Post-op: bowel activity

When bowels are handled and disturbed, as happens during a hysterectomy or any other abdominal surgery, they shut down activity for a period of time. This is why women are often surprised to find that they are limited to only liquids for the first day or so after their hyst: this gives the bowels a rest and doesn't overwhelm them before they are ready to resume activity. Eating too soon will only cause the undigestible food to back up, producing vomiting that is not a real appealing prospect for anyone who has just had abdominal surgery--not a pleasant thing to contemplate.

How do we know that our bowels are returning to function? Our caregivers can hear the sounds of sloshing when they listen with a stethescope, and before long, we can feel or hear the passage of gas. This is such an important recovery milestone that it is one of the criteria for discharge: we have to actually pass gas to demonstrate that our bowels are capable of taking up their digestive functions again.

For many women, this signals the most frustrating and uncomfortable part of recovery, however: dealing with gas and constipation. Narcotic drugs, low physical activity levels, a low-fiber diet, not drinking enough, and, for those who are users, lack of caffeine all contribute to impaired bowel motility and enhance these gas and constipation effects.

But those causes also provide us with a good set of things we can do to limit these unpleasant symptoms of our bowels recovering. 

Postop: walking and the prevention of surgical complications

When and why you have to start walking in the immediate postop recovery period is a concern I frequently see women "voicing" in the online forums. This tends to get short shrift in the pre-op teaching, other than a fleeting mention that you'll be up and walking "right away" after surgery.

Right away most likely means on the day of your surgery, a few hours after you get to your room from Recovery. Generally the order is written for you to "dangle" first and then, a few hours later, to get up and walk. This means that the first effort will simply be to sit on the edge of the bed with your feet hanging over the side. In itself, this is a minor production, and you'll have the help of your nurse getting all of your tubes (IV and catheter, at least) organized. Your nurse will show you how to use the bed controls to raise yourself, then swing your feet over and down from a sideways position so that you put less stress on your belly. This is a very effective and important technique that you'll be using in the weeks ahead, so take your time and use the help and coaching to get the hang of it. Your nurse should stay with you the whole time you're sitting up, since it may make you a bit woozy and light-headed.

Later, usually the evening of your surgery, you'll actually get out of bed and stand and walk a few steps. Sound scary? It's really not grim. You'll have your pain medication, and most nurses know to medicate you before you move around so you'll be prepared. You may want to hold a towel or small pillow to your belly to help with the sensation that it will fall out. This is an illusion from muscle weakness, but you'll feel more confident holding onto it. Standing up starts just like dangling, only you'll go all the way to standing up. Go ahead and stand up straight: there's nothing useful in walking hunched over and your back will appreciate the chance to stretch that good posture provides.

The first time you walk, you may only go a few steps across your room or down the hall. Each time you get up, it's a little easier to go a little further. By your next postop day, you may be ready to walk on your own, but do ask for someone to accompany you as long as you feel at all woozy.

So why is this so important? The most critical part of walking is that it helps to prevent the complications that can come from any surgery, and particularly abdominal surgery (and this applies to those whose surgeries used the vaginal route: the surgical site is in your abdomen, and that's what counts here). When our lungs are depressed from anesthesia and dried out from getting oxygen and we lie extra still in one position (as we do when under anesthesia and then later under pain meds), secretions can pool up in our lungs and make a perfect medium for bacterial growth. Pneumonias and loss of lung function can follow, so changing position, deep breathing and moving about are important measures to prevent this.

Another surgical complication is blood clots. These are caused by, again, lack of the normal movements that exercise our blood vessels and keep blood from pooling and clotting. Abdominal surgery makes us especially prone to blood clots, so your surgeon may order you to wear special elastic stockings or pneumatic leggings to help take over that blood vessel exercising when you're less active during the first operative day. As you move around more, the normal motions and muscular activity will resume this function. Still, it's important to move and stretch your legs every hour or so while you're in bed and to try to remember to never cross your legs or ankles while you're lying around (this constricts blood flow, too). The more often you walk, the more you're working to prevent blood pooling and the clots it can lead to.

