Great quote right? I came across this on the Storq instagram account. I do believe they have the single greatest compilation of birth and motherhood quotes EVER. The photos tagged with them are just as fun. Lots of public personas and celebs from all sorts of decades sportin’ their bumps and kiddos. Check it out here. And has anyone out there used Storq products? I’m digging the concept, check it out for yourself here. xoxo Allyson
There is a silent epidemic hitting postpartum women all over the U.S. It’s called Diastasis Recti, a condition where the front surface muscles of your belly seperate. I called upon renowned expert Melissa McElroy, PT, DPT, a trained Physcial Therapist from Bellarmine University who specializes in Women’s Health and Male/Female Pelvic Dysfunction to fill us in on how to prevent a Diastasis Recti, how to tell if you have it, and what to do if you suspect it.
So what exactly is Diastasis Recti and what causes it?
Diastasis Recti (DR) is a separation of the rectus abdominis muscle (think 6-pack muscle) midline down your abdomen, causing stretching and compromise to the connective tissue surrounding it. In general, this stretch and separation is caused by continuous or chronic repetitive pressure or force on the structures/ increased tension on the abdominal wall. This occurs in pregnancy, with increased incidence into the 3rd trimester when prolonged forces against the abdomen are greater.
What problems can occur if left untreated?
One of the primary functions of the rectus abdominis muscle and its associated connective tissue is support and compression of the abdominal organs as well as counter-balancing the muscles of the back. If left untreated, a DR can lead to chronic low back pain, pelvic organ prolapse (bladder falling, uterus falling), incontinence and hernias, as well as pelvic instability and increased incidence of pain with subsequent pregnancies.
How often do you see it in your practice and why do you think it has become so common?
Almost everyone who comes into our clinic (male or female) is tested for a DR because it is extremely common. I don’t think that there is necessarily an increased incidence of DR compared to 5/10/20 years ago, but I do think that it’s finally being given the attention that it desperately deserves.
So you are saying it has always been an issue for women, but that we have lagged in addressing it postpartum?
Yes. This is one reason why I’m seeing women who’s children are older/grown who come in due to prolapse issues; because their DR was never properly addressed.
Why is there such a massive gap in screening for it postpartum?
I feel that post-partum care as a whole is lacking in the US. As a society (medical and otherwise) we shift our focus to baby as soon as he/she arrives, often forgetting that the mother’s body went through a wonderful but traumatic event to bring baby into the world.
How do you know if you have it?
There is a simple test that can be easily performed at home. It can be done on your own, but it’s highly recommended that you have a friend or significant other perform the testing instead.
The patient lies on her back with knees bent and feet resting on the ground. The tester (friend/family member) places his/her fingertips into the belly button with their hand perpendicular to the abdomen. Then the patient is asked to raise her head off the ground while reaching with her hands towards her toes. A measurement is given based on how many fingers fit between the ridges that the abdomen makes when the patient raises her head. The test should be repeated above and below the belly button as well.
A positive DR is a measurement more than one fingertip’s width. Research is varying when determining how many finger widths should be considered “significant”. My thought is, if you’re worried enough to be testing yourself then you may just want to get things checked out by a professional.
If a woman suspects it, what should her next step be?
First and foremost, DO NOT TRY TO DO CRUNCHES. This will NOT, I repeat, will NOT help. It will most likely make it worse. If you suspect that you have a DR then find a physical therapist that treats it and go in for an evaluation.
What are some of the things that a woman should do, or more importantly, should NOT do, day to day?
Like I said before, your typical ab exercises (crunches, sit-ups, leg raises) could make your DR worse, so please don’t do them! (Obviously, if you are under the care of a licensed medical provider who is familiar and experienced treating DR and they have you performing a plank or leg lifts then maybe you’ve advanced to where its appropriate. For most of us, however, just stay away). Other day-to-day activities that you should be paying attention to are getting in and out of bed, getting in and out of a car, throwing laundry in the dryer, lifting the kids, lifting anything with weight to it. No forceful bending, raising up (like out of a recliner) or rotation. The general rule of thumb is, if your belly bulges when performing the activity then it needs to be stopped or modified so that there is no belly bulge with activity.
