Postcaesarean Ileus

Postcaesarean ileus is temporary failure of bowel movement after caesarean section, causing distension, nausea, vomiting and no passage of flatus or stool. It is caused by handling of the bowel, opioids, low potassium or magnesium, blood or infection irritating the peritoneum, and immobility. It usually settles within 72 hours, but a longer course points to bowel injury, obstruction or sepsis.

• Risk factors: emergency caesarean section, repeat surgery with adhesions, long operation, opioids, electrolyte disturbance, chorioamnionitis, diabetes, preeclampsia treated with magnesium sulphate.
• Colonic pseudo-obstruction (Ogilvie syndrome) can follow caesarean section and risks caecal perforation when the caecum exceeds 12 cm.
• Early feeding and mobilisation lower the risk.

Women have abdominal distension, nausea, vomiting, absent or reduced bowel sounds and no flatus beyond 48 to 72 hours, with mild generalised discomfort. Fever and marked tenderness are not typical.

• Tympanic distended abdomen without guarding.
• Pulse and temperature usually near normal.
• Differential diagnosis: bowel injury, peritonitis, endometritis, mechanical obstruction from adhesions, pelvic abscess, wound or rectus sheath haematoma, hypokalaemia, opioid effect.
• Complications: dehydration, aspiration, caecal perforation, prolonged admission, delayed breastfeeding and mobilisation, reoperation.

The approach is clinical, with tests to find a cause and to exclude injury or obstruction.

• Examine abdomen, wound and hernia sites; record pulse, temperature, urine output and bowel sounds.
• Potassium, magnesium, calcium, sodium, urea, creatinine, glucose, full blood count, C-reactive protein.
• Plain abdominal X-ray: gas in small and large bowel; caecum above 9 cm is concerning and above 12 cm risks perforation.
• Ultrasound or contrast CT if symptoms persist beyond 72 hours or peritonism develops.

The principle is correction of electrolytes, early feeding, avoidance of opioids and exclusion of a surgical cause.

• Supportive: clear fluids within 2 to 4 hours of surgery then normal diet; walk early; chewing gum for 30 minutes three times daily; Ringer's lactate 1 litre IV over 8 hours as maintenance when oral intake is poor; nasogastric tube on free drainage and nothing by mouth for persistent vomiting.
• Pharmacological: potassium chloride 40 mmol per litre infusion at a maximum of 10 mmol per hour to keep potassium above 4.0 mmol/L; magnesium sulphate 2 g IV over 2 hours if magnesium is below 0.7 mmol/L; metoclopramide 10 mg IV or oral 8-hourly for up to 3 days when there is no obstruction; bisacodyl 10 mg rectal once daily; lactulose 15 mL oral 12-hourly; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) with diclofenac 50 mg oral 8-hourly for 3 days if no contraindication; neostigmine 2 mg IV over 3 to 5 minutes with atropine 0.5 mg ready and continuous ECG for pseudo-obstruction with caecum above 10 cm after mechanical obstruction is excluded.
• Procedures: nasogastric decompression; colonoscopic decompression for caecum above 12 cm or failure of neostigmine; laparotomy for perforation, peritonitis or mechanical obstruction.
• Red flags: fever above 38 degrees Celsius, rigid abdomen, caecum above 12 cm, faeces or bile in the wound, vomiting of faecal fluid, rising lactate above 2 mmol/L, pulse above 110 per minute.
• Follow-up: abdominal examination and bowel function daily until passing stool; wound review at 1 week; review at 6 weeks.