What is the recommended bowel regimen for a patient with constipation after Lower Segment Caesarean Section (LSCS)?

Management of Constipation After Lower Segment Caesarean Section (LSCS)

For constipation after LSCS, a stimulant laxative such as bisacodyl 10-15 mg daily or sennosides should be used as first-line treatment, rather than stool softeners like docusate which have been shown to be ineffective. 1, 2

Initial Assessment

• Assess severity of constipation and rule out complications like impaction or obstruction
• Evaluate medication use (especially opioids for post-surgical pain)
• Check for adequate fluid intake and mobility status post-surgery

Treatment Algorithm

First-line Treatment:

1. Stimulant laxative options:

   • Bisacodyl 10-15 mg daily (goal: one non-forced bowel movement every 1-2 days) 1
   • Sennosides (shown to be more effective than sennosides plus docusate combination) 2

2. Lifestyle modifications:

   • Increase fluid intake to at least 1.5 L/day 1
   • Early mobilization as tolerated post-LSCS
   • Increase dietary fiber intake if tolerated (but avoid supplemental medicinal fiber like psyllium which may worsen constipation) 1

If constipation persists:

1. Add osmotic laxatives:

   • Polyethylene glycol (17g with 8 oz water twice daily) 1
   • Lactulose
   • Magnesium hydroxide or magnesium citrate 1

2. For severe cases:

   • Rectal bisacodyl suppository 1
   • Glycerin suppositories if impaction is suspected 1

Important Considerations

• Avoid docusate sodium: Research shows it is ineffective compared to stimulant laxatives alone 2, 3
• Opioid-induced constipation: If patient is on opioids for post-surgical pain, prophylactic bowel regimen is essential as patients do not develop tolerance to constipation 1
• Goal of treatment: One non-forced bowel movement every 1-2 days 1
• Caution with enemas: Use sparingly in post-surgical patients and be aware of possible electrolyte abnormalities 1

Special Situations

• If constipation is opioid-induced and resistant to standard treatment, consider peripherally acting μ-opioid receptor antagonists like methylnaltrexone (though use with caution in post-surgical patients) 1
• For patients with severe, persistent constipation, assess for other causes such as hypercalcemia, hypokalemia, or hypothyroidism 1

Common Pitfalls to Avoid

1. Relying on stool softeners alone (docusate) which have been proven ineffective 2, 3
2. Inadequate fluid intake post-surgery
3. Delaying mobilization which can worsen constipation
4. Using bulk-forming agents like psyllium in patients with inadequate fluid intake 1
5. Failing to provide prophylactic treatment when opioid analgesics are used 1

Early intervention with appropriate laxatives is crucial to prevent worsening constipation and associated complications in post-LSCS patients.