ABSTRACT
Diastasis Recti (DR) is a common muscular condition often present during and after pregnancy. This cross-sectional correlational study investigated the prevalence of DR among pregnant and postpartum women. A total of 250 pregnant and postpartum women were recruited using convenience sampling technique from obstetrics and gynaecology department, Aminu Kano Teaching Hospital, Kano, Nigeria. Age, body mass, height, BMI, parity, trimester, duration of DR postpartum, location of DR and DR status was recorded for each participant. Presence of DR was confirmed using the finger width method. Descriptive statistics of mean, SD, percentage were used to describe the data and determine the prevalence. Inferential statistics of Pearson’s and Spearman’s correlation were used to analyse the relationship between
prevalence of DR and age, parity and duration of DR postpartum. Chi square was computed to determine the difference in prevalence of DR across trimesters. The result of this study indicated high prevalence of DR in post-partum and pregnant women (84% and 64.7% respectively); the most common location of DR was at the
umbilicus in both pregnant and postpartum women. Prevalence of DR was high among the multigravida; and a significant relationship was found between prevalence of DR and age and parity of participants. There was a significant difference in prevalence of DR across the trimesters. It can be concluded that prevalence of DR among pregnant and postpartum women is high; age and
parity are determinants of DR prevalence. Evaluation of DR should be considered as routine assessment in both pregnant and postpartum women.
KEYWORDS
Diastasis Recti, Prevalence, Postpartum, Pregnancy, Location, Trimester
Fatima Bichi
Physiotherapist
Physiotherapy Department,
General Ahmadi Rimi Orthopedic
and Specialty Hospital, Katsina,
Nigeria
Dr. Shmaila Hanif
Assistant Professor
Physiotherapy Department,
Faculty of Allied Health Sciences,
College of Heath Sciences,
Bayero University, Kano, Nigeria
[Bichi F, Hanif S. Diastasis Recti among Pregnant and Postpartum Women in Kano, Nigeria: A Cross-Sectional Study. Pak. j. rehabil. 2017;6(1):15-20]
INTRODUCTION
Diastasis Recti (DR) is a muscular condition which occurs commonly during pregnancy and postpartum1-4; having main predisposing factors as multiple pregnancies, high body mass index, multiparity, large fetus, flaccid abdominal muscles and polyhydramnios5. It may be a transitory condition 6,7 or may remain throughout life 2,3,8. Diastasis recti is a midline separation of the two rectus abdominis muscle along the linea alba which causes widening of the linea alba 1,9. This condition is the most obvious visible change during and after pregnancy (postpartum)10,11.
Hormonal changes caused by relaxin, progesterone and estrogen coupled with growth of the uterus during pregnancy may stretch the abdominal muscles, which may affect the rectus abdominal muscles 12-14; thus leading to occurrence of DR15. Excessive distension may interfere the function of the abdominal muscles in stabilizing the trunk and this may lead to development of lumbar pain 2,8. Diastasis recti may appear as a ridge running in the midline of the abdomen, between the xyphoid process and the umbilicus. Straining the abdominal muscles makes the DR more prominent, though it may disappear once relaxed16.
Diastasis recti commonly occur in women who have had multiple pregnancies, because the muscles have become stretched during each pregnancy 17,18. Expansion of the abdomen is the most visible change that occurs during pregnancy causing some abdomens to become extensively damaged with very few accommodating this stretch10.
In early pregnancy, the signs of DR include extra skin and soft tissue in the front of the abdominal wall 17,18. However, with increasing size of abdomen during pregnancy, the top of the uterus bulges out of the abdominal wall with an outline of some parts of the fetus in severe cases of DR17,18. Diastasis recti of different severities that occur in pregnancy may not
resolve on its own postpartum17.
Boissonnault and Blaschak 19 reported a greater prevalence of DR during pregnancy (in the 3rd trimester) than during the early postpartum period. Boissonnault and Blaschak19 also reported a higher prevalence of DR in immediate postpartum period than in later postpartum period. There was a high
prevalence of postpartum DR in the study conducted by Spitznagle et al3. With respect to parity, Lo, Candido and Janssen20 reported a high prevalence of DR postpartum among multiparous compared to nulliparous and the incidence of DR increases with increasing age and parity of the mother. Similarly, Spitznagle et al3 reported a comparatively higher prevalence of DR among older (over 50 years) and multiparous women as compared to a study conducted by Lo et al20. The location of DR has been found out to vary at the umbilicus, above or below the umbilicus4,15,19 and this information is yet undiscovered in this part of the country.
