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Purpose and use

Bridge the Gap is a learning resource for physiotherapy students. It aims to bridge the gap between an uncertain, varied research literature and everyday clinical practice in the assessment and management of postpartum diastasis of the rectus abdominis muscles (DRAM). It supports supervised learning across maternity, community, musculoskeletal and private practice settings.

There is no universally accepted assessment protocol or single exercise programme for postpartum DRAM. Measurement research highlights differences between assessment methods and their measurement properties, while rehabilitation reviews do not establish one programme that is best for every woman (Benjamin et al., 2023; Gluppe et al., 2021; Skoura et al., 2024; van de Water & Benjamin, 2016).

Differing advice about the safety of abdominal activation and trunk loading can create uncertainty for clinicians and students. Skoura et al. (2024) identified substantial heterogeneity in exercise types, adjunct interventions, assessment methods and outcomes. Although exercise is a usual conservative approach, agreement remains limited on the most effective rehabilitation programme, adjunct modality, exercise timing and dosage. Systematic reviews also describe variation in diagnostic criteria, measurement sites, exercise dosage and outcome measures, limiting comparisons and confidence in a single prescription (Benjamin et al., 2023; Gluppe et al., 2021).

This website translates that evidence into a practical framework for assessment, education, exercise selection and progression. It helps students explain uncertainty, justify decisions and recognise when specialist review is needed. The exercise examples are options to adapt, not a universally validated protocol. Assess the person as well as the abdominal wall: inter-rectus distance (IRD) alone does not determine disability, exercise readiness or treatment success. Consider symptoms, function, goals, preferences and response to loading (Hernández-Granados et al., 2021; Skoura et al., 2024).

Students should work within competence and supervision, follow maternity or surgical restrictions, and use local referral pathways. This resource supports clinical learning; it does not replace individual assessment or supervision.

Abbreviations: IRD means inter-recti distance; TrA means transversus abdominis; NMES means neuromuscular electrical stimulation; and EMG means electromyography. DRA and DRAM refer to the same condition in this guide.

DRAM background

Understanding DRAM and postpartum recovery

Terminology and anatomy

DRAM, diastasis recti abdominis (DRA) and rectus diastasis describe widening between the rectus abdominis muscles associated with stretching and thinning of the linea alba. The linea alba is the connective tissue which links the two abdominal muscles together in the midline of the body. Hormonal changes during pregnancy allow this tissue to stretch as the baby grows. DRAM is commonly reported postpartum and may be accompanied by doming or a bulge of the connective tissue during movement. The phrase abdominal muscle separation can be useful in conversation, provided it is not explained as a torn muscle or inevitably damaged abdomen (Akram & Matzen, 2014; Coldron et al., 2008).

The European Hernia Society uses separation greater than 2 cm as a practical definition but acknowledges low-quality evidence for a definitive threshold. Values vary with measurement site, posture, task and postpartum timing. Record these conditions rather than using one number as a universal severity or exercise-readiness category (Hernández-Granados et al., 2021; van de Water & Benjamin, 2016).

Isolated DRAM is different from a hernia: it is widening of the midline without the same focal fascial defect. A hernia may coexist with DRAM. A focal lump or concerning symptoms therefore requires further assessment rather than reassurance based only on a broad midline separation (Akram & Matzen, 2014; NHS, 2026).

Recovery is individual

Separation often reduces naturally after birth, so improvement during early exercise cannot automatically be attributed to treatment. Use 8-12 weeks as a clinical review window, not a proven deadline for complete closure or evidence that acute strategies guarantee resolution. In a prospective cohort, DRAM remained present in 45.4% at six months and 32.6% at twelve months (Sperstad et al., 2016). Recovery and diagnostic definitions vary.

Assess birth mode, wounds, pain, fatigue, caring demands and associated symptoms individually. Do not assume that back pain, leakage or prolapse is caused by the gap. A smaller IRD does not establish full functional recovery (Coldron et al., 2008; Deering et al., 2018).

Communicating with a patient

Communicating this to a patient is vital. You may like to say:

During pregnancy, there is a normal widening and stretching of the connective tissue in the middle of your abdominal muscles. This increases the distance between the left and right muscles. Hormonal changes help the tissues stretch to make room for your growing baby. Heavy lifting and straining, including when constipated, can make bulging more noticeable; this does not mean you have damaged the tissue.

