A red tongue tip, swollen sides of the tongue, and a thick white coating at the back. A bowel movement only once every three days. Those are a few lines the doctor wrote in the record of a woman who came to the clinic a few weeks after giving birth. At that visit her breasts were still swollen, her milk was not yet flowing out fully, and she said that lately she had been irritable, flaring up over small things.
She has been seeing us for many years, including during her pregnancy, and at earlier visits the doctor had noted that she had both yin deficiency (阴虚 / 陰虛, yīn xū: a shortage of the body’s cooling, moistening substance) and effulgent fire (火旺, huǒ wàng: heat flaring upward). A red tongue, a hot temper and constipation make it easy to jump to "internal heat" and, out of habit, look for something that purges to cool you down. The doctor instead prescribed herbs that nourish blood and moisten the bowel, with a few mild heat-clearing herbs and herbs that release constraint, and no strong purgatives. The record does not say how her bowels were after that course, so this article only explains why the doctor chose that direction.
No bowel movement in the first few days
Constipation is very common right after birth. A survey in Finland found that a few days after birth about half of mothers were constipated, more often after a C-section than after a vaginal birth. By one month it was much less common: about one in ten mothers after a vaginal birth, slightly more after a C-section (Kuronen 2021).
The first bowel movement also often comes late. In a group of 101 mothers in the US, those who had a vaginal birth waited on average about a day and a half for their first bowel movement, and those who had a C-section more than three days (Graziano 2014). The information page of the UK National Health Service (NHS) also treats a few days without a bowel movement at first as normal. Nor have we found any agreed cut-off along the lines of "after so many days it becomes an illness".
Traditional medicine books take a fairly calm view of this. Xia Guicheng (夏桂成) writes that if the mother is only tired, is still eating, has no belly pain and is simply constipated, it may ease by itself within a few days and is not yet considered an illness. The Fù Rén Liáng Fāng (妇人良方 / 婦人良方, Effective Prescriptions for Women), as quoted by Fu Qingzhu (傅青主), gives almost the same advice. If a new mother is constipated but eating as usual and nothing is wrong in her belly, "just wait calmly and watch", giving only tonics.
A few things make constipation worse. Iron tablets are one: a Cochrane review pooling many studies (Cochrane is an organization that specializes in summarizing medical evidence) found that iron taken by mouth is clearly more likely to cause constipation than iron given by infusion (Jensen 2024). Even so, do not stop your iron on your own; tell the doctor who prescribed it, so they can change how you take it or switch the type. Opioid painkillers (narcotic painkillers), such as those containing codeine, can also cause constipation; in a trial described below, codeine was used precisely to hold stools back (Mahony 2004). And codeine is not used while breastfeeding anyway. Mothers who were constipated before or during pregnancy are more likely to be constipated again after birth (van Brummen 2006; Bradley 2007).
Many mothers tell the doctor they are afraid it will hurt to go, and those with stitches are afraid of "bursting the stitches" as well. Cochrane also notes pain when opening the bowels as one of mothers’ worries, especially with perineal stitches or hemorrhoids (Turawa 2020).
A dry bowel from blood loss
Xia Guicheng compares constipation after birth to "a river without water, where boats cannot move". Giving birth makes the mother lose blood, sweat a lot and use up body fluids (津液, jīn yè: the body’s fluids and moistening substances). Without that moisture in the bowel, the stool becomes dry and does not pass easily. He adds two kinds of people. In those who are yin deficient by nature, heat from within burns off part of the remaining fluid, while those who are qi deficient by nature lack the strength to push.
This idea goes back a long way. In the Jīn Guì Yào Lüè (金匮要略 / 金匱要略, Synopsis of the Golden Chamber), Zhang Zhongjing (张仲景 / 張仲景) describes three illnesses of women who have just given birth, one of which is difficult bowel movements, and he explains it as loss of body fluids leaving the Stomach dry. He says nothing about heat.
From this, Xia Guicheng sets out the treatment: mainly nourishing blood and moistening the bowel, and "bitter, cold purgatives should not be used carelessly, so as not to simply injure the middle qi" (中气 / 中氣, zhōng qì). In other words, do not purge yourself with bitter, cold herbs, or you will weaken your digestion. The books of Fu Qingzhu and of the classical Vietnamese physician Hai Thuong Lan Ong follow the same direction of building up the blood. Hai Thuong sums it up in a few words, "regulate the middle and nourish the blood" (调中养血 / 調中養血, tiáo zhōng yǎng xuè), while Fu Qingzhu writes that when someone has lost a lot of blood and the blood is dry, with hard, stuck stools, one must tonify the blood and not bring out a purgative formula. In the section on women with fever after birth, Fu Qingzhu advises that even with constipation and thirst, one should tonify blood and generate fluids; taking this for heat and using cold herbs is a mistake. This is experience recorded in the books; there has been no trial comparing nourishing blood and moistening the bowel with purgatives in mothers after birth.
