Study of Early versus Delayed Oral Fluid and Food after Cesarean Section

Article information Background: A cesarean section refers to the childbirth method involving the extraction of the baby through an incision made in the abdomen and uterus. This procedure is commonly conducted and ranks among the most frequently performed surgical interventions, with a global prevalence ranging from 37% to 67%. Aim of the work: To evaluate the impact of early maternal nutrition and gastrointestinal function following cesarean delivery. Patients and Methods: In a randomized controlled trial, there were 100 cases in the Study group [Group A] that were allowed early feeding without considering bowel sounds, as opposed to the Control group [Group B], which included 100 cases with delayed feeding regardless of bowel sounds. Results: There were no notable variations between the two groups in terms of BMI, age, gestational age, parity, surgical duration, blood loss, and ability to walk. However, a significant contrast was observed between the groups concerning bowel sounds and bowel movement. Group A demonstrated greater satisfaction levels compared to Group B, with statistically significant variances discerned between the groups. Conclusion: Giving early oral nutrition after a straightforward cesarean delivery is more effective than providing early feeding without listening for bowel sounds, commencing 6 hours after the operation. It leads to faster restoration of gastrointestinal function, ambulation, shorter hospital stay, increased satisfaction, reduced vomiting and nausea, and a lower incidence of significant gastrointestinal complications compared to delayed feeding.


INTRODUCTION
Cesarean delivery, also known as cesarean section, is when a baby is born through incisions made in both the abdominal wall [laparotomy] and the uterine wall [hysterotomy].Unlike in cases of uterine rupture or abdominal pregnancy, the fetus is not taken out from the abdominal cavity during this procedure [1] .
After abdominal surgery like this, patients are usually not allowed to eat or drink [NPO] until their digestive system shows signs of functioning normally, such as the presence of bowel sounds, passing gas or stool, or feelings of hunger [2] .
Early initiation of oral feeding is said to boost patient satisfaction, encourage early movement, and lead to a shorter hospital stay.The expense of oral feeding is considerably less in contrast to the everyday expenses of intravenous fluids, IV apparatus, catheters, and nursing assistance [3] .Enhanced Recovery After Surgery [ERAS], also known as fast-track, rapid recovery, or accelerated recovery, is a surgical care model designed for elective surgeries.It comprises various care components aimed at reducing the body's stress response and organ dysfunction after surgery.The ERAS protocol for planned cesarean sections includes improved preoperative education, minimized fasting before surgery, early reintroduction of oral intake, cessation of intravenous fluids, improved pain management satisfaction, and the opportunity for women to have their urinary catheter and IV cannula removed on the same day as surgery and be discharged the following day [4] .
Therefore, our research seeks to evaluate the effects of early maternal feeding on maternal contentment and gastrointestinal function postcesarean delivery.

PATIENTS AND METHODS
This is a randomized controlled study that recruited 200 women admitted to the labor and delivery ward at the Department of Obstetrics and Gynecology at Al-Azhar University Hospital [Assiut] between February 2023 and July 2023.When the decision was made to proceed with a cesarean section due to obstetric reasons, only elective cesarean sections were considered for inclusion in the research.
The 200 participants were randomly divided into two groups: Study Group [Group A] consisted of 100 patients who were given early postoperative oral fluids and semisolid food within 2 hours of the surgery, regardless of bowel sounds, flatus, or stool passage, and Control Group [Group B] comprised 100 patients who were provided with late postoperative oral fluids and semisolid food within 8 hours of the surgery, irrespective of bowel sounds, flatus, or stool passage.Written consent was obtained from each patient before their involvement in the study.
Patient criteria: Inclusion criteria included term singleton pregnancies, uncomplicated elective surgeries lasting under an hour, and standard blood loss during and after the cesarean section.Exclusion criteria included postpartum hemorrhage, surgical complications during or following the procedure, history of gastrointestinal surgeries, significant adhesions, medical comorbidities, hepatic diseases, gastrointestinal disorders, obstetric complications, placental abruption, gestational diabetes, anemia, use of tocolytic agents influencing blood loss, premature rupture of membranes and chorioamnionitis, multiple pregnancies, and fetal distress.
Patient Assessment Checklist: Comprehensive medical history was obtained, physical examination and vital signs were assessed, and transabdominal ultrasound was performed.
Postoperative Care: All patients were closely monitored every 4 hours in the initial postoperative period and then every 2 hours until discharge.

