Early versus delayed oral feeding after cesarean delivery under different anesthetic methods – a randomized controlled trial Anesthesia, feeding in cesarean delivery

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(1)Ginekol Pol. 2014, 85, 815-822. P R A C E. O R Y G I N A L N E po ł o ż n i c t wo. Early versus delayed oral feeding after cesarean delivery under different anesthetic methods – a randomized controlled trial Anesthesia, feeding in cesarean delivery Wczesne versus opóźnione odżywianie po cięciu cesarskim z różnymi metodami znieczulenia – badanie randomizowane 1

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(3) 3 1 2 3. Obstetrics and Gynecology, Eskisehir Osmangazi University School of Medicine, Department of Obstetrics and Gynecology, Eskisehir, Turkey Obstetrics and Gynecology, Dokuz Eylul University School of Medicine, Department of Obstetrics and Gynecology, Izmir, Turkey Biostatistics, Eskisehir Osmangazi University School of Medicine, Department of Biostatistics, Eskisehir, Turkey. Abstract Objective: The aim of the study was to evaluate the safety and efficacy of early feeding after cesarean delivery under different anesthetic methods. Study design: Two hundred women with elective cesarean delivery were randomly assigned to early oral feeding (EOF) or routine oral feeding (ROF) groups. EOF patients were informed that they could begin taking fluids orally (regime I) as soon as 2 hours after the delivery and then gradually progress to solid foods (regime III), if tolerated. ROF patients were informed that they could start regime I right after bowel sounds were heard on examination and then gradually move on to regime III. Hospitalization time and total time to ambulation (primary outcomes), gasstool discharge time and onset of bowel sounds (secondary outcomes) were compared in groups A [EOF patients after regional anesthesia (n=49)], B [EOF patients after general anesthesia (n=48)], C [ROF patients after regional anesthesia (n=47)] and D [ROF patients after general anesthesia (n=48)]. Results: There were significant differences in primary and secondary outcomes between group A and the remaining groups, especially group D. The status of patients from group B was not better than group C. In fact, the latter were discharged home sooner and passage of gas, as well as initiation of regime I occurred earlier as compared to the former. Conclusions: Cesarean section under regional anesthesia and encouragement of oral feeding 2 hours after the operation should be recommended in order to achieve postoperative recovery and early hospital discharge. Routine oral feeding (right after bowel sounds are heard on examination) after cesarean section under general anesthesia should be the last choice.. Key words: ambulation time / cesarean delivery / early oral feeding / / general anesthesia / Address for correspondence: Yunus Aydin Eskisehir Osmangazi University School of Medicine, Department of Obstetrics and Gynecology, Eskisehir, 26480, Turkey e-mail: aydin.yunus@yahoo.com phone number: +905335168740. Nr 11/2014. © Polskie Towarzystwo Ginekologiczne. Otrzymano: 18.11.2013 Zaakceptowano do druku: 14.05.2014. 815.

(4) Ginekol Pol. 2014, 85, 815-822. P R A C E O R Y G I N A L N E poł ożn i ct wo. Yunus Aydin et al. Early versus delayed oral feeding after cesarean delivery under different anesthetic methods.... Streszczenie Cel: Celem badania była ocena bezpieczeństwa i skuteczności wczesnego włączenia odżywiania po cesarskim wykonanym przy różnych metodach znieczulenia. Do badania włączono 200 kobiet po elektywnym cięciu cesarskim. Po randomizacji pacjentki przydzielano do grupy wczesnego odżywiania dojelitowego (EOF) lub grupy zwykłego włączania jedzenia (ROF). Pacjentkom z grupy EOF pozwolono pić płyny już 2 godziny po porodzie (reżim I) a następnie stopniowo przechodzić do pokarmów stałych (reżim III). Pacjentki z grupy ROF mogły rozpocząć odżywianie wg reżimu I gdy w badaniu osłuchiwaniem obecna była perystaltyka a następnie stopniowo przechodzić do reżimu III. Czas hospitalizacji, całkowity czas do uruchomienia (pierwotny punkt końcowy), czas do oddania gazów i stolca i czas do rozpoczęcia perystaltyki (wtórny punkt końcowy) porównano pomiędzy grupami A [pacjentki EOF ze znieczuleniem przewodowym, n=49], B [EOF ze znieczuleniem ogólnym, n=48], C [ROF ze znieczuleniem przewodowym, n=47] i D [ROF ze znieczuleniem ogólnym, n=48]. Wyniki: Zaobserwowano istotne różnice pomiędzy grupą A a pozostałymi grupami, zwłaszcza grupą D, w odniesieniu do pierwotnego i wtórnego punktu końcowego. Status pacjentek z grupy B nie był lepszy niż z grupy C. W rzeczywistości pacjentki z grupy C były zwalniane do domu wcześniej, również pasaż gazów i włączenie diety wg reżimu I następowały wcześniej niż w grupie B. Wnioski: Cięcie cesarskie ze znieczuleniem przewodowym i włączeniem odżywiania 2 godziny po operacji powinno być zalecane ze względu na szybszą rekonwalescencję oraz wczesny wypis ze szpitala. Jako ostatnie powinno się wybierać cięcie cesarskie ze znieczuleniem ogólnym i rutynowym włączeniem odżywiania po usłyszeniu perystaltyki jelit.. Słowa kluczowe: czas uruchomienia / /