It can also be common to notice some outward bulging during movement, lifting or exercise. This is called ‘doming’.

Much of the early recovery happens naturally in the first 8-12 weeks, although recovery varies and a gap may remain. If the separation persists or you are finding activities difficult, we can use further abdominal strengthening and gradual rehabilitation to build function, help manage doming and work towards your desired level of exercise. You do not need to wait until twelve weeks to ask for support.

This is an example explanation to adapt to the individual, not a promise of complete closure or a quotation from a research participant. Explain uncertainty, check understanding and agree on goals together (Donnelly, 2019; Gluppe et al., 2023; Skoura et al., 2024; Sperstad et al., 2016).

Evidence

Evidence priorities for physiotherapy practice

What the systematic reviews show

Systematic reviews and meta-analyses provide the main treatment synthesis.

Translating evidence through physiotherapy practice

Skoura et al. (2024) maps rehabilitation options and evidence gaps. As a scoping review, it describes the field rather than establishing the most effective treatment. Donnelly's (2019) framework considers the person, movement patterns, posture, respiration, ribcage, load and possible defect. It offers a useful assessment scaffold, not a validated rule that diagnoses pathology from posture or contour.

Physiotherapy measurement research supports consistent assessment rather than casual comparison across instruments or tasks (Billis et al., 2025; van de Water & Benjamin, 2016). Clinical physiotherapy resources help explain practical exercise techniques, but do not independently prove gap-closing efficacy (Gloucestershire Hospitals NHS Foundation Trust, 2025).

Assessment

Assessment in practice

Consent and history

Explain assessment, exposure and touch; obtain consent and provide privacy or a chaperone according to preference and policy. Declining measurement does not prevent functional rehabilitation.

Ask what matters most, symptom onset and course, pain, perceived weakness, focal bulges, caring-task difficulties and appearance concerns. Establish postpartum timing, birth mode, wounds, complications, bleeding, restrictions and medical history. Ask about leakage, urgency, emptying difficulty, vaginal heaviness, constipation and sexual pain when relevant and consented. Assess pelvic floor complaints separately; an internal examination is not required for DRAM measurement and requires appropriate training, consent and supervision (Donnelly, 2019; Hernández-Granados et al., 2021).

Agree one or two functional goals and consider activity demands, equipment, finances, communication needs, sleep and available support.

Observation

With consent, observe at rest and during a relevant movement such as rolling, sitting up, standing from a chair or a light lift. Note movement strategy, wound-related guarding, breathing, symptoms, abdominal contour and any focal lump. A small head lift may be considered if appropriate to recovery and comfort; it is not mandatory in acute care.

Describe visible midline bulging or doming neutrally. There is no established visual threshold that proves tissue damage or mandates stopping every exercise. If the response is uncomfortable, poorly controlled or concerning, reduce the demand, assess a focal defect where indicated, and discuss the finding with the supervisor. Do not use doming alone as a validated injury test (Lee & Hodges, 2016; Rejano-Campo et al., 2026).

Choosing a measurement method

Measurement research supports standardisation rather than casual comparison across methods (Benjamin et al., 2020; Billis et al., 2025; Bursch, 1987; Mota et al., 2013; van de Water & Benjamin, 2016; Vesting et al., 2021). Students should not convert “two fingers” into a fixed centimetre value or compare finger-width results directly with an ultrasound trial.

For follow-up, record the instrument and examiner; anatomical sites and their distances from the umbilicus; posture and knee position; resting or active condition; breathing phase; and symptoms. Use the same local protocol at reassessment. For example, a service may specify a resting measurement and a standardised head-lift task at recorded sites, provided the task is appropriate. This guide does not prescribe a universal measurement protocol or minimal clinically important change.

Use ultrasound when the clinical question warrants it and expertise is available, rather than making it a prerequisite for all care. Suspected hernia, uncertain diagnosis or unexplained persistent symptoms may need medical assessment and appropriate imaging. Repeated gap measurement at every visit is unnecessary if it does not change management (Hernández-Granados et al., 2021).

Applying the assessment illustration

Position and task. A practical standard starting position is supported crook lying: on the back, knees bent and feet supported. Adjust for comfort and document support. Measure at rest or during the same small head-lift task specified by the local protocol; these are different conditions, not interchangeable readings. A head lift is optional and should be deferred when pain, wound recovery or restrictions make it inappropriate. There is no single proven best position for every postpartum woman (van de Water & Benjamin, 2016; Vesting et al., 2021).

