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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 7  |  Page : 943-949

Effects of early oral feeding versus delayed feeding on gastrointestinal function of post-caesarean section women in a tertiary hospital in Enugu, Nigeria: A randomized controlled trial


1 Department of Obstetrics and Gynaecology, ESUT Teaching Hospital Parklane, Enugu State, Nigeria
2 Institute of Maternal and Child Health, College of Medicine; Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria Ituku-Ozalla Campus, Enugu State, Nigeria
3 Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria Ituku-Ozalla Campus, Enugu State, Nigeria

Date of Acceptance25-Mar-2019
Date of Web Publication11-Jul-2019

Correspondence Address:
Prof. C C Dim
Institute of Maternal and Child Health, College of Medicine, University of Nigeria Ituku-Ozalla Campus, P.M.B. 01129, Enugu - 400001
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_353_16

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   Abstract 


Background: Initiation of oral intake after caesarean delivery influences return of bowel function, ambulation of patients, and time to recover from surgery. Aims: To assess the effect of early versus delayed initiation of oral feeding after caesarean delivery on gastrointestinal function, pace of recovery, and maternal satisfaction at University of Nigeria Teaching Hospital (UNTH), Enugu. Settings and Design: This was a randomized controlled study of women who had caesarean delivery from December 2012 to September 2013 at the Department of Obstetrics and Gynaecology UNTH, Enugu, Nigeria. In all, 282 participants were randomized equally into early and delayed oral feeding groups. Oral intake was commenced at 8 h post operation for those in early feeding group and at 48 h post operation for those in delayed feeding group. The primary outcome measure was the time interval from the end of surgery to the return of bowel sound. Subjects and Methods: Analysis was by intention-to-treat. SPSS version 16 was used for data entry and analysis was done using cross tabulation and Fisher's exact test for categorical data and independent sample T-test for continuous data. P value of <0.05 was regarded as statistically significant. Results: Apart from gastrointestinal complications, there was significant difference between early and delayed feeding groups with respect to all the outcome variables: return of bowel sound (17.8 ± 4.3 h vs 35.2 ± 9.4 h; P < 0.001), return to regular diet 48.9 ± 5.2 h vs 85.5 ± 7.0 h; P < 0.001), postoperative time interval to ambulation (20.3 ± 7.0 h vs 30.9 ± 9.6 h; P < 0.001), and maternal satisfaction as estimated with visual analog scale (86.4 ± 10.4 mm vs 40.0 ± 25.9 mm; P < 0.001). Conclusion: Early initiation of oral feeding after caesarean delivery is safe and may be associated with earlier return of bowel functions, earlier ambulation, shorter postoperative time interval to become eligible for discharge, and high maternal satisfaction.

Keywords: Caesarean delivery, early initiation, oral feeding, southeast Nigeria


How to cite this article:
Mba S G, Dim C C, Onah H E, Ezegwui H U, Iyoke C A. Effects of early oral feeding versus delayed feeding on gastrointestinal function of post-caesarean section women in a tertiary hospital in Enugu, Nigeria: A randomized controlled trial. Niger J Clin Pract 2019;22:943-9

How to cite this URL:
Mba S G, Dim C C, Onah H E, Ezegwui H U, Iyoke C A. Effects of early oral feeding versus delayed feeding on gastrointestinal function of post-caesarean section women in a tertiary hospital in Enugu, Nigeria: A randomized controlled trial. Niger J Clin Pract [serial online] 2019 [cited 2019 Sep 22];22:943-9. Available from: http://www.njcponline.com/text.asp?2019/22/7/943/262519




   Introduction Top


Caesarean section is on the increase globally.[1] It is one of the most commonly performed major surgeries in obstetrics. As a result, any intervention geared toward alleviating the morbidities associated with the procedure will be a very important contribution to promoting the well-being of women. Postoperative feeding of women who delivered by caesarean section has been noted to impact reasonably on the morbidities associated with caesarean delivery.

Traditionally, after caesarean delivery a woman is given fluids and calories through intravenous infusion. She is not allowed to take anything by mouth for a period of time that varies from one part of the world to another and from one hospital to another within the same country.[2] Even within the same hospital, different clinicians may have different dispositions with respect to the time allowed before post-caesarean section patients are commenced on oral intake especially in a setting where institutional protocol is not in use. Subsequently, these patients are given oral feeds beginning with clear fluids and then gradually reverted to normal diet. At the time this study was conceived, in the study center, post-caesarean section patients were commenced on oral feeds on the second postoperative day (approximately 48 h post operation) to ensure reestablishment of normal bowel sounds.

