abdominis muscles that run vertically along the middle of the abdomen, from the sternum to the pubic bone.

Medically, “diastasis” refers to an abnormal separation of parts that are normally joined. In the context of pregnancy and postpartum, “diastasis recti” is the separation of the rectus abdominis muscles.

Q: How would you explain Diastasis Recti to a new mum?

A: Using over 2cm separation as a criteria, there are some studies which show at 1 year post child-birth, approximately 33% women still have diastasis of recti, that means, approximately 1/3 women continue to have muscle separation which did not return to its original position.

Along-side the diastasis, many women also have a lot of excess skin resulting from the expansion of their tummy during pregnancy, and often-times, after child-birth, this skin does not contract back to pre-pregnancy state.

This explains why despite exercise and dieting after pregnancy, some women persistently have a “big tummy”.

Q: So why does diastasis of recti and excess skin happen?

A: As your baby grows in your womb, the uterus expands and pushes against your abdominal muscles which cause separation of the abdominis rectus muscles and also stretches the tummy skin.

Another effect the expanding womb has is to tent the diaphragm and cause the ribs to flare outwards, also known as “rib flaring”. This can sometimes cause pain as the ribs are pushed outwards.

Factors which make it harder for diastasis recti to recover:

Baby factors:

• Big or heavy baby
• Having multiples (twins or triplets)

Mummy factors:

• Multiple pregnancies
• Poor core muscle strength before getting pregnant. Research indicates that regular exercise before pregnancy appears to reduce the risk of diastasis recti and narrows the separation distance between the muscles. Strong muscle fibers are better able to spring back together versus weak muscle fibers.
• Age? Possible but I would say, an older yoga or pilates instructor would probably have a better chance of muscle recovery than a more sedentary younger woman.
• Higher amount of visceral fat as this intra-abdominal fat also plays a part in how much pressure is exerted on the abdominal muscles.
  
  

Q: What's your thoughts on Postpartum Care?

A: I believe every mummy wants to be supported as best as possible after childbirth. Depending on your views, beliefs, and the information you have at hand, some will choose to hire a confinement nanny, a Jamu massage lady, see a physiotherapist, etc.

Image: Dr Pearlie with her two children.

I myself did all of this, but the one thing I regret, was not paying attention to the importance of a good abdominal binder.

People may say, “Hey, you're a doctor!?” but honestly, I was pretty clueless about a lot of things post child-birth, of which one of them was the importance of a good abdominal binder, and what do I mean by good?

1. It should be comfortable enough to wear all the time, supporting the healing of your abdominal muscles and encouraging skin contraction.
   
   
2. The design of the binder matters. The first one I had (which was the most popular brand at the time) was just one big piece/flap. If you are on the shorter side, the binder can end up cutting into your breasts or thighs when sitting.
   
   And if you accumulated a lot of weight during pregnancy, honestly, it’s nearly impossible to get sufficient snugness with just one piece.

It was only with my second child that I found a 3-panel abdominal binder, which was super comfortable and allowed me to tighten each flap differently. I could make it snug around my waist and a bit looser near my hips, which made sitting much more comfortable.

Q: How do mums know if they have Diastasis Recti?

Dr Pearlie using the ultrasound to measure the amount of separation of muscle (diastasis recti).

A: As most women may feel nervous about pressing into their own tummy, if you suspect you have diastasis, it is best to have a medical/health-care professional perform a thorough physical examination and examine the extent of widening of your rectus muscles.

Physical examination: It is measured in finger widths, for example two to four fingers’ separation of the edges of rectus abdominis muscles.

Symptoms of Diastasis:

• Persistent abdominal bulge that doesn’t improve year after year
• Tummy shape is particularly round and looks like it’s sticking out and unusually disproportionate compared to pre-pregnancy
• Softness or jelly-like feeling around belly button
• Poor muscle strength can lead to poor posture
  
  

Q: How does it differ from a hernia?

A: Using a hammock as an analogy.

Imagine pre-pregnancy, the hammock is tied tightly at its 2 ends, someone lies on the hammock, because the hammock is tight, there’s not much downward bulging of the hammock.

