Postoperative Oral Feeding After Cesarean Section—Early Versus Late Initiation: A Prospective Randomized Trial

Introduction

Patients are usually given a graduated dietary regimen after caesarean delivery to decrease the likelihood of developing postoperative ileus. ¹ Hospital stay of these patients is determined by the presence of postoperative complications (e.g., febrile illness) and return of normal bowel activity. Most cesarean deliveries are performed in younger patients, under regional anesthesia and with little bowel handling. Therefore, few recent studies have demonstrated that, after caesarean deliverym early oral feeding of patients is well-tolerated and is associated with a more rapid return to a normal diet.^2–6 Despite studies showing the feasibility of early oral feeding, many institutions still remain reluctant to modify their own practice. Patients are allowed to drink clear liquids only after return of bowel sounds and eat semisolids if flatus has passed. This study was undertaken to evaluate the safety and efficacy of early initiation of oral feeding in postcaesarean patients, compared to delayed, conventional feeding.

Materials and Methods

The study was conducted in the department of Obstetrics and Gynecology of Guru Teg Bahadur Hospital, in Delhi, India. Informed consent was obtained from each participant. Patients who underwent caesarean delivery under regional anesthesia during July 1, 2008 to October 31, 2008 were enrolled. Patients were excluded if they received general anesthesia or MgSO₄ therapy; or had abdominal adhesive disease, peroperative bowel injury, intra-abdominal drain insertion or any associated medical or surgical disease that precluded early feeding. The patients were assigned to one of two study groups: Group A was given early feeding and group B received delayed, conventional feeding. Group assignment was made via computer-generated randomized numbers. Patients were enrolled in the anesthesia recovery room and sealed envelopes were attached to postoperative orders according to randomization. Women assigned to the early feeding arm were allowed a sip of water at 4 hours after the end of the procedure, 100 mL of tea and and a biscuit at 6 hours followed by semisolids after another 2 hours; and solids after 12 hours. Patients in the delayed feeding group were allowed sips of liquids orally after return of bowel sounds.

Patients were eligible for discharge if they were able to tolerate solid food without emesis and if they had passed stools. Time of surgery was designated as 0 hour, second postoperative day was at 24–48 hours, and third postoperative day was at 72 hours. The operative time was defined as time of incision to time of closure of abdomen. Each patient's uterus was closed in two layers and her peritoneum was not closed. Duration of hospital stay was defined as the time interval between surgery and hospital discharge. Intravenous (i.v.) fluids were stopped when semisolid food was well-tolerated. Each patient was examined thrice by a resident doctor to obtain information about and document nausea or vomiting, return of bowel sounds, and passage of flatus or stools. The resident doctor also explained and reinforced the recommended diet. Mean patient satisfaction scores, using a 0–100 verbal numeric scale (in which 0 represents complete dissatisfaction and 100 represents complete satisfaction), were recorded at the time of discharge.

Mild ileus symptoms were defined as symptoms of nausea, vomiting, and abdominal cramps. Severe ileus was defined as abdominal distension, persistent vomiting, and inability to tolerate liquid.

The following parameters were assessed and compared statistically in both groups: patient's profile; intraoperative and postoperative findings; symptoms and signs of mild-to-severe ileus; length of hospital stay; and time to bowel movement. Categorical variables were assessed by a Chi-square test and continuous variables were assessed by a Student's t-test. SPSS-10 software was used and a p-value ≤0.05 was considered significant.

Results

A total of 200 women were enrolled in the study, 100 were assigned into each group. Women in both groups had similar demographic characteristics, including age, parity, gestational age, previous caesarean sections, prior abdominal surgery, and choice of elective cesarean (p > 0.05; Table 1).

The indications for caesarean section were also similar in the two groups (p > 0.05; Table 2).

During surgery, a low transverse incision was predominantly used in both groups (91% versus 87% in group A and B, respectively; p = 0.37). Intra-abdominal adhesions, mean estimated blood loss, and operating times were similar in both groups (p = 0.59, p = 0.41, and p = 0.29, respectively; Table 3).