Finger placement. Gently identify the medial borders of the two rectus muscles. Place adjacent fingertips across the gap, perpendicular to the midline, and estimate the number of finger widths between those borders without forcing fingers into the tissue. Assess at the umbilicus and at recorded distances above and below it according to the service protocol. The landmark dots are illustrative, not fixed universal measurement sites. Record the site, task and finger-width estimate separately (van de Water & Benjamin, 2016).

Calliper placement. First locate the medial muscle borders by palpation. Position the appropriate measuring tips transversely at those same two borders, following the instrument's instructions and local training. Measure the inter-rectus distance, not a pinched skinfold or the distance across the outer muscle borders. Use light contact, avoid wounds, and record millimetres or centimetres and the test conditions. If borders cannot be identified confidently, do not manufacture a precise reading; defer or seek a trained assessment. Callipers and ultrasound are not automatically interchangeable (van de Water & Benjamin, 2016; Vesting et al., 2021).

Palpation estimates DRAM in finger widths, not a fixed centimetre equivalent. Swelling, pain and guarding can limit comfort and identification of muscle borders, particularly after a caesarean birth. Uterine contractions (afterpains) may also limit comfortable assessment early after either birth mode; this is a practical clinical consideration, not a quantified measurement-error estimate. Avoid pressure over a healing incision, defer an uncomfortable head lift and document limitations or reassess when appropriate. Afterpains are not specific to caesarean birth (Oxford University Hospitals NHS Foundation Trust, 2024). The anatomy and measurement sites are illustrative.

The widened linea alba illustrates DRAM of approximately three finger widths, with three adjacent fingertips at each site. One hand is shown above and the other below the umbilicus to demonstrate the two assessment regions; record each site separately using the local protocol. Fingers point lengthways along the abdomen, while adjacent finger widths span the gap across the midline. Use gentle contact to identify the medial muscle borders, without forceful pressure. Report palpation in finger widths, with the site and task recorded. The drawing is schematic and does not prescribe exact distances from the umbilicus. Swelling, pain, guarding and early postpartum afterpains may limit assessment; take particular care with a healing caesarean incision (Oxford University Hospitals NHS Foundation Trust, 2024; van de Water & Benjamin, 2016).

Functional assessment

Choose goal-relevant tasks: rolling, transfers, walking and carrying early; squat, hinge, lift, resisted trunk movement and sport-specific loading later. Record load, repetitions or duration, assistance, symptoms and confidence, including recovery after the task. Avoid maximal tests when wounds or symptoms make them inappropriate. Use a suitable established outcome measure where indicated; do not present an informal task rating as a validated DRAM-specific score. Function can improve despite stable IRD (Deering et al., 2018; Gluppe et al., 2023).

Referral red flags

Referral and escalation

Stop and arrange urgent medical assessment

Urgent maternal illness can occur during the year after birth. Escalate new chest pain or breathlessness, collapse, severe or worsening headache with visual disturbance, heavy bleeding, severe persistent abdominal pain, or fever with systemic illness. Unilateral painful swollen calf requires urgent assessment; chest symptoms or collapse require emergency escalation. Also act urgently on severe mental health deterioration, psychotic symptoms or immediate risk of harm to the woman or baby. In Australia use local emergency procedures and call 000 for a life-threatening emergency (Centers for Disease Control and Prevention [CDC], 2024).

A newly painful or tender focal abdominal lump, particularly with vomiting, abdominal distension, inability to pass stool or wind, discolouration or a firm non-reducible swelling, raises concern for complicated hernia. Do not prescribe exercise or attempt forceful reduction; arrange urgent medical assessment. A suspected painless uncomplicated hernia also warrants medical review, although it is not automatically an emergency (NHS, 2026).

Use the local postpartum and neurological escalation pathways for suspected serious wound complications, new urinary retention or new major neurological deficits. These presentations require assessment beyond this DRAM guide. Do not explain concerning symptoms as normal separation or exercise soreness.

Arrange planned specialist review when indicated

Discuss persistent pelvic floor symptoms, significant pelvic or abdominal pain, uncertain diagnosis, suspected uncomplicated hernia or inability to progress with the supervising physiotherapist and relevant medical or pelvic health clinician. Persistent distress about appearance or fear of movement also deserves support. Review access barriers, adherence, dosage and competing conditions before concluding that conservative care has failed.

