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, uterus and rectum are pelvic organs, supported in the pelvic cavity by connective tissue (ligaments and fascia). The pelvic floor muscles also support the pelvic organs 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!

Image provided by Ciaran from Continence Foundation of Australia

If these supportive tissues are weakened or stretched, the pelvic organs are not as strongly supported and can push down into the vaginal wall. Thisbulging or sagging of the pelvic organs into the vagina is called prolapse.

Weakness in the pelvic floor muscles means there is also less upward support for the pelvic organs. So if the supportive tissues are stretched or weakened AND there is less support from the pelvic floor muscles underneath this may allow the prolapse to worsen.


What Causes Prolapse?

Some of the factors 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 people with 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 to see or feel a small lump or bulging inside the vagina or at the entrance to your vagina
  • You may notice some changes or difficulty with completely emptying your bladder or bowel
  • You may notice a difference during sex

How Can You Prevent & Treat Prolapse?

When looking at what you can do to prevent or treat prolapse, we need to remember the factors above that increase your likelihood of prolapse – and not all of these can be changed or avoided!

But here are some things to address if you have some degree of prolapse or that you are able to 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
Image provided by Ciaran
  • 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!

When you are assessed by a pelvic floor physiotherapist, they will be able to discuss all your management options and find the best plan that reduces your symptoms and gives you the freedom and confidence to return to the activities that 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 you have four layers:

  1. On the surface is your “six-pack muscles” rectus diastasis then
  2. External obliques then
  3. Internal obliques and then
  4. The deepest layer is your transversus abdominus.

Now the surface muscle rectus abdominus has two muscles running vertically and parallel to each other with a band of connective tissue (the linea alba), in between. During pregnancy in order for your 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, that needs to occur for your body to accommodate your growing baby!

Image provided by Ciaran

Imagine the linea alba is like a piece of glad wrap, as your stomach grows the glad wrap keeps getting stretched and is pulled taut by your stomach. Then after giving birth, the glad wrap won’t always go back to it’s original shape right away and it will be a bit thinner and less 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 doing other tasks that load the abdominal wall. For many women there will be normal recovery that happens after they give birth.

* Studies have found that this “gap” will generally remain slightly larger in women who have had a baby compared with those who haven’t had a baby. For around 60% of women, the separation won’t persist past 6-months postpartum.   

In the past there has been a large focus on the inter-recti distance i.e. the “gap” between the abdominal muscles. Women would often be told that their separation was “2-fingers wide” or “4-fingers wide” when assessed by healthcare professional. Unfortunately, this then meant that women became focused on “closing the gap” rather than on rehabilitating their abdominal wall as a whole!

Remember that there are four layers of muscle in the abdominal wall. Ideally these four layers should work together in a coordinated fashion, so that your trunk can accommodate loads well and function to transfer loads from upper body to lower body and vice versa!

Rather than just assessing the “gap”, your physiotherapist will also assess how your abdominal wall works when put under load. 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 or obvious overuse of some abdominal muscles and underactivity in other abdominal muscles!

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 like stretches, activation or strengthening exercises to rehabilitate how you activate 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?
Image provided by Ciaran

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 the sidelines of women’s sports fields and within private practice locations, she developed an interest in helping women with both musculoskeletal and pelvic floor issues! She has completed postgraduate courses in pregnancy physiotherapy, hip, pelvis and rib pain and women’s health management of incontinence, prolapse and return to sport screening!

She is passionate about working with women through their pregnancies and into the postpartum period, to help them remain active or return to the activities that they love!

Outside of the clinic, Ciaran has her hands full with 8-month old Owen. She is also a keen runner and loves a good sandhills session or more recently a run with Owen in the running pram!

Contact Details and to book an appointment with Ciaran:

Fit and Flow Physiotherapy

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. 
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