Post-pregnancy, imagine the hammock is now loose, the same person lies on it, and there’s a lot more down-ward bulge of the hammock. The hammock is your muscles, and the person lying on it is your abdominal contents. This situation of bulge is diastasis recti.

Using the hammock again as an analogy.

Now there is a hole in this hammock, and this person’s elbow gets stuck through this hole. 

Again the person lying on the hammock is your abdominal contents and visceral fat. This situation is called a hernia as some of your abdominal contents is actually passing through this hole. And there’s a “neck” where the contents are passing through the hole which can, in some cases, strangulate the hernia.

Small umbilical (belly-button) hernias can be common in post-pregnancy women, and are usually an aesthetic problem. But umbilical hernias can rarely become strangulated and this is an urgent medical issue.

A worsening and widening of diastasis of recti can lead to a hernia which can pose both aesthetic and functional problems.

I have a patient who is very slim but has a belly that sticks out causing her T-shirt to ride up. When I asked about her medical history, she told me her last baby was very big and was also low-lying. I sent her to have a CT abdomen which confirmed a very wide diastasis with some herniation of a loop of colon. I repaired this hernia and removed a lot of excess skin to restore her flat tummy.

Myths vs Facts

Q: Is it true that all postpartum mums will naturally recover without treatment?

A: This depends on baby and mummy factors and how well supported your healing is after child-birth. Can read above on these influencing factors.

Q: Does wearing a binder or doing crunches help or harm?

A: Wearing a binder will always help and support recovery of the muscles to return to its original mid-line position. They should be worn immediately after giving birth and be worn whenever standing and walking.

Abdominal crunches can worsen the diastasis if done too early. 

While your muscles are trying to heal and get back to their original position, abdominal crunches done too early may have the opposite effect and push them further apart.

It is best to see a postpartum physiotherapist early to examine and advice the best form of exercises and muscle therapy depending on the stage of post child-birth you’re at.

Q: What are the non-surgical and surgical treatments available for Diastasis Recti?

A: The exercises taught by a qualified and experienced physiotherapist can help with the recovery of early diastasis recti.

Past a certain stage, if the muscles haven’t come back to the mid-line and you have a persistent bulge after more than a year, it is unlikely to be able to get back to the mid-line despite exercise and dieting.

Exercise and diet reduces fat, not addressing laxity (loose skin). For Diastasis Recti, there is no proven non-surgical treatment to repair.

Image provided by Pearl Plastic Clinic.

The only and most effective option will be surgical repair. Your plastic surgeon will do an abdominal examination and usually advise you to have a CT scan of the abdomen to accurately assess the extent of diastasis and check for hernias. He or she will then plan your surgery with you which is usually repairing the diastasis along with removing excess skin and fat i.e. tummy-tuck and repair of diastasis recti.

Q: What would you say to a mum who feels self-conscious or overwhelmed about her postpartum body?

A: Speak to someone you trust. Anyone who cares about you will want you to get the right help and advice.

Q: When is the right time to seek help?

A: The earlier you seek professional help, the better. It can save you both time and money.

If physiotherapy is what you need, starting the right exercises early increases your chances of muscle recovery.

Beyond a certain point, if exercises are no longer effective, surgical repair may be necessary. Even if you choose not to proceed with surgery, your decision should be based on correct and accurate information.

In summary, appropriate exercise and diet loses fat, not skin. Skin stretched past a certain extent, will not shrink back to its original state. No proven non-surgical treatment out there can repair Diastasis Recti. Depending on its degree of laxity (looser skin), there are surgical and non-surgical options that can tighten skin.

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Dr Pearlie Tan is a senior female plastic surgeon, was the Head of the Plastic, Reconstructive & Aesthetic Surgery Service at Sengkang General Hospital. Before this, she completed her residency at Singapore General Hospital, with rotations at KK Women’s and Children’s Hospital and National University Hospital. Dr Pearlie (as she is fondly known by her patients) now leads Pearl Plastic Surgery, Laser & Scar Clinic, offering extensive experience in plastic, reconstructive, and cosmetic surgery and minimally invasive non-surgical cosmetic procedures. Discover more: https://www.pearlplasticsurgery.com.sg/about-us

Note: This article shares insights from a plastic surgeon’s perspective and is for informational purposes only. Please consult your healthcare provider for personalised medical advice.

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