A number of studies3,11,19,21,22 reported that the presence of DR can predispose an individual to certain conditions such as affectation of trunk stability, respiration, bowel movement, visceral support, and urinary as well as fecal incontinence. Studies have not been carried out here in Kano concerning DR. Thus, the major purpose of this study was to determine the prevalence of DR in primigravida and multigravida pregnant and postpartum women at different DR locations in Kano, Nigeria. Also, this study determined relationship between
the prevalence DR, age, parity and duration of DR postpartum.
METHODS
This study is a cross-sectional correlational study. The population of this study comprised of pregnant and postpartum women in Obstetrics and Gynecology (O & G) department, Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria. A total of 250 subjects were drawn from O&G department, both antenatal and post-natal clinics, AKTH, Kano. Convenient sampling technique was employed for the recruitment of study participants with the following inclusion and exclusion criteria:
Inclusion Criteria
Subjects aged between 15-55 years; both pregnant and postpartum women; postpartum women who have had either normal delivery/ caesarian section (CS); recruitment would be 8 weeks postpartum.
Exclusion Criteria
Women with abdominal surgeries (except CS)
Data Collection Instrument
These included:
1) Finger width method19: This was used to determine the presence DR.
2) Stadiometer (SECA gmbh/Germany): This was used to assess height and body mass of participants.
Data Collection Procedure
Approval to conduct the study was sought from the ethical committee of AKTH, Kano. Subjects were recruited from O & G department, both the ante-natal and post-natal clinics, AKTH. They were provided with information concerning the study and a consent form to sign. The following were recorded:
1) Age: The age of participants was recorded in years.
2) Parity: The number of deliveries was recorded.
3) Duration of DR Postpartum: This was recorded in weeks/months.
4) Stature: Participants height was measure barefoot or wearing thin socks. The participants were instructed to stand with their back against the stadiometer with their heels together. The horizontal bar was placed down firmly onto the top of the head
and the measurement was recorded23.
5) Body Mass: Participant weights were measured using a standard weighing scale with provision for calibration. Subjects were asked to present themselves in light clothing and to remove all heavy objects prior to measurement. They were then instructed to step on the weighing scale barefooted and stand erect, with the face looking straight forward and their hands by the side. The reading was then taken and recorded to the nearest 0.5kg24.
6) Body Mass Index (BMI): BMI is computed by diving the participants’ weight in kilogram to the square of their height in meter25.
BMI26= Body mass (kg)/Stature (m2)
7) Trimester: This was recorded as first, second or third trimester.
8) Location of DR: this was recorded as either above, at or below the umbilicus.
9) Inter-recti distance & location of DR: The subjects were examined for the presence of DR using the finger width technique. DR was measured with fingers because that is the easiest way to tell exactly how far the muscles have separated. Diastasis recti was classified as present or absent according to Nobles criteria1, that is, any separation above, below or at the umbilicus of less than or equals to two finger width was considered normal and anything greater constitute a DR. When using the finger width technique, the subject lay supine with the hip and knee flexed at 90°, feet flat and arms
extended. The subject was then instructed to perform a forward trunk flexion until the inferior angle of the scapula is off the bed.
The reference points for DR measurement are at, above and below the umbilicus. The assessor places the fingers perpendicularly between the rectus abdominis muscles on forward flexion of the trunk. The number of fingers between the medial edges of the rectus abdomins muscles, above and below the umbilicus, was used to grade the severity of diastasis. Each finger breadth is assumed to represents 1.5 cm. Diastasis recti was considered present and relevant if th separation was greater than 2 cm between the two recti muscles.
10) Location of DR: This was recorded as above, at or below the umbilicus.