Another big benefit to walking is the way it helps your guts to start working again. It's normal for abdominal surgery to cause our intestines to more or less shut down. They are cranky organs, and just don't like to be handled and disturbed. It may take a day or two for them to get over their snit. During that time, you'll find your doctor and nurses listening to your belly with a stethoscope and asking you if you've passed gas yet. Your diet will typically be very light at first, mostly clear things like jello and broth and fruit juices, so that you don't overload your nonfunctional guts. Walking will help stimulate your intestines to get back to work, and once they do so, it'll help keep things moving along. Many women find that the gas that builds up in non-functional guts is the greatest source of postop discomfort for them, and walking is the best way to keep it moving on its way. As you walk more and your guts work better, your appetite will recover and your diet will be advanced to more fulfilling foods. It's typical that you won't be discharged from the hospital till you pass gas, thus demonstrating returning bowel function. The more you walk, the sooner you'll be outta there, then. This is a worthy goal.

Once you're home, walking regularly will keep your guts moving despite the constipating influences of pain medications and inactivity. Walking is also the best, gentle exercise for rebuilding your stamina. The more you lie around and don't use your muscles, the weaker you get—strength is a real use it or lose it proposition. By walking regularly and for increasing duration and distance, we keep from losing ground and, safely, push ourselves to recover.

How much is enough? In the first week at home, just walking around the house to the bathroom and kitchen and sofa and bed will probably be enough. By the end of that week, though, you should be making brief forays outside--perhaps up the driveway or around the yard for a lap or two. By the end of the second week, women who have been hearty walkers before are doing blocks; those who may be in poor physical condition should still be able to walk a block or more at this point. So long as what you reach for is healthy fatigue, not exhaustion or extra soreness, you're on track for a healthy recovery. If you get sore or you don't feel refreshed after napping on your return, you need to back off a bit and give your body time to gather the additional resources to recover and be ready to progress again. For the first month, walking is your best exercise, and duration/distance, rather than speed or steepness of terrain, should be your goals.

Questions for your pre-op appointment

This is a list of basic questions to ask your doctor at pre-op appointments. It may not cover absolutely everything that might be pertinent to your surgery, but it should help you cover the important points. A good way to use this list would be to copy the page, paste it into a word-editing document, add extra lines between the questions, and print it out. Then you can take it to your appointment and write the answers down (or take a mini-recorder and tape them) so you can review them at home, when you have time to think things over. Be sure to jot down any other questions you may think of while reading this, so you remember to ask them, too.