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(19) Ginekol Pol. 2014, 85, 815-822. P R A C E O R Y G I N A L N E poł ożn i ct wo. Yunus Aydin et al. Early versus delayed oral feeding after cesarean delivery under different anesthetic methods.... Figure I. -YX]Y\^ /»YaMRK\^. 818. © Polskie Towarzystwo Ginekologiczne. Nr 11/2014.

(20) Ginekol Pol. 2014, 85, 815-822. P R A C E. O R Y G I N A L N E po ł o ż n i c t wo. Yunus Aydin et al. Early versus delayed oral feeding after cesarean delivery under different anesthetic methods.... Table I. Demographic characteristics of patients in the EOF and ROF groups.. Age (years) Body mass index, (kg/m2) Gestational week Cesarean indication 1. Elective 2. Cephalopelvic disproportion. EOF group (n:97). ROF group (n:95). P value. 29 (26-31). 28 (26-30). 0.900. 25.5 (24-27). 25 (24-27). 0.800. 39 (38-40). 39 (38-40). 1.000. 55 42. 53 42. 0.900 1.000. EOF group (n:97). ROF group (n:95). P value. 48 (37-56). 52 (36-63). 0.800. Values are given as median (quartiles), P-value <0.05 was considered statistically significant. +LL\O`SK^SYX]$ /90 q OK\Vc Y\KV POONSXQ% <90 q \Y_^SXO Y\KV POONSXQ. Table II. Clinical characteristics of patients in EOF vs. ROF groups during and after cesarean delivery.. Duration of surgery, min. Return of bowel movements, hour. 6 (5-8). 10.5 (8.6-11.5). <0.001.

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(23) . 17 (16-18). 20.5 (18-22). <0.001. Passage of feces after surgery, hour. 30 (27.5-31). 35 (31-37). <0.001. Time to ambulation after surgery, hour. 14 (13-15). 15 (14-16). 0.001. Regime I initiation after surgery, hour. 4.5 (4-5). 10.5 (8.6-11.5). <0.001. 31 (28.1-33). 33 (31-34). <0.001. 31 (28-34). 34.2 (33-36). <0.001. 2 (2). 2 (2). 1.000. 19 (20) 8 (8) 6 (6). 13 (13) 5 (5) 3 (3). 0.300 0.500 0.500. Regime III initiation after surgery, hour Length of hospital stay, hour Wound infection Gastrointestinal symptoms: Nausea Vomiting Distension. Continuous values are given as median (quartiles), categorical values are given as number (percentage); P-value <0.05 was considered statistically ]SQXSºMKX^ +LL\O`SK^SYX]$ /90 OK\Vc Y\KV POONSXQ% <90 \Y_^SXO Y\KV POONSXQ. Table III. Clinical characteristics of patients in the EOF vs. ROF groups during and after caesarean delivery under regional anesthesia.. Duration of surgery, min. Return of bowel movements, hour. EOF group A (n:49). ROF group C (n:47). P value. 47 (38-61). 48 (36-57). 0.900. 5.1 (4.5-6). 8 (6.8-9). <0.001.

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(26) . 17 (15.3-18). 17 (16.3-18). 0.200. Passage of feces after surgery, hour. 29 (26-30.6). 30 (28-33). 0.010.