RESULTS
There was no statistically significant difference between the studied groups regarding age, residence, education, parity, number of cesarean sections, gestational age, and BMI [Table 1].Similarly, there was no statistically significant difference between the studied groups in terms of operative time and blood loss [Table 2].
Additionally, the analyzed groups did not show any significant variations in postoperative nausea, vomiting, distension, and ambulation time.However, there was a statistically significant decrease [p-  3].In terms of postoperative satisfaction, there was a statistically significant increase [pvalue = 0.001] in the percentage of satisfied patients in Group A [93 patients, 93%] compared to Group B [76 patients, 76%] [Table 4].

DISCUSSION
After a cesarean section, it is common to limit oral intake for the initial 24 hours to prevent postoperative ileus.However, this approach continues in healthcare settings despite substantial evidence backing the advantages and safety of early oral feeding after a cesarean section [5] .This research was carried out to evaluate how starting maternal feeding early affects maternal contentment and gastrointestinal function postcesarean sections.It also examined the differences in outcomes between early and late feeding following cesarean delivery.
It is a randomized clinical trial involving 200 participants randomly allocated into two equal groups: the first group was assigned to receive fluids and semisolid foods 2 hours after surgery, while the second group was designated to receive fluids and semisolid foods 8 hours after surgery.
Several similar studies on early and delayed feeding after cesarean section have been published.The timing of initial feeding ranged from immediately post-procedure [6] to 8 hours postoperatively [7] in the early feeding group, and from 12 hours [8] to 24 hours [9] in the delayed feeding group.In this study, the 2-hour mark was chosen for the early feeding group to prevent complications such as aspiration occurring within this timeframe.Jalilian et al. [10] also selected the 2-hour postoperative time for the early feeding group.
There were no notable variations in the demographic, obstetric, and operative traits among the individuals in both groups; they were comparable concerning most fundamental variables.
As per Anwer et al. [11] , there were no statistically significant variations in the demographic, obstetric, and operative characteristics among the trial participants in the two groups.The average age of the participants was 30.23 ± 4.7 in one group compared to 30.81 ± 4.7 in the other group, with a p-value of 0.458.Similarly, the mean parity was 2.01 ± 1.1 in one group compared to 2.39 ± 1.3 in the other group, with p-values of 0.061 for the early and delayed feeding groups, respectively.
In our research, we found that Group A [early feeding] experienced the initiation of bowel sounds and bowel movement at a median time of 6 hours, whereas in Group B [late feeding], this occurred at 8 hours.There was a statistically significant contrast noted between the two groups.
Our findings regarding the restoration of bowel function can be explained by the fact that food intake may stimulate a reflex that enhances propulsive movements and triggers the release of gastrointestinal hormones, resulting in a generally favorable impact on bowel motility as observed by Steinert et al. [12] .These results are consistent with the study conducted by Mohammed et al. [13] , where the appearance of bowel sounds and passage of flatus occurred earlier in the study group [at 21.6 and 34.5 hours, respectively] compared to the control group [at 31.7 and 49.2 hours, respectively].
The early feeding group had a significantly briefer average time for the passage of solid stool compared to the late feeding group, 62.6 hours versus 69.9 hours [P = 0.035].We did not find any statistically significant variance in ambulation between the two groups.The median time for ambulation in Group A [early feeding] was 2 hours, whereas in Group B [late feeding] it was 2.5 hours.
In line with the study by Masood et al. [14] , after 15 hours following the operation, 316 women [53.8%] from the early feeding group could walk, while only 164 [27.9%] from the control group could do so.The early feeding group exhibited significantly elevated levels of thirst and appetite compared to the control group [P < 0.001 for both indicators], indicating statistical significance.
In our study, nausea did not show statistically significant differences, consistent with findings by Jalilian et al. [10] and Anwer et al. [11] , who conducted a study involving 100 cases.The early oral feeding group was defined as starting between 2 hours to 12 hours postoperatively.
These results align with the study by Ahmed et al. [15] , as they found less nausea in the early feeding group compared to the delayed feeding group, although the difference was considered negligible.Regarding the impact of each feeding approach on vomiting, there were 9 patients [9%] with vomiting in Group A compared to 15 patients [15%] in Group B, showing no statistically significant difference.Atef et al. [16] demonstrated no significant difference between the early and delayed feeding groups in terms of vomiting [P value > 0.05], with less vomiting reported in the delayed feeding group.
In contrast, a study by Mawson et al. [17] evaluating vomiting at 6-8 hours postoperatively found more cases of vomiting in the early feeding group compared to the delayed feeding group [5 cases versus 1 case], although the difference was statistically insignificant [P value 0.245].
Our study did not detect any occurrences of paralytic ileus or readmission in either group.As highlighted by Dar et al. [18] , there was no notable distinction between the early and delayed feeding groups regarding distension and ileus [P-value >0.05], with fewer incidences in the early feeding group.In cases where ileus did arise, it was classified as mild, with no instances of severe ileus observed.
Additionally, there was a significant reduction in hospital stay in Group A [median = 12 hours] compared to Group B [median = 20 hours].This finding is consistent with the study by Mostafa [19]   , which demonstrated that early ambulation significantly decreased the length of hospital stay.This supports our first feeding approach, as it resulted in the shortest mean ambulation time with a significant difference among all groups and between the early feeding groups.Our results align with those of Atef et al. [16] , as their research showed statistically significant shorter times to meet discharge criteria in the early feeding groups.
Upon comparing the two groups in terms of satisfaction, we observed that women in the early feeding group had significantly higher satisfaction levels compared to those in the delayed feeding group [P-value 0.001].
Our findings are consistent with Mostafa [19]   , where their research also demonstrated that the early feeding group exhibited statistically significantly higher satisfaction rates [P-value < 0.05].According to Adeli et al. [20] , maternal satisfaction was greater in the early-fed group than in the standard care group.This finding aligns with results from other studies.The increased satisfaction reported by the early-fed group could be attributed to the positive outcomes associated with this practice, such as early ambulation, shorter hospital stays, mental well-being from early recovery, and potential cost savings.