1. What is the full name of my surgery? (Write this down!) What exactly will you remove: uterus? ovary/ies? cervix?
2. Will you be combining this with any other procedures? Appendix removal? Bladder repair? Rectocele? Tummy tuck?
3. How will you remove the organs and where will the incision be? Abdominal (horizontal "bikini"? vertical?)? vaginal? using a laparoscope?
4. Which things you remove will be going to the lab for pathology tests and when will I get the results? If my surgery is for suspected cancer, how soon will I begin treatments and what will they be?
5. Should I donate blood before my surgery? If so, when? If not, what if I need a transfusion? If I don’t need a transfusion, is there something else I should do afterwards to build my blood back up?
6. Right now I am taking (list all of your vitamins, herbs, special dietary practices as well as prescription medications, birth control pills, hrt; if in doubt, list it!). Should I stop them before surgery? If so, when? And when can I go back to taking them after my surgery?
7. Will I have any special surgical preparation: enema? laxative? douche? Will I be shaved? If so, where and by whom? May I do it myself instead?
8. What if I have my period when I’m supposed to have my surgery?
9. I am planning to have my [whatever] pierced or get a tattoo. If I have it done before, how long must it have to heal before the surgery is scheduled? How soon may I have it done afterwards?
10. May I leave my finger- or toenail-polish and/or artificial nails on when I go to the OR? May I leave my wedding ring on?
11. What kind of anesthesia will I have? What if I prefer a different kind? Will I meet with my anesthetist before surgery?
12. How long will my surgery take? Will you report to my family afterwards, while I am still in the Recovery Room? How long will I be in Recovery before I am taken to my room?
13. How will my pain be managed and what will you be giving me? Will I receive it in the Recovery Room? Do I have to ask before I can have it, or will it be given to me? How often may I repeat it? What if that doesn’t work—will I have another option? How will I get that second option?
14. What if I become nauseated after surgery? May I have something for this? May I have it before I vomit? in the Recovery Room?
15. How long will I be on bed rest? When will I get up? How often should I get up?
16. Will I have a catheter into my bladder? Will I be awake when it is put in? When will it be taken out?
17. When can I take a shower? When will I be able to bathe? Use my hot tub?
18. Will I have vaginal bleeding after my surgery? How much and how long?
19. Will I have on special stockings or pneumatic leggings to prevent clots in my legs after surgery? How long will I have to wear them? Will I be receiving any medication for this purpose? Which one, and how long?
20. Will I be hooked up with/using any other equipment or special things after surgery? Tummy binder? Breathing exercise devices?
21. How long will I have an IV after surgery?
22. What will I be taking for post-op gas and constipation? How long will I need this? If I'm not prescribed something and develop these problems, what do you recommend I take?
23. If I am having my ovaries removed, when will I start taking hormones and which ones will I take? What is this choice based on? How can I expect them to make me feel? What if I don’t like the way I feel on the first prescription or think I am having a bad reaction?
24. If I am not having my ovaries removed, how can I tell if they are or are not working post-op? Will I have hot flashes anyway? If my ovaries don’t work right away, what will I experience? How long will I have to experience menopausal symptoms before I can take something to relieve them?
25. What things have to happen before I will be discharged from the hospital? How long should I expect to be in for?
26. When will I see you after I leave the hospital? What if something happens or I have questions about how I'm doing before then?
27. What pain medication and other medications will I go home with? If I run out of pain medication, how do I get more?
28. What kind of problems should I be watching for at home?
29. Do I need to have someone stay with me at home after I am released from the hospital? for how long? Should I arrange for another caregiver or board out my kids and/or pets?
30. What activity restrictions will I have at home? Stairs? Bathing? Driving? Housework including laundry and vacuuming? Lifting how much when? What about my kids or pets—when can I pick them up?
31. What if I do something and it makes my incision/belly really hurt? Can I hurt myself by doing too much too soon? How will I know?
32. Will I need to wear a tummy binder or light girdle at home for belly support? If so, for how long?
33. I am planning to do something special (go to my son’s wedding 2 weeks after surgery—move to a new state a month postop—return to grad school classes of 3 hours a day at about 3 weeks after surgery—take a tropical vacation 2 months after surgery—start paragliding lessons—whatever) in the first 6 months after surgery: is this going to be okay? Should I reschedule it or my surgery to accommodate this plan?
34. When can I return to my job? (Note: be sure that your doctor knows the exact nature of your work! A work-at-home web designer does not have the same physical demands as a warehouse worker toting hundred-pound sacks of cement mix working a twelve-hour shift.) If I return to work and find it too strenuous, will you authorize an extended leave or a limited return to work?
35. When may I have sexual intercourse (penetration)? May I engage in other forms of sexual activity (including orgasm) before that time? If so, when?
36. When may I resume exercising? I normally do for exercise (walk, run, swim, step aerobics, ride horseback, lift weights, bike)—is there any part of that activity I should avoid at first? When and how can I work on regaining tone in my belly? Will you refer me to physical therapy after surgery so that I can work with them on preventing internal scarring and regaining physical conditioning safely (check to be sure your insurance will cover this, but many will if your doctor orders it)? When can I do Kegels again, and should I?
37. If I have more questions after this appointment, how can I get them answered: email? fax?