by Dr. Katie Coleman, PT, DPT, WCS, CSCS
We’ve all heard of constipation during pregnancy; but for some women, constipation can last after delivery. Approximately 25%-40% of women experience constipation during pregnancy and up to 25% of women report this condition persists several months postpartum (1). What is constipation exactly? What causes it? And how can you find relief?
Constipation is defined as difficulty moving the bowels and is characterized by straining, lumpy or hard and dry stools. There is also a sensation of incomplete emptying that may require manual maneuvers or enemas (2). Along with constipation, women may suffer from hemorrhoids as well due to the constant straining and pressure from pushing during a bowel movement (1). There are many causes of constipation including: dehydration, hormonal changes, structural changes, medications, and pre-existing medical conditions.
Dehydration postpartum may be due to poor fluid intake and lack of dietary fiber (1). With poor hydration status, the small bowel and colon motility is diminished, resulting in slow transit time of stool and thus constipation.
Hormonal changes, such as increased progesterone, act to relax smooth muscles in the body during pregnancy and postpartum (1) This relaxation effect also contributes to slow gut motility and slower transit time. Further, anal sphincter contractions are diminished and defecation patterns become disrupted (2).
Structural changes of the pelvic floor include obstruction of the anal sphincter and perturbations in the function of the levator ani muscle to contract/relax properly during a bowel movement (2). Obstruction may be due to increased intraabdominal pressure from the increased weight of the uterus.
Medications such as antiemetics (nausea drugs) are often known to cause constipation as a potential side effect. These medications may include: ondansetron, promethazine, prochlorperazine, and antihistamines.1Iron supplements prescribed for anemia during pregnancy can also cause constipation. The degree of constipation is directly proportional to the amount of elemental iron ingested, with some formulations reporting an estimated 50% rate of treatment-related constipation (2). Tocolytic drugs, such as magnesium sulfate, which are used to prevent preterm labor or treat preeclampsia, are also known to cause constipation (1).
Pre-existing medical conditions such as Irritable Bowel Syndrome (IBS) may further predispose women to constipation. We know that the hallmark signs of IBS are abdominal pain, discomfort, and changes in bowel habits. Women of child-bearing age are the main demographic of all IBS diagnoses, and IBS may be exacerbated during pregnancy (2).
Thankfully, there are simple remedies to provide relief for constipation in the post-partum period. These include increasing water and fiber intake, use of a probiotic, and exercise (3-11). If these methods are ineffective, laxatives and/or stool softeners may be used as a second line of therapy.
While there is no “magic” amount of water intake that fits every woman’s needs, most researchers agree that consuming approximately 1.2oz (35ml) of water per kg of body weight is adequate to maintain good hydration postpartum (5). For women who exercise or spend more time in hot environments, more is likely needed. Good food sources of water include melon, cucumber, celery, soups, and even lean meats (5).
Fiber intake must include both soluble and insoluble fiber to promote regular bowel movements.4 Soluble fiber helps soften stools while insoluble fiber helps add bulk to stools. Besides food sources, postpartum women should aim to consume 20-35g of supplemental fiber each day (4). Food sources of fiber include cereal/bran, fruits such as plums or kiwis, and vegetables. Look for products that contain polydextrose, psyllium, chicory inulin, prebiotics, or synbiotics (4).
Probiotics are “healthy bacteria” that can alter the flora of the colon and may improve bowel function (9). Probiotics have been shown to improve gut transit time, stool frequency, and stool consistency (9). These should be taken daily.
In addition to water, fiber, and probiotic intake, exercise can be a simple yet highly effective treatment for postpartum constipation. Exercise helps improve colonic motility, reduce bloating, and help move stool into the rectum via abdominal contractions (10).
If first line therapies fail, second line therapy of bulk-forming laxatives, osmotic laxatives, or stimulant laxatives may be indicated (3). Talk with your OB first before beginning laxatives.
He or she may also recommend pelvic physical therapy to help improve muscular functioning of the levator ani. Pelvic physical therapy can help instruct women on relaxation techniques and toileting posture to help empty the bowels (11).
Postpartum constipation is more common than previously thought. Do not suffer in silence. Try these simple techniques and see how your bowel movements improve!
Still have questions? Contact Elevate Physical Therapy @ 513-975-1012 or email katie@elevatepelvicpt.com.
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10. Gao R, Tao Y, Zhou C, et al. Exercise therapy in patients with constipation: a systematic review and meta-analysis of randomized controlled trials. Scand J Gastroenterol. 2019;54(2):169-177. doi:10.1080/00365521.2019.1568544
11. Turawa EB, Musekiwa A, Rohwer AC. Interventions for treating postpartum constipation. Cochrane Pregnancy and Childbirth Group, ed. Cochrane Database of Systematic Reviews. Published online September 23, 2014. doi:10.1002/14651858.CD010273.pub2