Is there anything a woman can do to prevent DR while she is pregnant?
Gernerally, the better core control/core strength you have prior to pregnancy and the more you work your core muscles (with appropriate exercise) during pregnancy the better off you will be. Does this mean that if you have a 6-pack before pregnancy that you won’t develop a DR? NO. Does this mean that you won’t get a DR if you work out daily during your pregnancy? Sorry, No. But you will be more apt to better rehab and recovery.
Is there an online resource a woman can use to locate therapists who specialize in treating Diastasis Recti in her area?
The American Physical Therapy Association’s Website: www.apta.org has a “Find a PT” page that you could search for a PT who specializes in Women’s Health. That would be my first recommendation. However, there are a lot of PTs who aren’t listed in that database, so my next recommendation would be to talk with your OB/Gyn or local general PT to see if there is anyone that he/she recommends.
Thank you so much for sharing your wisdom with us Melissa! If you are in the Louisville, KY area and would like to make an appointment with Melissa you can find her at Dunn Physical Therapy.
For more information and some visuals on how to test and what it looks like check out: www.Fit2B.com.
So ladies lets spread the awareness! Post this to your FB page through the link below and make sure all your girlfriends read it!
I want to know from you! Had you heard of DR before and did your ob or midwife check you for it postpartum?
Hugs and kisses to you all!
To put it bluntly: we suck at having babies over here in the big red, white, and blue.
Not like 4th place suck, not even like 10th place suck, I’m talking like 31st.
And that is just a general composite score. When we break it down into parts we hit 46th for maternal health and 40th for children’s well being. If you want to go even further and look at our specific infant mortality rate we sit at 61st.
To put the icing on the cake we have also recently discovered that not only does our infant mortality rate suck, it’s getting worse!
Even more crazy to think that we spend more money on obstetrical care compared to any other industrialized country in the world.
Apparently you DO NOT get what you pay for.
So what in the heck is going on?
The vague answer to that (because these things are never so simple) can be found in looking at what the top 5 countries are doing that we are not and vice versa, what we are doing that they are not. (The rest of the vague answer can come in comparing what we both do and examining the difference in outcomes, but we will get to that later.)
Who are the top 5?
Finland, Norway, Sweden, Iceland, and the Netherlands have pretty much taken the cake for the past 15 years. The Scandinavians seem to know how to get it done.
On a side note, I will also be bringing Australia into our discussion as they have consistently sat in the top ten over the last decade or so. We have some interesting similarities with them such as high cesarean rates but they seem to be coming out with better outcomes and I think we have some things to learn from there.
What are the differences?
Over the past 12+ years studying birth and maternity care I have learned that the major differences in the way we care for women through pregnancy, birth, and postpartum pretty much boils down to:
- Pain Management Options
- Nutrition education
- Maternity Leave
- Postpartum Support + Education
This is probably one of my most favorite subjects to talk about so I am so excited for us to open up a discussion on it.
Over the next few months we will be taking a closer look at the above mentioned topics and hatching out the details so that we, as responsible consumers, stay informed on the approach of care that we should be receiving.
In light of our fun Mother’s Day Contest where I quizzed you on the recent change in ACOG’s guidelines, we will start looking at:
Have you ever noticed that a lot of gals get induced? In general about 22 % of women in the United States are induced somewhere between 38 to 41 weeks gestation. Back in the 1990s it was around 10%.
The catch is, that number comes from a national survey done in 2006. Many people argue that it is grossly underreported, varies widely by area, and has experienced a sharp increase over the last few years.
A study lead by Dr. Deborah Ehrenthal looked at a pool of 24,679 women and found 44% of them were induced and in the Listening to Mothers Survey done by the Childbirth Connection nearly 41% of women said that induction was attempted by their care-provider.
The reason there has been A LOT of attention on inductions these days is because of the current focus on decreasing our high cesarean rate of 32%.
Numerous studies have tied the dramatic increase of c-sections with the two-fold increase in inductions. Especially affected by the risk are first-time mothers who are twice as likely to end up with a cesarean when induced too early.