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(28) hour. 13 (12.5-15). 14 (13.3-16). 0.010. Regime I initiation after surgery, hour. 4 (4-5). 5 (4.5-6). <0.001. Regime III initiation after surgery, hour. 29.5 (26-33). 32 (30.7-34). 0.003. Length of hospital stay, hour. 31 (26.7-34). 32.5 (28.5-34). 0.100. Wound infection. 0 (0). 1 (2). 0.300. Gastrointestinal symptoms: Nausea Vomiting Distension. 9 (20) 3 (6) 2 (4). 6 (13) 2 (4) 1 (2). 0.100 0.500 0.500. Mann Whitney-U test; Continuous values are given as median (quartiles), categorical values are given as number (percentage); P-value <0.05 was MYX]SNO\ON ]^K^S]^SMKVVc ]SQXSºMKX^ +LL\O`SK^SYX]$ /90 OK\Vc Y\KV POONSXQ% <90 \Y_^SXO Y\KV POONSXQ. Nr 11/2014. © Polskie Towarzystwo Ginekologiczne. 819.

(29) Ginekol Pol. 2014, 85, 815-822. P R A C E O R Y G I N A L N E poł ożn i ct wo. Yunus Aydin et al. Early versus delayed oral feeding after cesarean delivery under different anesthetic methods.... Table IV. Clinical characteristics of patients in the EOF vs. ROF groups during and after caesarean delivery under general anesthesia. EOF group B (n:48) Duration of surgery, min. Return of bowel movements, hour

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(32) Passage of feces after surgery, hour. ROF group D (n:48). P value. 45 (38-57). 43 (36-53). 0.800. 8.7 (7.8-9.6). 11.2 (10.5-12.5). <0.001. 19 (17-21). 21 (20-22.1). <0.001. 31 (30-36). 36 (33.8-36). <0.001. 14.5 (13-15.6). 13 (14-16). 0.100. Regime I initiation after surgery, hour. 9.1 (7.8-9.9). 11.4 (10.8-12.7). 0.003. Regime III initiation after surgery, hour. 32 (29.8-34). 33 (32-35). 0.007. 34 (32-35). 35 (34-37). 0.020. 2 (4). 1 (2). 0.400. 10 (20) 5 (10) 4 (8). 7 (14) 3 (6) 2 (4). 0.300 0.400 0.500.

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(35) . Length of hospital stay, hour Wound infection Gastrointestinal symptoms: Nausea Vomiting Distension. Mann Whitney-U test; Continuous values are given as median (quartiles), categorical values are given as number (percentage); P-value <0.05 was MYX]SNO\ON ]^K^S]^SMKVVc ]SQXSºMKX^ +LL\O`SK^SYX]$ /90 OK\Vc Y\KV POONSXQ% <90 \Y_^SXO Y\KV POONSXQ. Table V. Statistical differences in groups A, B, C, D related to each other during and after caesarean delivery. Groups. Group A (n=49). Group B (n=48). Group C (n=47). Group D (n=48). -. -. -. -. B. <0.001. C. <0.001. ns. D. <0.001. <0.001. Duration of surgery, min Return of bowel movements, hour.

(36) surgery, hour. Passage of feces after surgery, hour. Initiation of ambulation after surgery, hour. Regime I initiation after surgery, hour. Regime III initiation after surgery, hour. B. <0.001. C. ns. D. <0.001. 0.005. 0.004. B. <0.001. C. ns. ns. D. <0.001. 0.01. B. ns. C. ns. ns. D. <0.001. ns. B. <0.001. C. ns. D. <0.001. B. 0.030. C. 0.040. D. <0.001. <0.001. <0.001. <0.001. ns. <0.001. 0.002. <0.001. ns. 0.040. 0.030. B. <0.001. C. ns. D. <0.001. ns. <0.001. Wound infection. ns. ns. ns. ns. Gastrointestinal symptoms: Nausea Vomiting Distension. ns. ns. ns. ns. Length of hospital stay, hour. 0.010. Kruskal Wallis Test; P-value <0.05 was considered statistically significant.. 820. © Polskie Towarzystwo Ginekologiczne. Nr 11/2014.

(37) Ginekol Pol. 2014, 85, 815-822. P R A C E. O R Y G I N A L N E po ł o ż n i c t wo. Yunus Aydin et al. Early versus delayed oral feeding after cesarean delivery under different anesthetic methods.... B # # ! ! = - * # . ! / # ! # * ! # # ! 8 ) $4 :' = # B ) BBB . ! # BBB !B