Some mothers’ stools are not dry, yet they are still hard to pass, because the mother is tired and has no strength to push. Xia Guicheng’s book covers this case too. The lương y (traditional medicine practitioner) Nguyen Huu Duc, in his lecture notes on traditional Vietnamese herbal formulas, classes constipation after birth among the symptoms caused by losing strength during the birth, with qi not being sufficient, and treats it with a qi-tonifying formula plus herbs that strengthen the Spleen and moisten dryness (helping digestion and making the bowel less dry). In other volumes, he adds a blood-tonifying herb when a mother is constipated, and increases it when the constipation is severe. In the pages we read, he tonified qi and blood; we did not see him prescribe a purge.
Traditional medicine does sometimes purge
Traditional medicine does use purging at times. The Jīn Guì has two places where it uses a strong purgative formula for women after birth, for example when the lower belly is hard and painful, there has been no bowel movement for many days, and there is also fever and restlessness. Xia Guicheng’s book and the Chinese internal medicine textbook (中医内科学 / 中醫內科學, Zhōngyī Nèikēxué) both say that when it truly is an excess pattern (实证 / 實證, shí zhèng: a real blockage inside, such as a hard, painful belly and many days without a bowel movement), one should not hesitate, but should stop as soon as the treatment has hit the mark. Whether a mother has that pattern, how much to use and when to stop are for the physician to decide after examining her. The formulas textbook (方剂学 / 方劑學, Fāngjìxué) lists women after childbirth among those for whom purgatives should be used with caution or not at all.
Nguyen Huu Duc tells the story of an elderly man, nothing to do with childbirth. He boiled a whole basket of candle bush leaves (Senna alata) and drank them to "purge toxic heat". He purged so much that he had to go to the emergency department for IV fluids. Back home he still could not open his bowels, and even asked the teacher whether he should drink more candle bush. The teacher gave him yin-tonifying herbs.
Laxative teas, "detox" teas and laxative leaves sold in packets are very easy to buy. These packets may contain Fan xie ye (Senna alexandrina leaf), that is, senna leaves, so read the ingredients carefully. In trials in mothers after birth, senna helped bowel movements come sooner, but the group taking senna had clearly more abdominal cramping (Turawa 2020). After giving birth, do not buy laxative teas, laxative leaves or purgatives on your own "to cool down".
When the stool is too hard, the doctor may prescribe a stool softener. Macrogol (PEG) and lactulose are barely absorbed into the blood, and LactMed, the database on drugs during breastfeeding, says breastfeeding mothers can use them with no special precautions. Mahony’s trial was done in mothers who had a deep perineal tear reaching the anal sphincter, which had been repaired. One group took lactulose to soften the stool, the other took codeine to hold the stool back. The lactulose group had their first bowel movement sooner and had less pain (Mahony 2004). Use these as your doctor prescribes.
Her prescription, and why
In her case the heat was real, seen in the red tongue tip and her irritability. The treatment principle the doctor recorded was to soothe the Liver (疏肝, shū gān: release constraint, the frustration that has been pent up), clear constrained fire (calm the heat that comes from constraint), strengthen the Spleen (help digestion) and nourish blood. The prescription was mainly blood-nourishing and bowel-moistening herbs, including an oily seed that helps lubricate, plus a few mild heat-clearing and Spleen-strengthening herbs. The idea was to calm the heat and make up for what was lacking; the prescription contained no strong purgative. The doctor planned to check after one batch of herbs (one day’s dose) whether her milk was flowing more easily, and after six batches to look at her bowel movements again.
Xia Guicheng describes how constipation, pain and irritability after birth tend to drag one another along, and he describes that cycle in some detail. Dry stools mean straining, a lot of straining brings on sweating, and the anus tears and hurts. Pain makes you afraid to go, and stool that stays longer in the bowel has more water drawn out of it, so it gets even harder. The person becomes fearful, anxious and impatient, the qi movement (气机 / 氣機, qì jī: how things move and work inside the body) becomes constrained, and going gets harder still.
What you can do at home
Xia Guicheng gives some very down-to-earth advice: comfort the mother so she worries less, drink plenty of water, practice going to the toilet at a fixed time, and even without the urge, sit on the toilet for a while. He also points out that eating less so you don’t have to go "solves nothing". You can start with these:
- Keep a water bottle where you usually sit to breastfeed, and take a few extra sips at each feed;
- Eat cooked vegetables and fruit every day;
- Walk around the house gently once the doctor allows it, alternating with rest;
- Go as soon as you feel the urge; don’t hold it in out of embarrassment or because you are in the middle of something;
- Rest your feet on a low stool when sitting on the toilet, so your knees are higher than your hips, and lean slightly forward;
- Breathe steadily and relax; don’t strain hard or sit for too long;
- Tell your doctor if your constipation gets worse while you are taking iron or painkillers; don’t stop the medicine on your own.