Postoperatively, mild ileus symptoms occurred in 7% women in the early feeding group compared to 9% in the delayed feeding group (p = 0.31). Similarly, severe ileus symptoms were also comparable in both groups (p = 0.46). However, mean time of recovery of bowel sounds was significantly less in the early feeding group, compared to the delayed feeding group (7.8 ± 1.4 hours versus 14.7 ± 2.1 hours, respectively; p < 0.001). Mean postoperative time interval to bowel movement was shorter in the early fed group than in the delayed feeding group (42.3 ± 6.7 hours, compared to 69.4 ± 7.3, respectively; p < 0.001). The mean number of i.v. fluid bottles used was significantly less in group A, compared to group B (3.9 ± 0.9, compared to 7.7 ± 0.7. respectively; p < 0.001). Mean hospital stay was also significantly less in group A, compared to group B (59 ± 7.3 hours versus 88 ± 9.5 hours, respectively; p < 0.001). As thirst and hunger are distressing to patients in the postoperative period, the mean maternal satisfaction score on the visual analogue scale was significantly higher in the early feeding group, compared to the delayed feeding group (89.6 ± 6.1. compared to 49.7 ± 7.5, respectively; p < 0.001). These results are shown in Table 4.

Discussion

Conventionally, patients are allowed oral intake after 24 hours of a major surgical procedure following a gradual dietary regimen that consists, initially, of liquids, then semisolids, and finally solids. This is done to decrease postoperative ileus in these patients. However, with respect to the minimal invasiveness of laparoscopy surgery, several studies have shown that early feeding with solid food is well-tolerated after laparoscopy.^7,8 This is especially true in patients in whom minimal gut handling was done during surgery, with no overt intraoperative bowel complication. This concept was extended to patients undergoing caesarean section who were generally young women with surgery being performed under regional anesthesia and usually without any significant bowel handling. It was decided to allow early feeding in these patients, to decrease postoperative hospital stay. Several studies proved that patients tolerated an early solid diet after caesarean section.^2–6,9–16 However, only very few prospective randomized studies have evaluated and proven the effect of early feeding on hospital stay and postoperative morbidity after caesarean section. Therefore, this protocol is still not being accepted by many hospital units.

Various studies comparing early versus late feeding regimens after cesarean concluded that early feeding after cesarean section is well-tolerated and associated with shorter hospital stay compared to delayed feeding. However, in these studies, the number of patients included was small.

Benhamou et al. showed that early feeding after cesarean delivery reduced the severity and incidence of distressing symptoms of hunger and thirst, thus improving overall patient satisfaction score, with no increased side-effects. However, effect on hospital stay was not evaluated. ¹⁴

The current study was a prospective randomized trial including 200 patients that evaluated the effect of early feeding on postoperative course, including hospital stay. The rationale behind using early feeding after cesarean is that the time when patients should be allowed oral intake after any surgery should depend on the type of procedure done, amount of bowel handling, presence or absence of intraoperative bowel complications, and type of anesthesia. The use of general anesthesia may slow the return of bowel activity. Similiarly, significant bowel handling and intraoperative bowel injury mandate that patients be kept away from oral intake for longer periods, until bowel activity returns, to decrease postoperative bowel ileus and other complications. Given that cesarean is performed under regional anesthesia, requiring no significant bowel handling, early feeding initiation seems to be a logical and well-justified option. As studies have proven, early feeding reduces distressing symptoms of thirst and hunger, allowing early return of bowel activity, decreasing hospital stay, and, thus, improving overall patient satisfaction, with no increase in complications.

Women in the early feeding arm had a more rapid return of bowel movement (42.3 ± 6.7 versus 69.4 ± 7.3). The current study demonstrated that women who were given solid food shortly after cesarean had a shorter mean hospital stay by nearly 24 hours (59 ± 7.3 versus 88 ± 9.5). This translated into a greater overall patient satisfaction score in the early feeding group without any increase in complications. Early hospital discharge also has a significant impact on overall cost of surgery, which is very important, especially in developing countries such as India. However, the current study did not evaluate this impact. More prospective, randomized controlled trials, including larger numbers of patients, should be carried out to evaluate the economic effect of early feeding after cesarean delivery.

Conclusions

Early oral intake of food, following uncomplicated caesarean section under regional anesthesia, is safe and well-tolerated; produces a better outcome, compared to delayed feeding; does not cause significant increase in postoperative paralytic ileus; and results in better patient satisfaction.