(38) !$%&' # # # 6 ! 9 ! $%%' : # !B #.6!%A!4/ .%7!&A!4/ .,A ! ,4/ B .0!4 ! %A!4/ BBB.,%!,,/ .,% ! ,0!&/ # . BB/! B D E6 # # .0E = 07 -/ # . BBB/! # > ! $0' !! # # ! K E6 # .06 = 06 -/# # B BBB = ! ) =. BP/! # 5 !$4' # D !(# 5 ! # !!: . # ! # D & ! 9 = B E!% BBB ,& !( = # ,0 0!: 5 !$4'! B * H # H ) !? + <# . # H !. Nr 11/2014. # P - # , ! # . BBB/ * ) ! ## < # # # # D ! * +# ! 9 # B # +! * !9 # # # ) !. Conclusions K . = & ! B . # /. !. Authors’ statement: This is to certify, that the publication will not violate the copyrights of a third party, as understood according to the Act in the matter of copyright and related rights of 14 February 1994, Official Journal 2006, No. 90, Clause 63, with respect to the text, data, tables and illustrations (graphs, figures, photographs); there is no possible relationship(s) of the author(s) with the ZK\^cZK\^SO] ³ ^RO WKX_]M\SZ^ RK] XY^ LOOX Z_LVS]RON SX Y\ ]_LWS^ÔN ^Y. any other journal. Authors’ Contribution: 1. Yunus Aydin – concept, study design, analysis and interpretation of data, article draft, corresponding author. 2. Sabahattin Altunyurt – study design, assumption, revised article critically. 3. Tufan Oge – acquisition of data, revised article critically. 4. Fezan Sahin – analysis and interpretation of data, revised article critically. ³. >RO\O S] XY mMYX»SM^ YP SXÔ\O]^]p aRSMR YMM_\] aROX ^RO K_^RY\ \OWKSX]. in a financial or personal relationship which unjustly affects his/her actions associated with the publication of the manuscript. ³. =Y_\MO YP ºXKXMSXQ$ XYXO. © Polskie Towarzystwo Ginekologiczne. 821.

(39) Ginekol Pol. 2014, 85, 815-822. P R A C E O R Y G I N A L N E poł ożn i ct wo. Yunus Aydin et al. Early versus delayed oral feeding after cesarean delivery under different anesthetic methods.... Re fe re nc e s 1. Duncan A, Horowitz IR, Kalassian K. Postanesthesia and postoperative care. In: TeLinde’s operative gynecology. 8th ed. Eds. Thompson JD, Rock JA. Philadelphia: JB Lippincott–Raven; 2008, 133. 2. Kovavisarach E, Atthakorn M. Early versus delayed oral feeding after cesarean delivery. Int J Gynaecol Obstet. 2005, 90, 31-34. 3. Danielsen B, Castles AG, Damberg CL, Gould JB. Newborn discharge timing &readmissions: California, 1992-1995. Pediatrics. 2000, 106, 31-37. 4. Mulayim B, Celik NY, Kaya S, Yanik FF. Early oral hydration after cesarean deliveryperformed under regional anesthesia. Int J Gynaecol Obstet. 2008, 101, 273-276. 5. Orji EO, Olabode TO, Kuti O, Ogunniyi SO. A randomized controlled trial of early initiation of oral feeding after cesarean section. J Matern Fetal Neonatal Med. 2009, 22, 65-71. 6. Burrows WR, Gingo AJ Jr, Rose SM, [et al.]. Safety and efficacy of early postoperative solid food consumption after cesarean section. J Reprod Med. 1995, 40, 463-467. 7. Correia MI, da Silva RG. The impact of early nutrition on metabolic response and postoperative ileus. Curr Opin Clin Nutr Metab Care. 2004, 7, 577-581. 8. Malhotra N, Khanna S, Pasrija S, [et al.]. Early oral hydration and its impact on bowel activity after elective cesarean section-our experience. Eur J Obstet Gynecol Reprod Biol. 2005, 120, 53-56. 9. Martin JA, Hamilton BE, Ventura SJ. Births: Final data for 2009. National Center for Health Statistics. National Vital Statistics Reports. 2011, 60, 1-70. 10. Fink AM. Early hospital discharge in maternal and new born care. J Obstet Gynecol Neonatal Nurs. 2011, 40, 149-156. 11. Patolia DS, Hilliard RL, Toy EC, Baker B. Early feeding after cesarean: randomized trial. Obstet Gynecol. 2001, 98, 113-117. 12. Soriano D, Dulitzki M, Keidar N, [et al.]. Early oral feeding after cesarean delivery. Obstet Gynecol. 1996, 87, 1006-1008. 13. Miller GH. The effects of general anesthesia on the muscular activity of the gastrointestinal tract of ether, chloroform, ethylene and nitrous-oxide. J Pharmacol Exp Ther. 1926, 27, 41-46.. 822. © Polskie Towarzystwo Ginekologiczne. Nr 11/2014.

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