Conclusion
Early oral feeding after uncomplicated cesarean section significantly improves patient outcomes, including accelerated recovery of gastrointestinal function, early ambulation within 6 hours postoperation, reduced hospital stay duration, increased satisfaction, decreased vomiting and nausea, and lower incidence of significant gastrointestinal complications compared to delayed feeding.

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The information was examined using the Statistical Package for the Social Sciences [SPSS] version 24.Tests for normality [Kolmogorov-Smirnov and Shapiro-Wilk tests] were performed.Continuous variables were reported as median and interquartile range [IQR].A p-value less than 0.05 was considered to indicate statistical significance.
value < 0.001] in the time taken for the first occurrence of flatulence in Group A [median = 6 hours, IQR = 5 -8 hours] compared to Group B [median = 8 hours, IQR = 6 -10 hours].Similarly, there was a marked and statistically significant reduction [p-value < 0.001] in the time taken for the first bowel movement in Group A [median = 8 hours, IQR = 7.12 -10 hours] compared to Group B [median = 13 hours, IQR = 12 -15 hours].Moreover, there was a statistically significant [p-value < 0.001] decrease in hospital stay in Group A [median = 12 hours, IQR = 10 -15 hours] compared to Group B [median = 20 hours, IQR = 18 -21 hours] [Table

Table [ 1
]: Comparison of demographic data between studied groups Table [2]: Comparison of operative data between studied groupsGroup A [N = 100] Group B [N = 100]Table[3]: Comparison of post-operative data between studied groups