The rationale for this traditional approach to initiation of oral feeding after caesarean delivery was based on the assumption that if oral feeds were started earlier, the patient may develop postoperative ileus. However, available evidence has not supported such assumption.[3] On the contrary, available reports suggest that early postoperative feeding may be associated with decreased protein store depletion, better wound healing, faster recovery, and consequent earlier discharge from the hospital at reduced cost.[4],[5],[6],[7],[8],[9] As a result, the emphasis has shifted toward early initiation of oral feeding after caesarean section. This practice is based on the premise that even with no stimulation by oral intake, up to 2 L of gastrointestinal fluid is secreted daily [10] and that the actual return of bowel function precedes the clinically detectable signs by at least 24 h.[7]

Early initiation of oral feeding after caesarean delivery has been shown to mitigate the negative impact of the metabolic response to trauma and postoperative ileus. The metabolic response to trauma be it from surgery or otherwise is a physiologic phenomenon. Its impact varies with the magnitude and duration of the event and it can affect a patient's morbidity and survival.[11] The other advantages of early oral feeding include rapid return to normal diet,[8],[12] early ambulation,[12] reduced analgesic requirements,[5],[13] decreased sepsis,[14] better wound healing,[15] and shorter hospital stay.[6]

Despite the available evidences concerning the safety and beneficial effects of early initiation of oral feeding post-caesarean delivery,[3],[12],[14],[16],[17] empirical observation suggests that the practice is yet to be widely adopted in health institutions in southeastern Nigeria. It is against this background that this study was carried out to compare the gastrointestinal functions, pace of recovery, and maternal satisfaction following early versus routine (delayed) initiation of oral feeding in women who had caesarean delivery in the University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu, Nigeria.


   Subjects and Methods Top


This randomized controlled trial was carried out in the Department of Obstetrics and Gynaecology of the University of Nigeria Teaching hospital (UNTH) Ituku-Ozalla, Enugu, Nigeria. The teaching hospital serves as a referral center for both the secondary and primary healthcare centers in Enugu State and the neighboring states. The obstetric unit of the hospital has an average delivery rate per year of 1000, and a 5-year survey of caesarean section rate of the obstetric unit of our center revealed a caesarean section rate of 27.6%.[18] All consenting women booked for emergency or elective caesarean delivery in the obstetric unit of the hospital from December 2012 to September 2013 were eligible for the study. Exclusion criteria included obstructed labor with features suggestive of peritonitis, medical conditions such as diabetes mellitus and severe preeclampsia, previous major abdominal surgery except caesarean section, intraoperative bowel injuries even among those recruited, and use of magnesium sulfate and other tocolytics in the immediate period before surgery.

A total of 282 consenting eligible women were randomized in the immediate preoperative period into two equal groups (ratio of 1:1), namely, the early feeding group (A) and the delayed feeding group (B). A statistician blinded to the study's objectives generated the allocation sequence by simple randomization using computer-generated random numbers. The allocation concealment was achieved by placing the allocation in sequentially numbered, opaque, sealed identical envelopes. The envelopes were secured and placed in the postnatal ward from where they were drawn serially, by a nurse who was not associated with the study, until completion of the study. After obtaining a written informed consent from an eligible woman, she was assigned a sequential number by the investigator who then called the nurse (keeping the envelopes) to open the corresponding envelope and assign the participant to the study group (A or B) indicated on the allocation paper in the envelope.

Participants in the early feeding group were commenced on oral sips of water at 8 h post-caesarean delivery. The first oral feeding of black tea (100 mL) was given to the mother under supervision at 12 h post operation and 6 hourly afterward. A low residue diet, corn pap (akamu), was introduced after 24 h.

On the other hand, participants in the delayed feeding group were managed in the usual manner which involved commencement of graded oral sips of plain water, followed by black tea and then low residue diet (corn pap) at 48 h post operation once there was presence of normoactive bowel sound and absence of abdominal distension. The nurses at postnatal ward of the hospital were trained on the study to enable them assist in the administration of oral feeds as prescribed for each participant.