Surgery may be discussed for selected women with persistent functional problems or coexisting hernia after appropriate assessment and conservative care. Gap width alone is not a sufficient referral or operative rule. Decisions should consider goals, future pregnancies, associated anatomy, benefits, complications and informed preference (Carlstedt et al., 2021; Hernández-Granados et al., 2021; Jessen et al., 2021; Lelli et al., 2025).

Education & shared decisions

Ask what the woman understands, what she has been told and what she wants help with. Explain the findings in everyday language and discuss the options and uncertainty together. Agree on a goal, and review the plan to reach that goal. Include appearance concerns when she raises them, without making appearance the definition of recovery.

While recovery may be slow, using these strategies and building strength are important parts of rehabilitation. Choose a manageable starting point together, progress according to symptoms and function, and review the plan as her needs and goals change (Donnelly, 2019; Gluppe et al., 2023).

Exercise progression

Selecting and progressing exercise

Name the intended outcome before selecting an exercise: an easier transfer, improved trunk strength, a comfortable lift or return to an activity. Choose two or three feasible options, demonstrate them and observe practice. “Activates the core” is not a complete rationale.

1. Record the functional goal and baseline symptoms.
2. Trial a manageable amount and observe pain, wound discomfort, breathing, pelvic floor symptoms and confidence.
3. Ask about recovery later that day and the following day. An acceptable response is individual; no universal DRAM pain score or 24-hour threshold is validated.
4. Progress range, repetitions, hold time, lever length, load or complexity when tolerance is repeatable and greater demand serves the goal.
5. Reduce demand or reassess if symptoms persist. Do not substitute indefinite avoidance for investigating a problem.

Changes in muscle thickness or EMG activity are not interchangeable with strength or treatment success. Biomechanics can explain demand but cannot rank all exercises by postpartum clinical effectiveness (Bini & Bini, 2021; Calatayud et al., 2017).

Adjunct options

Support garments or taping may help comfort without guaranteeing closure (Depledge et al., 2021; Keshwani et al., 2021). Discuss cost, uncertainty and contraindications before NMES; it does not replace exercise (Wu et al., 2025). Hypopressive exercise is an option, not an established best treatment; manual-treatment case series do not establish efficacy (Kirk & Elliott-Burke, 2021; Soto-González et al., 2024).

Acute recovery

Exercise examples across the recovery stages

Acute means the immediate postpartum period and early weeks; subacute means recovery is established and basic tasks are easier; later means readiness for more demanding loading. These are teaching categories, not validated week boundaries or automatic clearance dates. Wounds, symptoms and maternity or surgical restrictions take priority.

Trial-informed identifies an exercise family included in a postpartum study, not proof that the isolated exercise closes DRAM. Adapted examples simplify positioning, cues or starting amount. Unless labelled as a study dose, repetitions and holds are illustrative trials rather than established optimum prescriptions.

Start smaller or with more support than illustrated if needed. Arrows for breathing and pelvic floor awareness are symbolic, not measured tissue movements. Stop and assess new pain, wound symptoms, leakage or vaginal heaviness. Doming alone is not a validated injury threshold.

Acute priorities: evidence-informed early care

Early care combines practical physiotherapy advice with research on exercise and recovery. Distinguish strategies for comfort, mobility and bowel function from interventions proven to change IRD; no acute package guarantees closure (Benjamin et al., 2023; Gluppe et al., 2021).

• Transfers and daily tasks: trial rolling onto the side and using the arms to sit up when this is easier. Ask for help with demanding lifting and follow surgical restrictions. Avoid holding the breath or forcing a painful task. Side-rolling and lifting advice are practical physiotherapy recommendations, not independently proven gap-closing treatments (The Dudley Group NHS Foundation Trust, n.d.).
• Bowel care: encourage appropriate fluids, fibre and movement. A footstool can reduce the need to strain. Seek help for persistent constipation. These strategies support bowel and wound comfort rather than having established independent effects on DRAM (Worcestershire Acute Hospitals NHS Trust, n.d.).
• Gentle activation: begin in comfortable side-lying or supported crook lying. Gently draw in the lower abdomen during exhalation, with pelvic floor participation if appropriate; keep breathing and release fully. Physiotherapy guidance suggests four or five repetitions, gradually building toward holds of up to ten seconds and ten repetitions. Adapt to symptoms; this is practical guidance, not an established optimal DRAM dose (Gloucestershire Hospitals NHS Foundation Trust, 2025; Gluppe et al., 2021).
• Activity and support: gradually build walking and low-impact activity according to recovery. Delay swimming until bleeding has stopped, wounds have healed and pelvic pain has settled (Gloucestershire Hospitals NHS Foundation Trust, 2025). Optional support wear may help comfort; evidence does not establish additional gap reduction over natural recovery. Stop if uncomfortable or causing pelvic pressure (Depledge et al., 2021).

