Physiotherapy management options for women who experience separation of their abdominal muscles in the first 6 months after giving birth

The two exercise intervention arms will be delivered via a consultation with a physiotherapist prior to discharge from hospital, with review sessions scheduled for 6 weeks, 12 weeks and 26 weeks post randomisation (all with a physiotherapist), The two exercise intervention arms in the trial are: 1) Transversus Abdominus (TrA) training - between 1-10 repetitions held for 3-5 seconds of TrA activation in either a crook lying, side lying or 4-point kneeling position depending on patient-specific ability and technique to complete as measured by lateral slide and change in thickness of the TrA using ultrasound machine. The treating physiotherapist will cue and observe the exercise at the time of prescription to determine the optimal starting dosage, position and map out appropriate progressions for the first six weeks postpartum, given abdominal muscle function is likely to change significantly across this time. 2) Rectus Abdominus (RA) training - between 1-10 repetitions of a crunch movement held for 3-5 seconds each repetition. The patient will be cued to lift their head to a level they are able to control and tolerate well. This may be a head lift or up to a crunch movement where the shoulder blades leave the bed, dependent on patient ability. This is to best match what would typically be prescribed clinically and accounts well for both differences in abdominal muscle function across both vaginal and Caesarean Section deliveries. The dosage will once again be prescribed depending on each patient’s technique. The exercise will be completed and assessed in a crook lie position and exercise prescription based on the number of repetitions able to be completed with good technique and prior to the onset of doming or caving of the linea alba. Dosage for both groups will be 1-2 sets per day, >5 days of the week with compliance measured electronically via Simple Set (exercise prescription software). Participants will then be asked to come in for re-assessment and progression of dosage and/or position (if appropriate) at 6 and 12 weeks postpartum. Initial contact with the physiotherapists is expected to last 30-45 minutes, with up to 30 minute review appointments, all being held as one on one , face-to-face appointments. 6-week progression of programs: TrA The dosage will remain between 1-10 repetitions prescribed, but progression will be determined by either increasing the length of the contraction, increasing the number of the repetitions (if originally prescribed less than 10) and/or progression from early training positions (crook lie, side lie and/or 4-point kneeling) to sitting, standing and/or walking (as would be used functionally throughout the day). This will once again be determined based on observed lateral displacement of the TrA muscle during contraction as measured on ultrasound and matches what a typical progression would clinically be. RA The dosage will also remain between 1-10 repetitions of the exercise. However, as RA is not typically used during functional tasks in the same way the TrA is, the position will not be altered. However, if a participant can achieve 10 repetitions of a 2 second crunch without doming or caving of the linea alba, they will be instructed to increase the range of the movement as a progression up to and including lifting the scapula off the bed depending on participant technique. Dosage will once again be based on the number of repetitions able to be achieved with good technique and no doming or caving of the linea alba. In both active intervention groups, exercises will be taught in a mother-baby friendly way by incorporating either infant tummy time or encouraging 4-point kneeling over the supine infant to aid in adherence. At 12 weeks participants will be advised they do not need to continue to adhere to their specific exercise program. A final re-assessment will then be completed 6 months postpartum.