Data were collected with the aid of proforma designed for the study. Participants were assessed regularly (8 hourly) during the first 48 h. Bowel sound was assessed by auscultation. Patient ambulation was assessed by intermittently encouraging the patient to attempt getting out of bed unaided. Participants were given a sheet of paper to note the time they passed flatus, stool, and time of their first tolerated solid diet. Data recorded by participants were later transferred to the study proforma. Axillary body temperature was assessed using clinical thermometer. Participants were also intermittently interviewed for the following symptoms: vomiting, nausea, and passage of watery stool. Assessment for abdominal distension was done by clinical examination of the abdomen. All the participants were given narcotic analgesics (intramuscular pentazocine 30 mg every 6 h) in the first 48 h according to the hospital's protocols. Uniform perioperative antibiotics were administered to all participants according to the hospital's protocol. Also, all the participants were given intravenous fluid until oral intake was well-tolerated. At the time of discharge from the ward, satisfaction with the time of initiation of oral feeds and overall postoperative progress was assessed using visual analog scale (VAS) – a 100-mm straight horizontal line where the 0 mm (left) end represented no satisfaction while the 100 mm (right) end represented best satisfaction. Each participant marked a point on the line that best described her perceived satisfaction with the time of oral feed initiation. The distance in millimeter from the left end to the patients' marked point was recorded as equivalent VAS score ranging from 0 to 100. Participants' assessments/examinations described above were carried out by the principal investigator and three trained resident doctors. The sample size of 141 per group was based on standard deviation of mean time interval to return of bowel sound after caesarean section from a previous study,[19] assumed standardized effect size of 0.35, power of 80%, 5% level of significance, and 10% drop-out rate.

The primary outcome measure was the time interval from the end of surgery to the return of bowel sound, while secondary outcome measures included the time interval for passage of flatus, passage of stool, return to regular diet, patient ambulation, and time interval to become eligible for discharge. Other secondary outcome measures included rate of ileus symptoms and maternal satisfaction from time of initiation of oral feeding after caesarean section.

Data analysis was performed using SPSS version 16. Analysis was by intention-to-treat using cross tabulation and Fisher's exact test for categorical data and independent sample T-test for continuous data. P value of less than 0.05 was regarded as statistically significant. For the purposes of this study, operation time was defined as the time from the onset of surgery to the completion of skin closure; end of surgery was defined as the time of the completion of the skin closure; time of end of surgery was designated as time 0 h; time interval to return of bowel sound was defined as the time interval between the end of surgery and the time that bowel sound became normoactive; patient ambulation was defined as the ability of the patient to get out of her bed unaided; time interval to patient ambulation was defined as the time interval between the end of surgery and the first time the patient got out of her bed unaided; time interval to first passage of flatus was defined as the time interval between end of surgery and the time that the patient passed first flatus postoperatively; time interval to first passage of stool was defined as the time interval between the end of surgery and the first stool that the patient passed postoperatively; time interval to first tolerated regular diet was defined as the time interval between the end of surgery and the first time that the patient ate any of her usual solid diet; time interval to become eligible for discharge was defined as the time interval between the end of surgery and when the patient demonstrated the following criteria: able to tolerate solid food without emesis, passed flatus, or had bowel movement and demonstrated no febrile morbidity for at least 24 h;[3] maternal satisfaction was defined as the degree to which participants expressed contentment with respect to time (early or delayed) of initiation of oral feeding following caesarean delivery. This was measured by VAS. Ethical clearance for this study was obtained from the ethics committee of the UNTH Ituku-Ozalla, Enugu (NHREC/05/01/2008B; 6th May 2012).


   Results Top


During the period of the study, 915 deliveries were conducted. Of these, 390 of the deliveries were by caesarean section giving an overall caesarean section rate of 42.6%. Of the 390 patients who delivered by caesarean section, 282 (72.3%) met the eligibility criteria and gave their consent to participate in the study. The 282 women enrolled for the study were randomized into early feeding group (n = 141) and delayed feeding group (n = 141). All the participants completed the study and were analyzed [Figure 1].
Figure 1: Flowchart of the study

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As shown in [Table 1], there was no significant difference between the basic characteristics of the participants in both the early and delayed feeding groups except for the estimated intraoperative blood loss, the mean of which was significantly higher for the participants in the delayed feeding group.
Table 1: Basic characteristics of study participants