Modify demanding tasks when they are uncomfortable or difficult to control, but do not treat doming alone as proof of damage. A postnatal review informs progression rather than automatically clearing every exercise. STEP's early exercise trial included vaginal births and excluded caesarean births; its day-one programme cannot be transferred directly to abdominal surgery (Shohaimi et al., 2023). Systematic reviews remain uncertain about the best exercise sequence (Benjamin et al., 2023; Gluppe et al., 2021).

Exercise positions are illustrative; follow the accompanying instructions.

Acute example one comfortable breathing with gentle abdominal participation

Purpose and performance. Use supported side-lying, sitting or lying with knees bent. Relax the shoulders. Take an easy breath in, then breathe out while gently drawing the lower abdominal wall inward. Avoid a forceful hollow, hard brace or pushing downward. Continue breathing, release completely, and repeat only if comfortable. The aim is comfortable coordination rather than maximum contraction.

Starting trial and modification. Try 3-5 easy repetitions, resting between them. Use a smaller contraction or practise breathing alone if the movement increases discomfort or creates unnecessary gripping. There is no requirement to keep the abdomen contracted throughout the day.

Evidence link. A physiotherapy-guided adaptation of early isometric activation and breathing approaches. Reviews do not establish isolated TrA work as the best method of reducing IRD (Donnelly, 2019; Gluppe et al., 2021; Lyons et al., 2026). A comfortable supported position is also described in NHS postnatal physiotherapy guidance (Gloucestershire Hospitals NHS Foundation Trust, 2025).

Acute example two gentle abdominal contraction with an arm movement

How to perform. Lie supported with knees bent and feet resting on the surface. Begin a gentle abdominal contraction, then move one arm a short distance toward the ceiling and overhead. Lower it slowly and release. Keep the movement small enough that breathing remains easy and the task does not provoke wound discomfort.

Starting trial and modification. Try 3-5 movements on each side. Reduce the arm range or return to contraction alone if difficult. Progress to both arms only if the smaller task is well tolerated.

Evidence link. Adapted from the arm-movement component of STEP. The one-arm, shorter-range version and starting repetitions are teaching adaptations, not the original trial prescription (Shohaimi et al., 2023).

Acute example three short heel slide when basic activation is comfortable

How to perform. Lie with both knees bent and feet supported. On an easy exhalation, gently engage the abdominal wall and slide one heel away along the surface. Keep the heel supported and stop before the movement becomes uncomfortable or the pelvis rolls substantially. Slide back, relax and alternate sides. Do not lift a straight leg off the bed as a substitute.

Starting trial and modification. Try 3-5 short slides per side. A shorter slide reduces demand; a longer supported slide is a progression. Delay this task if wounds or symptoms make it unsuitable.

Evidence link. Adapted from early alternating leg movement in STEP. Neither this modification nor a particular slide distance has been independently established as an effective DRAM treatment (Shohaimi et al., 2023).

Acute accompanying pelvic floor practice when appropriate

How to perform. In a comfortable position, gently close and lift around the back and front passages without squeezing the buttocks or pushing downward. Breathe, then release fully. The contraction should be appropriate to comfort and ability; use individual pelvic health assessment if pain, emptying difficulty or inability to relax is present. Do not practise by repeatedly interrupting urine flow.

Starting trial and modification. A few comfortable contractions with full relaxation may establish awareness; a strengthening dose needs assessment of contraction quality and endurance. Do not insist on maximum pelvic floor contraction with every abdominal exercise.

Evidence link. Included for pelvic floor recovery and assessed pelvic floor needs. Systematic review evidence supports relevant pelvic floor outcomes, not a promise of closing DRAM (Beamish et al., 2025; Gluppe et al., 2021). The movement description follows NHS physiotherapy guidance (Gloucestershire Hospitals NHS Foundation Trust, 2025).

