Twelve hours Postpartum Feeding After Cesarean Section

Twelve hours Postpartum Feeding After Cesarean Section

Globally, one of the fastest rising operative procedure is cesarean section. In the southeast asian countries, Cesarean rate varied from 12-39% based on a study of nine hospitals in Indonesia, Malaysia, Philippines and Thailand. The Philippines showed a 22.7% Cesarean section rate which was conducted at Philippine General Hospital.³ Caesarean section is a common operation in obstetric care. Caesarean section rates are around 25–40% in some of the large Asian countries which included two hospitals from China, three from India , four from South Korea and five from Thailand . Delayed initiation of oral fluids and food may be uncomfortable for women in the postoperative period. Women who have regional anesthesia for caesarean section may be more comfortable with taking oral fluids and food early⁴. However, established hospital routines often restrict early intake of food and fluids for the fear of abdominal distention and possible vomiting. In Thailand, the general policy after caesarean section is to keep the women "nil per mouth" for 12–24 hours or until bowel sounds return. After this, oral fluids and clear diet are initiated, later followed by regular diet.^5-8                                

Several recent prospective studies have demonstrated that after cesarean delivery early feeding both clear liquids and food is well treated and is associated with a  faster recovery thus lessening the hospital stay. However, a challenge of possible post-operative ileus is anticipated. The 2009 -2010 Records Section Census at the Baguio General Hospital and Medical Center showed that cesarean section rate is 21.53% for 2009 and 23.69% for 2010. In these cases, most of the patients were confined at an average of 3-5 days duration⁹.This study herefore aims to assess the benefits of early feeding versus traditional diet protocol with regards to acceptability of  early 12 hours post-operative feeding, with reduction of length of hospital stay and with possible gastro-intestinal complications of early feeding.

  Traditional post-operative care maintains patient who have had uncomplicated surgery may be given clear liquids on the first post-operative day if bowel sounds are present, if  abdominal examination reveals presence of bowel sounds and there is no abdominal distention and if patient is no longer nauseated from her anesthesia. After flatus is passed, patient is given soft diet.And, if first bowel movement is observed,  the diet should be as tolerated.         

Opening the peritoneal cavity completely abolishes coordinated gut motility. Intestinal manipulation appears to increase the duration of post-operative ileus, with the degree of bowel manipulation during surgery being directly proportional to the duration of ileus. Small intestinal motor function typically returns first, often within several hours of surgery. Gastric motility may return 24-48 hours after surgery. Colonic function is last to return, generally occurring 48-72 hours after surgery. The return of colonic motility is thought to be frequent rate-limiting step in the resolution of post-operative ileus.^1,4,10 Food intake elicits a reflex response that is propulsive in action. Several intestinal reflexes connecting various parts of the gastrointestinal tract respond to food intake, producing coordinated propulsive activity¹¹. In addition, the presence of food stimulates the secretion of various intestinal hormones, with an overall stimulating effect on gastrointestinal motility¹²

          In a Cochrane review by Magnesi and Holfer entitled Early compared with delayed oral fluids and food after caesarean section, which includes clinical trials with random allocation comparing early versus delayed oral fluids and/or food after cesarean section, early oral fluids or food were associated with: reduced time to first food intake(one study,118 women; the intervention was a slush diet and food was introduced according to clinical parameters: weighted mean difference -7.20 hours, 95% confidence interval -13.26 tp -1.14); reduced time to return of bowel sounds (one study,118 women; -4.30 hours, -6.78 to -1.82 hours) reduced post-operative hospital stay following surgery under regional anesthesia (two studies, 220 women; -0.75 days, -1.37 to 0.12, random effects model); and a trend to reduced abdominal distention (three studies, 369 women; relative risk 0.78, 0.95% confidence interval 0.55 to 1.11) No significant differences were identified with respect to nausea, vomiting, time to bowel action/passing flatus, paralytic ileus and number of analgesic doses. The author concluded that there is no evidence from randomized trials to justify a policy of restricting oral fluids or food following uncomplicated cesarean section.¹³

In a study done by Guedj, participants included were unpremedicated women undergoing cesarean section under epidural anesthesia (Elective or Emergency). Early group had immediate unlimited oral intake of water, coffee or tea with sugar. Delayed group fasted for at least 24 hours post-operatively. Patients were observed if they will have post-operative nausea and vomiting, onset of peristalsis, rectal gas emission, patient convenience and first bowel movement. In the early group the first flatus was passed on day 2 and in the delayed group the first flatus was passed on day 3. Bowel sounds returned within 12 to 24 hours in all women. The comfort of the women was stated to be greater in the early oral fluid group with less local pain from the drip site.

In a study done by Patolia, which includes women due for cesarean section (elective or emergency). Early feeding wherein solid food within 8 hours of surgery was given and compared to traditional feeding nothing by mouth for 12-24 hours, clear fluids up to 24 hours and regular diet 24-48 hours if liquid tolerated and flatus or stool passed, liquid diet if flatus not passed, in which case full diet was started after 48-72 hours. Solid food given to early group after 5.0 (SD 1.2) versus (10.6) hours for traditional group. Primary outcomes includes mild ileus symptoms( anorexia, abdominal cramping, non-persistent nausea and or vomiting). Secondary outcomes noted were severe ileus (Abdominal distention, >3 episodes of vomiting in 24 hours and inability to tolerate oral fluids or requiring nasogastric tube or abdominal X-ray)(0/60 versus 1/60), post-operative  febrile morbidity (oral temperature >/=37 derees Celsius two times at least 6 hours apart, 24 hours post-surgery; post operative time to bowel movement: median 34.5(IQR 25-49) versus 51 (43-62) hours; hospital admission 1/60 versus 2/60; analgesia.

          In a study done by Weinstein, participants were women who were to undergo caesarean section for various reasons. Interventions. The early feeding group were assigned to PROEF (post operative regimen for oral early feeding) diet. They were given a slush type diet, to be eaten with a straw or with a spoon immediately after surgery and thereafter every 8 hours. This was to be continued until the surgeon believed that the patient should have a regular diet. Delayed feeding group were given sips of water post operatively advancing from clear fluids to regular diet at the discretion of the operating physician. The decision of the physician depended on the abdominal physical findings of the absence of distension, the presence of bowel sounds and the passage of flatus. Results revealed a reduced time to first food intake (one study, 118 women; weighted mean difference -7.20 hours, 95% confidence interval-13.26 to -1.14).

          In the above mentioned reviews, data showed that there was a reduced time to first food intake, reduced time to return of bowel sounds, and reduced post-operative hospital stay and trend to reduced abdominal distention. Hence, there is consistency in that all the outcomes which show significant differences are in favour of the early feeding group. Similarly, this prospective research would evaluate the safety and effect in the gastrointestinal tract of twelve (12) hours post-operative feeding after cesarean delivery in the Baguio General Hospital and Medical Center setting. In addition to the previous studies objectives, patients acceptability to which diet schedule is preferred will be assessed as part of the research and diet change as to no preceding oral fluids would be given prior to giving of fulldiet.