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Of the 253 participants who had regional anesthesia, 246 (97.2%) had spinal anaesthesia, 5 (2.0%) had epidural anaesthesia, while 2 (0.8%) had combined spinal epidural anaesthesia. Of the 246 participants who had spinal anaesthesia, 124 (50.4%) belonged to the early feeding group, while 122 (49.6%) belonged to the delayed feeding group. Also, of the five participants who had epidural anaesthesia, three (60.0%) belonged to the early feeding group, while two (40.0%) belonged to the delayed feeding group. One participant each belonged to the early and delayed feeding groups out of the two participants who had combined spinal epidural anaesthesia. The indications for caesarean section for the participants are shown in [Table 2].
Table 2: Indications for caesarean section by participants' groups

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Participants in early feeding group had significantly shorter postoperative time interval to return of bowel sound (17.8 ± 4.3 h vs 35.2 ± 9.4 h; P < 0.001) and return to regular diet (48.9 ± 5.2 h vs 83.5 ± 7.0 h; P < 0.001). Similar findings were observed for the time interval to passage of flatus and stool. The details are shown in [Table 3].
Table 3: Effect of time of initiation of oral feeding after caesarean delivery on return of gastrointestinal functions

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[Table 4] shows the effects of time of initiation of oral feeding after caesarean delivery on gastrointestinal complications. There was no significant difference between the early and delayed feeding groups with respect to gastrointestinal complications following initiation of oral feeding.
Table 4: Effect of time of initiation of oral feeding after caesarean delivery on gastrointestinal complications

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Participants in the early feeding group had significantly less postoperative time interval to ambulation when compared with their delayed feeding counterparts (20.3 ± 7.0 h vs 30.9 ± 9.6 h; P < 0.001). Also, participants in the early feeding group became eligible for discharge significantly earlier than their delayed feeding counterparts (2.2 ± 0.3 days vs 3.5 ± 0.3 days; P < 0.001).

The number of liters of intravenous fluids consumed by the participants in the early feeding group was significantly less than that of their delayed feeding counterparts (3.8 ± 0.5 L vs 6.4 ± 0.6 L; P < 0.001).

Using the mean VAS scores per group, maternal satisfaction was also significantly higher among participants in the early feeding group than their delayed feeding counterparts (86.4 ± 10.4 vs 40.0 ± 25.9; P < 0.001).


   Discussion Top


In the study center, delay of initiation of oral feeding till second postoperative day after uncomplicated caesarean section had been a routine practice. This “precaution” was based on the assumption that early initiation of oral feeding after caesarean delivery increases the risk of development of postoperative ileus more so if bowel sounds had not returned.[19] The findings from this study suggest that such fears are unfounded, thus the gastrointestinal complications experienced by participants in the early feeding group were few and were not significantly different from that of delayed feeding group. This agrees with the reports of related studies from other centers.[4],[7],[8],[19] Orji et al. in southwestern Nigeria reported no significant difference in ileus symptoms between early and delayed feeding groups.[19] Similarly, Adupa et al. reported no significant difference in the incidence of ileus symptoms between early and delayed feeding groups.[4] Furthermore, Soriano et al. reported no significant difference in the gastrointestinal morbidity between early and delayed feeding groups.[7] Also, Patolia et al. reported no significant increase in ileus symptoms in both early and delayed feeding groups.[8] A systematic review by Hsu et al. reported no significant increase in ileus symptoms in early feeding group compared with their delayed feeding counterparts.[20]

Our study suggests that early initiation of oral intake after caesarean delivery hastens the return of bowel functions. The finding agrees with reports from other related studies.[3],[4],[7],[14],[17],[19],[20],[21] For instance, Gocmen et al. reported that first postoperative bowel sound was heard sooner in early fed women than the traditionally fed women.[3] Soriano et al. also reported shorter time to first bowel movement.[7] Similarly, Weinstein et al. reported that the early fed group had more rapid return of normal bowel sound and earlier acceptance of a regular diet.[14] Malhotra et al. from India reported that bowel sound was heard 4 h earlier, flatus was passed 6 h earlier, bowel evacuation occurred 8 h earlier, and return to full diet occurred 3 days earlier in the early fed group when compared with delayed group.[17] Orji et al. from southwestern Nigeria reported significantly shorter mean postoperative time interval to return of bowel sound, first passage of flatus, and first bowel movement.[19] Also, a more recent report from Northcentral Nigeria showed shorter time to both development of bowel sound and interval in return of bowel movement in the early feeding group when compared with routine delayed feeding group.[21] Again, Hsu et al. reported that early oral intake was associated with earlier return of gastrointestinal functions by the following number of hours: bowel sound (9.2 h), passage of flatus (10 h), and bowel evacuation (14.6 g).[20] The variations in the figures reported may be explained by the variation in nature of diets across different geographical locations and the variation in the length of time before initiation of oral feeding.