Beyond 12 weeks

From early recovery to rehabilitation beyond 12 weeks

Early care supports healing, comfortable movement and gradual activity while natural recovery occurs. At around 8-12 weeks, review symptoms, confidence and function rather than expecting every gap to have disappeared. Persistent separation is not automatically failed recovery, and women need not wait until twelve weeks to seek help (Coldron et al., 2008; Sperstad et al., 2016).

When separation persists beyond twelve weeks alongside weakness, discomfort, activity limitations or return-to-sport goals, offer continued assessment and progressive rehabilitation. This is relevant to students in private practice, community and musculoskeletal settings as well as maternity wards. Reassess lifting, trunk strength, whole-body conditioning and pelvic floor symptoms. Build goal-specific loading; introduce impact or sport demands according to tolerance and relevant postpartum guidance, not the calendar or gap width alone. Twelve weeks is a review point, not automatic clearance to run, jump or lift heavily. Rehabilitation may also be appropriate when IRD has narrowed but capacity remains limited (Deering et al., 2018; Donnelly, 2019; Skoura et al., 2024).

Are crunch-type exercises supported?

Yes, for selected later-postpartum strengthening; they are not proven to close the gap. Gluppe et al. (2023) studied 70 women 6-12 months postpartum. A twelve-week programme containing head lifts and curl-up variations, five days weekly, improved abdominal strength and muscle thickness without improving or worsening IRD. It did not establish benefit for pelvic floor symptoms or pain. A curl-up therefore need not be universally prohibited because DRAM remains, but this trial does not establish suitability on the postnatal ward or automatically at twelve weeks.

Start with a tolerable head lift or small curl-up, assess symptoms and progress individually. Distinguish this from prescribing demanding full sit-ups immediately after birth. Broader systematic reviews do not identify one best exercise programme; neither crunches nor isolated deep-muscle activation should be promised as a cure (Beamish et al., 2025; Gluppe et al., 2021).

Review and documentation checklist

• Record consent, postpartum and birth context, restrictions, red-flag screen and the woman's priorities.
• Record symptoms and associated conditions separately from the DRAM description.
• Describe the functional baseline and any IRD measurement conditions.
• Document the explanation and options discussed, agreed goal, exercise rationale and actual dose.
• Record the response, self-management plan, escalation advice and review arrangements.
• At follow-up, review goal progress, symptoms, confidence and task capacity; modify or refer when indicated.

Subacute exercise

Exercise positions are illustrative; follow the accompanying instructions.

Subacute example one posterior pelvic tilt

How to perform. Lie with knees bent and feet supported. Gently roll the pelvis backward so the lower-back curve decreases slightly, then return to the comfortable starting position. Keep the shoulders relaxed and use a small range rather than pressing hard into the surface. Continue breathing.

Starting trial and modification. Try 5-8 slow repetitions. A brief pause may be added when comfortable. The aim is tolerable pelvic movement and coordination; it is not necessary to maintain a flattened back throughout other activities.

Evidence link. Included in postpartum exercise programmes and physiotherapy guidance. Its individual effect on IRD is not isolated from the surrounding programme (Gloucestershire Hospitals NHS Foundation Trust, 2025; Shohaimi et al., 2023; Thabet & Alshehri, 2019).

Subacute example two bridge

How to perform. Lie with knees bent, feet comfortable and arms resting beside the body. Press through the feet and lift the buttocks a manageable distance. Avoid forcing the lower back into an arch. Lower slowly while keeping breathing easy.

Starting trial and modification. Try 5-8 repetitions with a brief pause if comfortable. Start with a smaller lift; later add repetitions or resistance when the task is repeatably tolerated. Reassess if it provokes pelvic pain, vaginal heaviness or wound symptoms.

Evidence link. A trial-informed option for integrated trunk and hip loading. Bridging appears in the STEP programme and postnatal physiotherapy resources; the isolated exercise is not proven to close DRAM (Gloucestershire Hospitals NHS Foundation Trust, 2025; Shohaimi et al., 2023).

Subacute example three bent-knee leg lift or march

How to perform. Lie with knees bent and both feet supported. Gently engage the abdomen, lift one foot a few centimetres with the knee remaining bent, then replace it before changing sides. Keep the movement controlled and continue breathing. Begin with one foot moving at a time rather than taking both feet off the surface.