Data Analysis Procedure
Descriptive and inferential statistics was used to analyze data. The mean and standard deviation was used to describe the age, body mass and stature of study participants. Simple percentage was computed to determine the most common location of DR and the prevalence of DR. Pearson product moment correlation was used to determine the relationship between the prevalence of DR with mothers’ age and duration postpartum. Spearman rank order correlation was computed to determine the relationship between the prevalence of DR and parity. Chi square was used to determine significant difference in prevalence of DR across the trimesters. Statistical package for Social Sciences (SPSS) version 15.0 was used to analyze data. Probability level of 0.05 or less was considered in all analysis.
RESULT
A total number of 250 subjects participated in this study; 150 pregnant and 100 postpartum women. The duration of DR postpartum was within the range of 8 weeks to 2 years. The participants have been described in Table 1. It shows that the participants fall within the middle age and normal BMI category.
| Table 1: Physical characteristics of participants (n=250) | ||
| Variables | Pregnant Women (n=150) Mean+SD | Postpartum Women (n=150) Mean+SD |
| Age (years) | 28.88+7.2 | 29.22+5.5 |
| BM (kg) | 65.63+12.1 | 62.24+11.5 |
| Stature (m) | 1.61+0.93 | 1.61+0.85 |
| BMI (kg/m2) | 25.34+4.75 | 24.03+3.97 |
DR status of participants (pregnant and postpartum) is shown in table 2 and it is categorized as either present or absent. Table 2 shows that there is a high prevalence of DR among both pregnant and postpartum women have DR.
| Table 2: Prevalence of DR among pregnant and postpartum women | |||
| DR Status | Pregnant Women n (%) | Postpartum Women
n (%) |
Total |
| Absent | 53(35.3%) | 16 (16.0%) | 69 (27.6%) |
| Present | 97 (64.7%) | 84 (84.0%) | 181 (72.4%) |
| Total | 150 (100%) | 100(100%) | 250 (100%) |
The site of DR of all study participants (pregnant and postpartum women) is shown in the table 3. The umbilicus was the most common site for DR in both pregnant and postpartum women, followed by DR above the umbilicus with the least proportion of women having a DR below the umbilicus.
| Table 3: Site of DR in pregnant and postpartum women (n = 250) | ||
| Site of DR | Pregnant Women n (%) | Postpartum Women n (%) |
| Above umbilicus | 53 (35.3) | 38 (38.0) |
| At umbilicus | 98 (65.3) | 84 (84.0) |
| Below umbilicus | 21 (14.0) | 11(11.0) |
| Total | 150 (100) | 100 (100) |
Prevalence of DR with respect to number of pregnancies (parity) is shown in table 4. It shows that DR is more prevalent in multigravida.
| Table 4: Prevalence of DR with respect to parity (n = 250) | |||
| DR | Primigr avida n (%) | Multi gravida n (%) | Total n (%) |
| Absent | 47 (60.3) | 22 (12.8) | 69 (27.6) |
| Present | 31(39.7) | 150 (87.2) | 181 (72.4) |
| Total | 78(100) | 172(100) | 250 (100) |
Prevalence of DR across the trimesters among pregnant women is shown in table 5. There is equal number of participants in each trimester. Majority of participants in the second and third trimester were diagnosed with DR, with very few having DR in the first trimester.
| Table 5: Prevalence of DR across the trimesters among pregnant women | ||||
| DR Status | First Trimester n (%) | Second Trimester n (%) | Third Trimester n (%) | Total n (%) |
| Absent | 27(54) | 15 (30) | 11 (22) | 53 (35.3) |
| Present | 23(46) | 35 (60) | 38 (76) | 96 (64) |
| Total | 50(33.3) | 50 (33.3) | 50 (33.3) | 150 (100) |
Table 6 shows the relationship between prevalence of DR and age, parity and duration of DR postpartum using Pearson’s and Spearman correlation. There is a significant positive relationship (P<0.05) between prevalence of DR and age. Similarly, there is also a significant positive relationship (P<0.05) between prevalence of DR and parity. This can further be explained; as age and parity increases, prevalence of DR increases.
| Table 6: Relationship between prevalence of DR and age, parity and duration postpartum | ||
| Variables | r | p-value |
| Age | 0.35** | 0.00 |
| Parity | 0.47** | 0.00 |
| Postpartum Duration | -0.18 | 0.06 |
The difference in prevalence of DR across the trimesters of pregnancy using Chi-square is shown in table 7. There is a significant difference (P<0.05) in prevalence of DR across the three trimesters.