This study also shows that early initiation of oral feeding after caesarean delivery hastens recovery. This is because compared with participants in the delayed feeding group, participants in the early feeding group ambulated earlier and also became eligible for discharge earlier. This was in agreement with previous reports from related studies.[3],[4],[5],[16] This was not much of a surprise since earlier return to regular diet would mean earlier supply of adequate calories which will provide energy for ambulation and also mitigate other effects of starvation and negative effects of metabolic response to trauma thereby accelerating recovery. Hospital stay could not be directly assessed during the study because the protocol at the study center during the study period was to discharge uncomplicated post-caesarean section patients between the fifth and seventh postoperative day; however, a predetermined criterion [3] was used to assess postoperative time interval to become eligible for discharge indirectly.

Even though cost was not directly assessed as one of the outcome measures, the fact that participants in the early feeding group consumed significantly less quantity of intravenous infusion and became eligible for discharge significantly earlier compared with their delayed feeding counterparts may suggest that early initiation of oral feeding after caesarean section may save cost. This corroborates the report of Orji et al. from southwestern Nigeria.[19] This may be of immense value especially in this part of the world where a majority of the citizens live on less than 1 dollar per day and yet do not enjoy any form of coverage by National Health Insurance Scheme.[22] It may also improve acceptability of caesarean section as a mode of delivery by our women. In other words, it may go a long way in reducing the aversion that our women have for caesarean section.[23]

Maternal satisfaction was also noted to be significantly higher among the early fed women. This agrees with reports from similar studies.[21],[24],[25],[26] This is very important since the whole essence of the intervention is to improve maternal well-being.

The randomized controlled design used for the study was its major strength. Unfortunately, it was very difficult to apply blinding of any form in the study because of the peculiarity of its design; however, the effects of this on the study's outcomes were likely to be very minimal. Also, certain outcome variables such as postoperative time interval to first passage of flatus depended on the participants to record the time, hence minimal errors could not be ruled out but were unlikely to bias the study's results. Participants' monitoring was done 8 hourly, hence the exact time of establishment of normal bowel sound was likely to be earlier that the point of monitoring. This could have overestimated this outcome measure per group but would not have affected outcome groups' comparison. Direct assessment of the effect of early initiation of oral feeding on duration of hospital stay could not be ascertained due to the limitation of the protocol operating at the study center. Finally, a multicenter trial would have improved the generalization of the study outcomes; however, since the study population characteristics were likely similar to those of other pregnant women in the study area, Enugu, Nigeria, the study outcomes could be generalized to the study area.

In conclusion, early initiation of oral feeding after caesarean delivery is safe and could be associated with several advantages such as earlier return of bowel functions and earlier return to regular diet, earlier ambulation, shorter postoperative time interval to become eligible for discharge, and high maternal satisfaction. Therefore, women who had uncomplicated caesarean delivery in the study area should be given the option of early initiation of oral feeding at 8 h post operation.

Acknowledgement

The authors appreciate resident doctors of obstetrics and gynecology, nurses of postnatal ward, and staff of the dietetics department of the UNTH, Enugu, for their assistance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Villar J, Valladares E, Wojdyla D, Zavaleta N, Carroli G, Velazco A, et al. Caesarean delivery rates and pregnancy outcomes: The 2005 WHO Global survey on maternal and perinatal health in Latin America. Lancet 2006;367:1819-29.  Back to cited text no. 1
    
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Gocmen A, Gocmen M, Saraogolu M. Early post-operative feeding after caesarean delivery. J Int Med Res 2002;30:506-11.  Back to cited text no. 3
    
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Burrows WR, Gingo AJ Jr, Rose SM, Zwick SI, Kosty DL, Dierker LJ Jr, et al. Safety and efficacy of early postoperative solid food consumption after caesarean section. J Reprod Med 1995;40:463-7.  Back to cited text no. 5
    
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Mohadeseh A, Nastaran R, Fatemeh T, Saeed E. The effect of early post cesarean feeding on women's satisfaction. J Fam Reprod Health 2010;4:79-82.  Back to cited text no. 25
    
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