DRAM and Abdominal Separation

Clearing up some misunderstandings

Firstly, DRAM – or Diastasis Rectus Abdominis Muscles – is the medical name for the width between the two inner edges of your six-pack muscles. It also gets called abdominal separation, diastasis abdominis, stomach separation or splitting. However, most health professionals abbreviate it to DRAM as it’s much easier to say and write! So, if you ever hear DRAM mentioned in reference to abdomens, this is what they’re talking about.

If you do a quick social media search for information about postpartum abdominal separation or DRAM, you find some wildly fantastical information out there! I wanted to clear up some of the misunderstandings and so you can be informed from evidence-based information.

Myth #1: DRAM / Abdominal separation is your abdominal muscles tearing

False!

We all have connective tissue that runs down the middle of our abdomens, connecting the two halves of the abdominal muscles. This connective tissue, called the linea alba, runs from the base of the sternum (breast bone) to the top of the pubic bone.

When someone is pregnant, this linea alba stretches to allow more room for the baby. This is so the vertical rectus abdominis muscles, commonly known as the six-pack muscles, don’t have to stretch as much over the widest part of the bump. While some people talk about feeling a tearing sensation during their pregnancy, this is almost always the linea alba undergoing this stretching process.

Myth #2 – The aim is to get to zero separation again after having a baby

Everyone’s linea alba has a certain width, regardless of age or gender. When you look at a muscular person, you can see their clearly defined muscles (feel free to Google “six pack male model”, just to double check what we mean 😉), they have a gap between the two halves of the rectus abdominis muscles. Recent research suggests the normal range for linea alba width is up to 34mm1. We cannot expect to get back to zero width, especially if we never started there!

So, if you have your DRAM assessed in the few days post-delivery, the connective tissue will still have some of the increased length from pregnancy. The most recoil of this connective tissue occurs in the first 12 weeks postpartum, but it can continue to slowly reduce in width and increase in firmness naturally for up to 12 months.

Most DRAM assessment guidelines will still say that a DRAM of 2cm or less is considered normal at or after the 12 week postpartum mark, as they haven’t been updated. These guidelines also haven’t considered the other important aspects of DRAM assessment – the amount of doming that occurs, and the development of tension/stiffness in the connective tissue.

While not many people check prior to having a baby, I would love it to become common practice at the dating scan (or around this time) for someone to assess the width of a person’s linea alba. This way we would help manage everyone’s expectations of what is their body’s starting point. This would help reference what is normal for them. For example, if someone has a 2cm linea alba width in early in pregnancy (before any stretch has occurred), then there’s no way they’re going to be less than 2cm after having a baby.

Myth #3 – The width of the separation is the most important factor

Not true!

Researchers published evidence in 20192 which shows that the tension, or stiffness, of the linea alba is integral in how our abdominal system all works together, as well as how much doming occurs.

If the linea alba is loose and floppy, even if it’s only 1cm wide, this floppy tissue isn’t very good at transferring load across the abdomen and is more likely to bulge outwards. This means that if someone is picking up a toddler and twisting to put them in a car seat, the load of lifting the toddler and the abdominal muscle contractions doesn’t efficiently spread across the linea alba to the opposite side of the abdominal wall. Therefore, these muscles and cross-tissue patterns can’t help and may mean that the spine and back muscles take a greater proportion of the toddler-lifting load. If there is more stiffness/tension in the linea alba, even if it is 3cm wide on assessment, the load transfer is more efficient and we can use the cross-body muscles and connective tissues to our advantage.

Overall, the human body is amazing. It’s incredible to think that the linea alba length increases automatically during pregnancy to accommodate the growing bump and protect the muscles. Additionally, our bodies have the ability to reduce this stretch and increase firmness afterwards, returning our abdominal load transference abilities.

In our next post, we will discuss how to assess for DRAM yourself, and what to do if you feel this is an issue for you.

References:

1 Kaufmann RL, Reiner CS, Dietz UA, Clavien PA, Vonlanthen R, Käser SA. Normal width of the linea alba, prevalence, and risk factors for diastasis recti abdominis in adults, a cross-sectional study. Hernia. 2022 Apr;26(2):609-618. doi: 10.1007/s10029-021-02493-7.

2 Dufour S, Bernard S, Murray-Davis B, Graham N. Establishing expert-based recommendations for the conservative management of pregnancy-related diastasis rectus abdominis: a Delphi consensus study. J Womens Health Phys Ther. 2019 Apr 1;43(2):73-81