Raising your feet carries little risk. In healthy people, this position makes it easier to go with less straining. We have not found any study in mothers after birth, but the Royal College of Obstetricians and Gynaecologists (RCOG, UK) still recommends this way of sitting for mothers with a deep perineal tear.
Hemorrhoids
Hemorrhoids and anal fissures often come along with constipation. In France, doctors examined the anus of 165 mothers and found that about one third had thrombosed external hemorrhoids (an external hemorrhoid with a blood clot in it, swollen, hard and painful) or an anal fissure within two months after birth. Most of the thrombosed hemorrhoids appeared on the very first day, and the factor most clearly linked to them was difficult, painful bowel movements (Abramowitz 2002). In Lithuania, constipation, long pushing, a heavy baby and a history of hemorrhoids were the factors linked to them (Poskus 2014).
Traditional medicine books explain hemorrhoids during pregnancy and after birth as blood pooling in the pelvis, plus the pushing during birth (Maciocia). The acupuncture therapeutics textbook (针灸治疗学 / 針灸治療學, Zhēnjiǔ Zhìliáoxué) lists pregnancy and childbirth among the causes of hemorrhoids, with two main patterns: damp-heat (dampness and heat) pouring downward (湿热下注 / 濕熱下注, shī rè xià zhù), and qi deficiency (a lack of qi, not enough strength) failing to lift. Hai Thuong Lan Ong’s book records the words of Xue Lizhai (薛立斋 / 薛立齋): for hemorrhoids with constipation, moisten dryness and nourish blood.
Sitting in a basin of clean warm water is recommended in many places, even though there is little scientific data on it (Qureshi 2026). Ask your doctor first, make the water just warm, and test it with the back of your hand before sitting down, so you don’t burn skin that is already sore. Xia Guicheng separates two things: no tub baths during the postpartum period, while sitting in a basin is still used in the books. Don’t boil leaves from word-of-mouth remedies for steaming or soaking. Ma dou ling (Aristolochia fruit), an herb that was once used to steam and wash hemorrhoids, contains aristolochic acid, which can damage the kidneys, and the Chinese materia medica textbook (中药学 / 中藥學, Zhōngyàoxué) says pregnant women and young children must not use it. Do not use this herb.
See a general clinic or a hospital when:
- There is a hard, purple, very painful lump at the anus;
- There is heavy bleeding, or bleeding that will not stop;
- Every bowel movement brings a burning pain like a knife cut, for many days;
- You cannot hold in gas, or stool leaks out.
Belly cramps every time you breastfeed
In the first few days, many mothers feel the lower belly cramp each time the baby feeds, like period pain, because the uterus is contracting. A research group in the UK that followed 50 mothers who had just had a vaginal birth found that almost all of them had pain while breastfeeding; measured with instruments, women who had given birth several times had more pain, and their uterine contractions also lasted longer (Holdcroft 2003). This pain usually goes away after a few days, about two to four days (Deussen 2020). Traditional medicine books call it "infant’s-pillow pain" (儿枕痛 / 兒枕痛, ér zhěn tòng), and Xia Guicheng also regards mild lower belly pain after birth as a common reaction that gets worse when breastfeeding, is more common in women who have given birth several times, and goes away by itself within a few days. Zhang Jingyue (张景岳 / 張景岳) advised that pain without bloating, which likes to be rubbed and warmed and eases after eating, is deficiency pain, and "expelling and purging herbs must not be used carelessly"; Xia Guicheng’s book also notes that the blood deficiency pattern of belly pain after birth comes with constipation. Among the painkillers tested for this pain, anti-inflammatories such as ibuprofen have the best evidence, while for paracetamol the results are uncertain (Deussen 2020). Both can be used while breastfeeding (LactMed); take them as your doctor advises. If the pain is getting worse instead of easing, your belly is too tender to press, or it comes with fever, chills or foul-smelling lochia, see a doctor right away; other danger signs are in the article "Warning signs after birth that need care right away".
When to come in to the clinic
We suggest coming in for a check if, after the first week after birth, you still only have a bowel movement every few days. At the visit, also tell us about your sleep and your milk, and whether you have been tired or irritable lately. You should also come in if it burns or bleeds after you go, or if you have already taken a laxative tea and then had cramps and felt drained.
References
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