Moms shouldn't do sit-ups...or should they?

Are sit ups bad for our pelvic floor and abdominal wall? Do we avoid sit ups forever?

Understanding the pelvic floor and the abdominal wall

As a pelvic floor physical therapist I hear a lot of things. Some of them good, some bad, and some that don't make any sense. The one that continues to floor me the most is "Aren't sit ups bad for your pelvic floor?" or "My doctor told me not to do sit ups after I had my kids". Now there can be truth in these statements depending on the person....but let's agree, sit ups are functional!  Navigating postpartum exercise and postpartum fitness can be challenging with the presence of social media and influencers. I would like to shed some light on why this theory is so common in the postpartum world and what to look our so you can decide is sit ups are right for you. Let's go over the two main muscle groups to focus on which are the pelvic floor and abdominal wall.

The pelvic floor is a group of muscles that support the organs in the pelvis, including the bladder, uterus, and rectum. During pregnancy, these muscles play a crucial role in providing stability and support for the growing baby and maintaining proper bladder and bowel control. After giving birth, the pelvic floor muscles can become weakened or stretched from childbirth. If weakness persists, that weakness can lead to issues such as urinary leakage, prolapse, pain with sex, and even low back pain.

The abdominal wall also changes during pregnancy. To accommodate a growing baby those muscle can be stretched and even separate. The separation of the abdominal wall is referred to as "diastasis recti abdominis or DRA" and is a hot topic of conversation for new moms. This separation of the abdominal wall is VERY common during pregnancy and likely is still present post-partum. When there is abdominal separation, we may see abdominal wall "coning or doming", which can make the abdomen look like it has pouch or bulge with certain movements or exercises. 

Best practice is to get an assessment from a physical therapist, but here's a way to do a quick self assessment. 

I know what you're thinking...."Bailey what do I do?!"  I'm here to tell you that abdominal wall separation and pelvic floor weakness can happen, but it is often different for each individual. It may also not be due to pregnancy! Did you know that even men can have diastasis recti? Yes you heard me, men can have DRA. This weakness can happen to anyone and is often a pressure management and coordination issue.

Pressure Management and DRA

The abdominal wall, pelvic floor, paraspinals, and diaphragm essentially make a box that I like to call our "core canister" This core canister has to adjust to pressure and load so that we can sit up in bed and lift heavy things. When there is a weak spot in our core canister, we can often see pelvic floor problems(like leaking) or coning/doming present. 

Check out this neat graphic here to see the core canister

Sit ups often get a bad rap because they are one of the movements that increase our abdominal pressure and we can clearly see coning or doming in postpartum period. This is OK as your body changes with pregnancy and postpartum, but we need to know how to manage and work with our core. This is where physical therapy can be VITAL in a post partum journey. We will assess if DRA is present and review any pelvic floor concerns. We assess if your pelvic floor and abdominal wall can contract the right way AND at the right time. There is some level of strength, structural integrity, and coordination needed to manage diastasis IF it is even present. 

Remember, not every woman who has had a baby will have abdominal wall separation. So why are we relegating all new moms to put sit ups on the shelf? When talking to my clients in the clinic the two women that have avoided sit ups had their children more than 5 years ago. Did you hear that? 5 years ago! Let's be better and educate new moms on DRA and give progressions so we can be proactive not reactive.

Core rehab- sit up version

Fortunately, there are plenty of options and places to start for anyone at any stage.

1. TA bracing: This is where we start always. Think of pulling in the abdomen from the top of the pelvis to the bottom on the ribcage. I often like to have clients picture a zipping up a coat and the ribs come down LAST. This is easier to learn with breath control. Inhale to fill the abdomen with air then exhale and zip up. Repeat and assess for coning/coming.

2. Dead bug variations: Depending on your fitness level and or post partum timeline this may be easy or challenging. I like to start with the head hold variation. Do the TA brace first and THEN lift the head of the ground checking for coning/coming. If this looks good then try and lift the arms, then the legs and etc. Remember pain or coning/doming is when your abdomen is saying that its not ready.

3. Assisted sit up are my favorite progression. Get a band and tie it around a rig or column. Use the tension on the band to help assist you to the ground AND bring you back up to the top of the sit up. We should still be maintaining a good TA brace with no evidence of coning or doming. The back also should stay in neutral with no bending, rounding, or over extending.

4. Eccentric sit ups: this is hardest version before graduating to a full sit up. Start with hands holding under the knees and a good TA brace. Try and maintain that core tension and back position without coning or doming. The hands can help assist the core to control speed and how much force your generating. 

Remember, things that are NOT NORMAL and signs of straining are coning/doming, urinary leakage, increases in pelvic pressure, pelvic pain, and or low back pain. If these are present during exercises then you are likely straining that muscle group past its capacity.

Consulting with a healthcare provider for personalized exercise recommendations

Every pregnancy and postpartum journey is unique, and it is important to consult with a pelvic floor physical therapist for personalized exercise recommendations. The postpartum workout you see on instagram may not be right for you!

We consider factors such as your overall health, your goals, any existing pelvic floor issues, and the stage of your pregnancy or postpartum recovery. We often discuss what works best for your body and we might even throw in a sit up or 2. So ask yourself if moms should really avoid sit ups or do we just need better postpartum care.

References:

1. 
   Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016 Sep;50(17):1092-6. doi: 10.1136/bjsports-2016-096065. Epub 2016 Jun 20. PMID: 27324871; PMCID: PMC5013086.
2. https://youtube.com/shorts/hX4eMs2adS0?feature=shared
3. Dietze-Hermosa M, Hitchcock R, Nygaard IE, Shaw JM. Intra-abdominal Pressure and Pelvic Floor Health: Should We Be Thinking About This Relationship Differently? Female Pelvic Med Reconstr Surg. 2020 Jul;26(7):409-414. doi: 10.1097/SPV.0000000000000799. PMID: 32574030; PMCID: PMC8974352.
4. Neumann P, Gill V. Pelvic floor and abdominal muscle interaction: EMG activity and intra-abdominal pressure. Int Urogynecol J Pelvic Floor Dysfunct. 2002;13(2):125-32. doi: 10.1007/s001920200027. PMID: 12054180.