Anna Field RN-BC, BSN, RD
Many women of childbearing age have given thought to what may happen with their bowels during childbirth, but perhaps not what happens in the days after the baby is born. The body has just carried out one of the most major metabolic processes of a lifetime. The bowels can be sluggish due to stretched and weakened muscles, soreness, and side effects of some pain medications. (1) The bowels may not immediately bounce back to what they were before pregnancy and delivery.
There are a variety of factors that affects the first bowel movement for the mother after birth.
EPISIOTOMIES & TEARS
One factor that can affect the first bowel movement is any incision made or natural tearing that may occur during delivery. The doctor or midwife can sometimes make a surgical cut to widen the opening called an episiotomy if they believe the baby or mother is in distress, and the baby needs to be quickly born, this is not standard practice, but it does happen.
Nine out of ten women experience perineum (the area between the vaginal opening and the anus) tears during birth, this happens because the baby stretches the vagina to the extent that the skin strains so much it tears apart. To indicate how severe the tear, a system of degrees is used. (2) A 1st-degree tear is minimal and does not need stitches. 2nd-degree tears extend from the back of the vagina to the musculature of the perineum. A 3rd-degree tear extends from the back of the vagina to the anal sphincter. 4th-degree tears extend into the rectum. 2nd-, 3rd-, and 4th-degree tears require stitches to close. 3rd- and 4th-degree tears are strongly correlated with first vaginal birth. (3)
When a mother experiences a 3rd- or 4th-degree tear, the doctor may mention to the mother that she could temporarily experience fecal incontinence that should improve within the first 6 weeks. (3) Something a new mother wants to hear or think about in the weeks after birth, but there are treatment options should this symptom persist.
Experiencing a tear or episiotomy during delivery can cause apprehension regarding having a bowel movement. A new mom may worry about potential pain, or the stitch may tear open while bearing down to the bowels, this is a very valid concern, although doctors tell us that it is unlikely.
Several interventions can be implemented to ensure a smooth, less painful return of bowel function.
Keep bowels soft by drinking at least 64 ounces (or 8 cups) of water per day.
A glass of warm water with lemon upon waking is a great way to get peristalsis (the wave of muscles of the gastrointestinal tract relaxing and contracting to move food through) started.
Stay regular by eating fresh fruits, vegetables, and salads.
Dried prunes and figs are excellent for bowel motility.
Avoid constipating foods such as white rice and flour, refined foods, and chocolate.
Use a stool softener if recommended by a physician. (4)
Bulk-forming laxatives like psyllium or bran increase bulk and moisture in the stool that stimulates bowel movement. (4) Psyllium and bran can be added to cereals or smoothies.
With any opening or injury to the skin, even if closed with stitches, infection prevention is important.
Avoid unwanted bacteria and keep the vagina and perineum clean with the following tips:
Wipe from front to back.
After wiping, use a peri bottle (a plastic squirt bottle to cleanse and soothe the perineal area) to spray warm water on the stitches and then pat dry.
Use medicated wipes such as Tucks, which are soothing and reduces itching.
Change sanitary pads frequently.
To support the comfort of the stitched area during the bowel movement, apply a clean, cold, wet pad. (5)
Sit in warm water (sitz bath) for 15 to 20 minutes after bowel movements if the area is still painful and having a bowel movement aggravates it. (6)
BREASTFEEDING
Dehydration can lead to constipation. While it is easy for any new mom to become dehydrated, breastfeeding women are at higher risk due to their output of fluid in the breast milk. A good rule of thumb: when baby drinks, mom drinks. The average adult needs 64 ounces (8 cups) of water per day. If a newborn consumes about 16 ounces of breast milk each day, a new mom should have 80 ounces (10 cups) of water daily to replenish water used to make breastmilk. (7) Dehydration symptoms to watch out for are dark-colored urine, dry lips, muscle cramps, and fatigue. Constipation occurs because a significant amount of water is used for digestion in the large intestine. As food passes through, it soaks up water from the surrounding area as its digests and absorbs nutrients. (8) A dehydrated stool appears darker in color and looks like pellets or pebbles.