As was stated before, our infant and maternal mortality rate has been going up instead of going down alongside the increased use of interventions so there is reason to believe we are not using them appropriately.
After several publications of research and public pressure, ACOG finally released their revised guideline emphasizing the importance of waiting until 41 weeks to induce unless medically necessary.
Why did we think it was ok to induce before 41 weeks?
Well the “new” guidelines actually use to be the “old” guidelines. Up until the early 1980’s it was commonplace for a woman to go to the 42-week mark. I myself was a two-week “overdue” baby. Most people don’t know that the definition, straight from the American College of Obstetrics and Gynecology, of a truly post-term pregnancy is one that hits 42 weeks and beyond (not the “due date” that they give you!)
Why we began to trend to earlier inductions is a bit of a mystery considering that the rest of the industrialized world has always stuck to the protocol of inducing between 41 and 42 weeks. It is considered by many as the sweet spot to garner the best outcomes for mama and baby.
There were several recommendations of practice that were published around the time when inductions began to increase in an effort to better our infant mortality rates. The data emphasized the importance of keeping baby in until the 39th week mark unless absolutely necessary. The recommendation came from strong evidence that shows trips to the NICU decrease dramatically when following these guidelines.
I don’t think ACOG ever had the intention when publishing and supporting this info but, unfortunately, the way this information perhaps began to be interpreted by practitioners and the public alike was that once a gal hit 39 weeks she was considered full term and it would be totally safe to induce.
It may have just been one of those things that snowballed. Sadly medicine and science fall victim to trends and fads just like everything else.
What are the stats elsewhere?
It is INSANELY difficult to find specific inductions stats overseas. One, because the majority of the studies are published in the native language and two, because the definition of induction of labor as well as the way we record it varies widely country by country.
Of the bits that I have been able to pick up I have found most of the countries that we talked about above do consistently have a lower number in induction rates. For example I found one study that put a Swedish hospital at a 12% induction rate and another showing some hospitals in Finland with a 17-20% rate of induction.
Data from the UK is easier to pull up and I found rates ranging between 12-17% Even though they don’t make the top 5, they do have a lower cesarean rate of 25.5% compared to our national average of 32%.
It is easy to look at the numbers above and think that, yes, these countries have lower induction rates and they also have lower cesarean rates so there must be something there.
However, one of the things that I continue to notice study after study is not so much when we induce but how we induce in the United States that may make all the difference.
A key difference that is not getting attention
As with any piece of research, as soon as one finding is published, it is immediately followed by another that “proves” the opposite. It’s sort of sciences dirty little secret: statistically you can just about prove anything.
There was a study published in April by Khalid Khan of Queen Mary University of England that concludes that we actually have it all wrong: elective inductions at term or post term decrease cesareans and fetal complications.
They came up with a 12% decrease in chance of cesarean delivery with women who were induced compared to women who were left to let nature take it’s course.
I have a bit of an issue with the study because it piles low and high risk women together, first time mothers with “veteran” moms, and has a broad defintion of a pregnancy being at term between 37 and 42 weeks, but what jumped out at me is where they found that women who were induced with prostaglandin E2 (I will explain below what that means) experienced a reduction of cesareans and women who were induced by oxytocin-aka Pitocin combined with amniotomy-aka breaking your waters did NOT experience a lower cesarean rate.
Hooking you up to Pit and breaking your waters is much the standard mode of induction for many obstetrical practices here in the U.S.
So I did a little sleuthing.
Turns out, most of the top rated countries don’t use Pit that much.
What do they do?
All the top rated countries follow, with some slight variations, the guidelines issued by the World Health Organization which go something like this:
If a woman goes into 41 weeks the midwife (because midwives attend the majority of births in all these places) will discuss stripping your membranes (where your care-provider kind of lifts up the bag of waters from the walls of your uterus during a vaginal exam.) Some may bring it up at 40 weeks, some may have you come in three days in a row in your 41st week, however it goes, this is usually the first approach to getting things going.