Starting trial and modification. Try 4-6 lifts per side. Return to supported heel slides if symptoms increase. A larger lift or more repetitions increases demand; moving both legs together is not a required next step.

Evidence link. Adapted from bent-knee leg lifting used in the physiotherapy-led pilot programme reported by Keshwani et al. (2021). Pilot findings support feasibility questions, not a firm claim of programme superiority (Benjamin et al., 2023; Skoura et al., 2024).

Subacute example four sit to stand and supported squat

How to perform. Sit on a stable chair with feet comfortably apart. Lean forward enough to bring weight over the feet, then stand. Sit down slowly. Use the hands or a higher chair initially. Progress to a shallow standing squat toward the chair when comfortable.

Starting trial and modification. Try 5-8 repetitions. Change chair height, range and hand support before adding a light external load. Use a comfortable breathing pattern; an easy exhalation during standing may help avoid unnecessary breath holding.

Evidence link. A functional physiotherapy adaptation consistent with postnatal squat guidance and goal-based load assessment. It targets daily capacity; no isolated DRAM-closing effect is claimed (Donnelly, 2019; Gloucestershire Hospitals NHS Foundation Trust, 2025).

Later exercise

Exercise positions are illustrative; follow the accompanying instructions.

Later example one head lift progressing to curl up

How to perform. Lie with knees bent, feet resting on the surface and arms reaching along the thighs. Begin with a small head lift. If tolerated, curl the upper trunk until the shoulders begin to lift, then lower slowly. Keep the neck comfortable rather than pulling on the head. Breathe through the effort and stop before fatigue substantially changes the task.

Starting trial and modification. Try 5 controlled repetitions, then review. Reduce to a head lift or smaller range if needed. Build range or repetitions according to response; altered arm position or resistance can be considered later. No mandatory IRD reduction is required before progression.

Evidence link. Trial-informed from Gluppe et al. (2023), who studied a 12-week programme in women 6-12 months postpartum. Strength improved without IRD worsening. The technique here is a practical teaching description, not a reproduction of every trial detail or proof of readiness at an earlier stage.

Later example two plank with a suitable support level

How to perform. Choose a wall, secure bench or floor position. Place hands or forearms on the support and move the feet or knees back to create a manageable trunk lever. Hold the body comfortably aligned while continuing to breathe, then rest before control deteriorates. Avoid maximal-duration efforts as an obligatory starting test.

Starting trial and modification. Try 3 holds of approximately 5-10 seconds if appropriate. A wall or high bench reduces demand; lower support, a longer lever or a longer hold increases it. These modifications and amounts are examples, not a research-established progression ladder.

Evidence link. Planks are included in postpartum trials, and a small study examined static and dynamic versions. Findings do not establish that a plank is essential or appropriate for every woman (Khademi et al., 2024; Shohaimi et al., 2023; Thabet & Alshehri, 2019).

Later example three side plank from bent knees

How to perform. Lie on one side with knees bent and the supporting elbow under the shoulder. Press through the forearm and knees to lift the pelvis a small distance. Keep breathing, lower slowly and rest. Repeat on the other side if comfortable.

Starting trial and modification. Try 2-3 brief holds per side. Reduce lift height or hold time if difficult. A straight-leg side plank is a later option, not a mandatory target. Check shoulder comfort and any pelvic symptoms.

Evidence link. A modified option from the side-plank exercise family included in Keshwani et al. (2021). The bent-knee version and starting amount are clinical adaptations. The pilot does not establish an isolated side-plank effect on DRAM (Benjamin et al., 2023; Skoura et al., 2024).

Later example four quadruped reach progressing toward bird dog

How to perform. Start on hands and knees. Slide one foot backward while keeping the toes supported, then return. Progress to lifting that leg slightly, then to an opposite arm-and-leg reach if tolerated. Keep the reach within a comfortable range without forcing the trunk to remain motionless.

Starting trial and modification. Try 4-6 movements per side. Shorter reaches and keeping one limb supported reduce demand. Change only one main variable at a time and review symptoms and breathing.

Evidence link. An indirectly supported strengthening option: bird-dog biomechanics describe abdominal recruitment, not proof of postpartum DRAM treatment efficacy. It is presented as a clinical adaptation rather than a superior gap-closing exercise (Bini & Bini, 2021; Skoura et al., 2024).

References & further reading

Sources cited in the guide, followed by additional clinical reading from the supplied bibliography.

References