STAY HYDRATED
Coconut water is an excellent source of electrolytes and has a natural sweetness.
Drink water every time you nurse and every time you pump. Keep a bottle of water with your pump or wherever you tend to nurse your baby.
Mix juice with water if you don’t like the taste of plain water.
Track water consumption by using a large water bottle with markings for milliliters and ounces.
CESAREAN SECTIONS
Women who had a C-section tend to experience delayed motility of the gastrointestinal system in the postoperative period. (9) Which affects the timing of their first bowel movement. On average, a woman who has a C-section has her first bowel movement within 3 days, which is slightly longer than the time to first bowel movement for a mother who delivered vaginally. Since a C-section is considered abdominal surgery, one can expect a slower return to normal. Researchers from Turkey found that chewing sugar-free gum, interestingly enough, activates the cephalic vagal reflex and can stimulate bowel function in the immediate postoperative period. (9) It is good news for moms: less abdominal distension and discomfort early on after delivery.
If you are worried about pain at your incision site while bearing down when having a bowel movement, splint your belly with a pillow while on the toilet. Additionally, go to the bathroom like our ancestors did: use a toilet stool under your feet so that they are elevated, making your pelvis positioned in a squat position. By assuming a squatting position, the colon is opened up for better elimination, and minimal straining. (10) There are many stools available for this sort of activity - a quick google search will yield many results.
Tips:
Chew sugar-free gum to stimulate bowel function early on after C-section.
Splint abdominal incision with a pillow or hands when having a bowel movement to relieve pain.
Elevate your feet with a “potty” stool.
Mothers can universally agree that the first stool after delivery can be nerve-wracking and intimidating. Stay calm, stay hydrated, and position yourself correctly for a smooth experience.
REFERENCES
1. Turawa, E. B., Musekiwa, A., & Rohwer, A. C. (2015). Interventions for preventing postpartum constipation. The Cochrane database of systematic reviews, 2015(9), CD011625. doi:10.1002/14651858.CD011625.pub2Goh, R.,
2. Goh, D. & Ellepola, H. (2018). Perineal tears - a review. Australian Journal of General Practice. Volume 47, Issue 1–2, January–February 2018.
3. Eason, E., Labrecque, M., Marcoux, S., & Mondor, M. (2002). Anal incontinence after childbirth. CMAJ : Canadian Medical Association Journal, 166(3), 326–330.
4. Liu L. W. (2011). Chronic constipation: current treatment options. Canadian journal of gastroenterology = Journal canadien de gastroenterologie, 25 Suppl B(Suppl B), 22B–28B.
5. East, C., Begg, L, Henshall, H., et al (2012) Local cooling for relieving pain from perineal trauma sustained during childbirth. Cochrane Databse System Rev. CD006304.
6. Incision care after vaginal birth (2018). Fairview Health Services. Retrieved from https://www.fairview.org/sitecore/content/Fairview/Home/Patient-Education/Articles/English/i/n/c/i/s/Inci`sion_Care_After_Vaginal_Birth_82258
7. Jacobson, H. (2007) Mother food: a breastfeeding diet guide with lactogenic foods and herbs. Rosalind Press.
8. Azzouz L.L. & Sharma, S. Physiology, large intestine. (Updated Apr 2019) StatPearls. Treasure Island, FL. StatPearls Publishing.
9. Akalpler, O., & Okumus, H. (2018). Gum chewing and bowel function after Caesarean section under spinal anesthesia. Pakistan journal of medical sciences, 34(5), 1242–1247. doi:10.12669/pjms.345.15772
10. Sikirov, D. (2003) Comparison of straining during defecation in three positions results and implications for human health. Digestive Diseases and Sciences. Vol. 48, No. 7 (July 2003), pp. 1201–1205 (°C 2003)