Next is to place low-dose vaginal prostaglandin E2s. This can be an out-patient procedure where they send you home for the night, other practices may have you stay at the hospital. They come in the form of gel (Prepadil) or a tampon-like insert (Cervadil).
More often than not, just the placement of the cervical softeners and stripping of the membranes will start up contractions, but if not, then the third recommended step is to hook up Pitocin to stimulate the uterus.
The WHO guidelines do not recommend breaking your waters until much later in established labor, around the 6 cm mark.
They also advise clear across the board that induction by only breaking your waters is strongly not recommended as it poses too much of a risk such as cord prolapse, fetal distress, and infection- all which translate into a cesarean.
Why do we use Pit so much?
Once again I think we are swimming in “trending” being the answer to that question.
The bottom line is Pitocin is a great drug for induction IF it is used on a woman with a favorable cervix.
That last part is the key that perhaps our obstetrical community has not taken seriously enough.
It is not that other countries do not use Pitocin but they do seem to use it much more conservatively than we do and there is a major focus on making sure the cervix is in a favorable position before attempting its use.
So whats a girl to do?
- First and foremost do not assume that your care provider has read the new guidelines…..or is privy to following them. Simply by waiting to be induced until 41-42 week mark will exponentially take you out of the risk of cesarean group. Most women will go into spontaneous labor by then and if they do not they will most likely have a softened cervix by that time. Have this conversation early in your pregnancy! Straight up ask them how long they will “let” you go, and what their routine approach to inducing is. If it’s not what you were expecting to hear, bring them a print-out from ACOG’s web and see if they will be open to following the guidelines. If they are not, well, it might be time to find somebody else.
- If your pregnancy is trucking along just fine and you have no complications coming up, keep that baby in there til’ at least the 41 week mark, especially you first time mamas. And let me tell you, it’s easy to say yes to that now, but once the last weeks of pregnancy hit, you will come to completely understand how it can be so tempting to get induced. Last weeks of pregnancy are a bitch. You can’t sleep, you can’t breathe, you can’t bend over. Beached whale feeling can mess with your patience, you have been warned.
- If you are approaching the 41-week mark consider making your first step be stripping your membranes at each visit. It is not a fun procedure, and can cause some bleeding and discomfort afterwards but for women who want to try a non-pharma intervention it might be a good tradeoff.
- If nothing has happened and it looks like you need to encourage baby out, take special heed to your Bishop score. If your bishop score is below a 6 consider insisting on getting cervical ripeners. If your bishop score is above a 6 (some practices say that first time mothers should ideally be above an 8 before inducing with Pit) you may have three options. After weighing the risks and benefits, you could:
One, get **cervical ripeners anyways with the hopes that it may trigger your uterus to labor. Two, you could opt for getting Pitocin right away, or three, you could do nothing. There is no law that states you have to have your baby by 42 weeks. If, after reading the risks, you just really feel it’s not for you then know that you don’t have to. Sign a consent form. If your care-provider just can’t handle that, find another one.
- It might be very tempting to want to try to break your waters as that is a non-pharma approach but save it as a last resort or until you are much further along in labor. That bag of waters serves as a cushy saftey net for your baby during the rigours of labor, let it pop on it’s own.
- Finally, don’t get hung up on the statistics. They are just generalizations. Sometimes inducing before 41 weeks is the best, other times letting nature take it’s course is the best. The best method of induction varies woman to woman. Do your research and then make the decision that is ultimately best for YOU and YOUR circumstance.
**cervical ripeners are not recommended in women who have had a previous cesarean or any sort of surgery to the uterus due to the increase risk of uterine rupture. Also, there is a type of off-label cervical ripener called Cytotec (misoprostol). It is a prostaglandin E1 (not an E2 like Cervadil and Prepadil) and has been linked to more maternal deaths than I care to share. The fact that it is not illegal is beyond me. The World Health Organization supports the use of misoprostol and I completely disagree with their stance but we will get into that another day.
So, what do you think? What has been your experience with inductions? Do these findings surprise you?
As always, remember that this should not be taken as medical advice but as information for you to open up a discussion with your care provider!
Some further reading to churn your brain juice is:
Hugs and kisses to you all!