Postpartum Constipation


Constipation is a disorder of the large bowel that results in symptoms such as pain upon passing stools, straining, hard and lumpy stools, and a sense of incomplete emptying. This discomfort during bowel movements can be particularly concerning for a mother after the birth of her baby. After all the stress of pregnancy and delivery, and especially if she sustained tears to her labia or perineum or developed hemorrhoids, the first stool after birth and the possibility of constipation can be anxiety-inducing. Not all hospital policies recommend the use of enemas before labor or allow women to eat during the early labor process, and this may affect their postpartum ability to have a regular bowel movement.


Postpartum Constipation


Postpartum constipation, with symptoms of discomfort, straining, and hard stools, is a common condition affecting mothers during pregnancy and after delivery. Hemorrhoids, pain at the episiotomy site, the effects of pregnancy hormones (primarily progesterone), and the use of iron-containing supplements in pregnancy can increase the risk of postpartum constipation.


How Common is Postpartum Constipation?


The prevalence of postpartum constipation has been reported to be 41.8% by individuals self‐reporting and 24.7% as classified by the Rome criteria (3). Overall, 1 in 4 women suffer from constipation throughout pregnancy, and for another three months postpartum (4).


There is an association between bowel problems in early pregnancy (12 weeks gestation), and constipation at 12 months after childbirth (5). 1 in 3 women in their third trimester of pregnancy report two or fewer bowel movements a week (6). Sensations of incomplete evacuation of bowel contents and time spent defecating were significantly more during all three trimesters of pregnancy compared with after birth. The symptoms of bowel urgency were 41% higher in nonlactating mothers compared to 17% of lactating women (7).




Causes of Postpartum Constipation


Progesterone: Constipation during pregnancy and the postpartum period is thought to be caused by the high progesterone levels. Progesterone decreases gut transit time and slow peristaltic mobility. (17)
Food: Constiation can be linked to different type of food consumed during and after pregnancy. Also, interruption in dietary intake can affect constipation(8). 
Hemorrhoids are also a common complaint among pregnant women due to the increased pressure on the rectum, the larger blood supply to the rectum, and straining from constipation. 
Tearing/Episiotomy: Stitches from Perineal injury, lacerations, and episiotomy can contribute to constipation.
Fear of expected pain from swollen hemorrhoids, pain at the episiotomy site or lacerations, may also contribute to the increased incidence of postpartum constipation. 
Activity: Reduced physical activity following delivery can increase the risk of developing postpartum constipation (9). 

How Do You Know if You Have Constipation?


According to the Rome diagnostic criteria III (1), the diagnosis of constipation needs to include two of the following criteria: 

Straining during at least 1 of every four defecations Lumpy or hard stools in at least 1 of every four defecationsA sensation of incomplete evacuation during at least 1 of every four defecationsA feeling of rectal obstruction/blockage during at least 1 of every four defecationsManual maneuvers such as digital evacuations to aid 1 of every four defecations, Fewer than three defecations per weekLoose stools only with the use of laxatives (2)


Bristol Stool Scale to Describe the Types of Stool : Type and Description


1. Separate hard lumps like nuts (difficult to pass)

2. Sausage shaped but lumpy

3. Sausage shape with cracks on the surface

4. Like a sausage or snake, smooth and soft

5. Soft blobs with clear cut edges (passes easily)

6. Fluffy edges with ragged edges (mushy)

7. Watery, entirely liquid



How to Prevent Constipation


When the stool stays in the colon too long, the colon absorbs too much water from the stool, which makes the stool hard, dry, and painful to pass (9). The interventions for preventing constipation include medications and other interventions such as lifestyle changes, including exercise and high fiber diets. In many cases, that is all that is needed (10). 


Food: High‐fiber foods such as fruits, vegetables, beans, and legumes can help to relieve symptoms and prevent constipation in the postpartum period (11). Exercise: Walking is encouraged to lower the chance of constipation. 
Educational: Incident of postpartum constipation is quite high, and providing information about the incidence of postpartum constipation, quality of life, time to first bowel movement after delivery can help prevent and resolve the condition faster. (14)
Behavioral interventions: Educating about the proper defecation techniques. Avoiding straining while passing the stool is essential, and alternative methods to promote defecation helps to prevent constipation.
Medication: Laxatives are the drugs of choice in preventing and relieving symptoms of constipation and can be taken in a variety of formulations. Laxatives are grouped into categories according to their method of action: 
Bulk-forming laxatives: Bulk-forming laxatives are bran and methylcellulose that increase the weight and water content of stool to facilitate movement of the stool through the colon, called peristalsis. (12)
Stool softeners and Lubricants: Osmotic laxatives, such as magnesium (Milk of Magnesia) and lactulose, work by retaining water in the colon to soften the stool (9). 
Stimulant laxatives: stimulant laxatives directly stimulate the colonic nerves, thereby irritating the walls which ease bowel movements (13). Stimulant laxatives are reserved for occasions when the others are ineffective.
Acupuncture and Chinese herbal medicine: Chinese herb works by improving the peristaltic mobility. Lin and colleagues found a significant benefit of traditional Chinese herb in treating constipation. (18)



The postpartum period is a crucial time for the new mother. Several health changes and problems may occur during this period. Postpartum Constipation is a fairly common condition and generally not discussed. Constipation has a significant negative impact on the quality of life of the mother and should be addressed right away.





References

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