| Table 7: Difference in Prevalence of DR across the trimesters of pregnancy | |||||||
| Trimesters | |||||||
| First | Second | Third | Total | X2 | p-value | ||
| DR Status | |||||||
| Absent | FO | 27.7 | 15 | 11 | 53 | 12.14* | 0.002 |
| FE | 17.7 | 17.7 | 17.7 | 53.3 | |||
| Present | FO | 23 | 35 | 39 | 97 | ||
| FE | 32.3 | 32.3 | 32.3 | 97.0 | |||
| Total | FO | 50 | 50 | 50 | 150 | ||
| FE | 50.0 | 50.0 | 50.0 | 150.0 | |||
DISCUSSION
The prevalence of DR in this study was found to be high in pregnant women and postpartum women. This is consistent with the result of Boissonnault and Blaschak19 who reported high prevalence of DR during pregnancy and following delivery. Lo et al20 also reported a higher prevalence of DR in postpartum women which is also in line with the findings of this study. The findings of this study also show that DR may not resolve spontaneously after pregnancy. This can be as a result of the continuous stress and stretch on the soft tissues of the abdominal wall exerted by the gravid uterus during pregnancy and poor abdominal conditioning. The number of pregnancies (parity) or children a woman has can also contribute to the high prevalence of DR in the population studied. The results also suggest that advancing pregnancy influences the strength of linea alba and in many cases results in a separation between the recti muscles.
This study revealed that majority of pregnant and postpartum women had DR at the umbilicus, followed by DR above the umbilicus with least proportion below the umbilicus. Boissonnault and Blaschak19 found that majority of participants in their study had DR at the umbilicus with some above the umbilicus and very few below the umbilicus, similar to the findings of this study. Parker, Millar and Dugan4 found the most common location for DR to be at the umbilicus, which is in line with the findings of this study. This could be explained by the fact that the anterior aspect of the rectus sheath is presumed to be stronger below the umbilicus19; this increased reinforcement might be enough to prevent separation in this area. Another probable reason for it being the most common at the umbilicus is because of the stretch the soft tissues are subjected to which is exerted by the growing fetus during pregnancy. This stretch tends to be more at the umbilical region.
There was a relationship between the prevalence of DR and age and parity. These results support previous studies reporting a strong relationship between the presence of DR and age and parity 2,19,20. Diastasis recti was higher in women with greater parity; this finding is similar to the finding of Chiarello, Falzone, McCaslin, Patel and Ulery2,20. Also, it was found out that DR is more common in multiparous women. This can be as a result of weak abdominal wall muscles or as a result of repeated stretch of the abdominal wall muscles due to previous pregnancies. Other factors such as poor abdominal conditioning may have contributed to separation contributing to the deterioration of DR2. Age is also a precipitating factor that can facilitate the appearance of a DR because as a woman ages, the abdominal and other muscles in the body tends to be weak.
The prevalence of DR across the trimesters varies in pregnant women. The study result indicated that the prevalence of DR is highest in the third trimester of pregnancy. This is consistent with the findings of Boissonnault and Blaschak19 who reported the prevalence of DR to be higher in the third trimester followed by second trimester. This can be as a result of hormonal changes coupled with growth of the fetus in the uterus which cause stretching of the abdominal muscles.
Prevalence of DR did not differ between pregnant and postpartum women. This is not consistent with the findings of Boissonnault and Blaschak19 who reported a greater prevalence of DR during pregnancy than the immediate postpartum duration. A number of factors could have accounted for this outcome: poor abdominal conditioning before and during pregnancy and other factors that could precipitate DR. Limitations of the study include varied sample size within the group between pregnant and postpartum women. Also, the age range was high, hence increasing the standard deviation of the result.
CONCLUSION
Prevalence of DR is high in pregnant and postpartum women and it is related to mothers’ age and parity. The most common site of DR was at the umbilicus in both pregnant and postpartum women. Evaluation of DR should be considered a routine assessment in both pregnant and postpartum women to ascertain those who would need attention. All women with DR need to receive physical therapy management soon postpartum for a better recovery. Also, physical activity during pregnancy is also recommended.
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