Constipation after Emergency Caesarean Section

 

Dr Emily Leadbeater, Dr Richard Skelly, Dr Suni Halder

Oxford University Hospitals NHS Foundation Trust

 

Introduction

Negative feedback was received from a staff member about their postnatal care. Constipation management was responsible for much of the negative experience. 

Elective caesarean section patients (ELCS) were subsequently surveyed in 2023 aiming to elucidate the incidence of constipation.

60% of the surveyed women who had undergone ELCS  reported symptoms of constipation. This prompted the development of local guidelines and a change to prescribing practices. The incidence of symptoms in patients undergoing emergency caesarean sections was unknown. 

It was unclear how laxative medications were being  prescribed, or if they were being administered on the postnatal wards.

Constipation is a taboo subject. Patients may find it difficult to bring it up to health care professionals, and similarly, health professionals may be embarrassed to ask, preferring to ask ‘open questions’.

Objective

We sought to determine whether the EMCS population were experiencing a similar burden of symptoms as the ELCS cohort in order to improve our care, prescribing practises and ultimately patient experience.

Methods

Women undergoing EMCS during a specified time period were contacted by telephone, verbal consent was obtained. 

They were interviewed on the telephone and asked a series of open and closed questions.

Their medical notes and drug prescription charts were reviewed for prescribing practices and drug administration rates. 

Midwives working on the postnatal wards were interviewed about their laxative administration practise.

Patient survey

Open question: “Did you experience constipation?

Closed questions: “Did you have to strain to open your bowels?

Were you passing < 3 stools per week?

Did you feel like there was still stool to come out when you had finished? [Incomplete evacuation]

Were you spending excessive amount of time on the toilet?

Were you passing hard stool?

Findings

62% Report constipation on open questioning

82% Report constipation on closed questioning

58% Stated that constipation had negatively impacted their life. 

52% of women stated that no one had actively asked them about constipation. 

Most likely group to actively ask were midwives (36%).

Laxatives

Prescribing laxatives as ‘regular’ instead of ‘PRN’ improved administration from 31% to 56%. 

Mean duration of symptoms with macrogol postnatal prescription was 4 days compared to 10 days with lactulose. 

36% Prescribed inpatient laxatives. However, only 24% received them.

Postnatal midwives perspective

More likely to give:

• Lactulose than macrogol, “it’s on the trolley”
• “If patient has a tear”
• “If woman reports constipation”
• “If they haven’t already opened their bowels on day one”
• “if they are taking regular oramorph/codeine”

Future

Diagnosis - provide teaching sessions to anaesthetists, midwives and obstetricians. Ask direct questions.

 

Prescribing - re- audit prescribing practise, preferential prescription of macrogol.

 

Administration - tea trolley teaching for postnatal midwives to ensure that prescribed regular laxatives are administered.

 

Speak up! Encourage patients to report constipation to health care professionals.