Early oral feeding compared with delayed oral feeding after cesarean section: a meta-analysis

Early versus delayed oral feeding after major gynaecologic surgery

BACKGROUND

This is an updated and expanded version of the original Cochrane review, first published in 2014. Postoperative oral intake is traditionally withheld after major abdominal gynaecologic surgery until the return of bowel function. The concern is that early oral intake will result in vomiting and severe paralytic ileus, with subsequent aspiration pneumonia, wound dehiscence, and anastomotic leakage. However, clinical studies suggest that there may be benefits from early postoperative oral intake. Currently, gynaecologic surgery can be performed through various routes: open abdominal, vaginal, laparoscopic, robotic, or a combination. In this version, we included women undergoing major gynaecologic surgery through all of these routes, either alone or in combination.

OBJECTIVES

To assess the effects of early versus delayed (traditional) initiation of oral intake of food and fluids after major gynaecologic surgery.

SEARCH METHODS

On 13 June 2023, we searched the Cochrane Gynaecology and Fertility Group's Specialised Register, CENTRAL, MEDLINE, Embase, the citation lists of relevant publications, and two trial registries. We also contacted experts in the field for any additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared the effect of early versus delayed initiation of oral intake of food and fluids after major gynaecologic surgery, performed by abdominal, vaginal, laparoscopic, and robotic approaches. Early feeding was defined as oral intake of fluids or food within 24 hours post-surgery, regardless of the return of bowel function. Delayed feeding was defined as oral intake after 24 hours post-surgery, and only after signs of postoperative ileus resolution. Primary outcomes were: postoperative ileus, nausea, vomiting, cramping, abdominal pain, bloating, abdominal distension, need for postoperative nasogastric tube, time to the presence of bowel sounds, time to the first passage of flatus, time to the first passage of stool, time to the start of a regular diet, and length of postoperative hospital stay. Secondary outcomes were: infectious complications, wound complications, deep venous thrombosis, urinary tract infection, pneumonia, satisfaction, and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias, and extracted the data. We calculated the risk ratio (RR) with a 95% confidence interval (CI) for dichotomous data. We examined continuous data using the mean difference (MD) and a 95% CI. We tested for heterogeneity between the results of different studies using a forest plot of the meta-analysis, the statistical tests of homogeneity of 2 x 2 tables, and the I² value. We assessed the certainty of the evidence using GRADE methods.

MAIN RESULTS

We included seven randomised controlled trials (RCTs), randomising 902 women. We are uncertain whether early feeding compared to delayed feeding has an effect on postoperative ileus (RR 0.49, 95% CI 0.21 to 1.16; I² = 0%; 4 studies, 418 women; low-certainty evidence). We are uncertain whether early feeding affects nausea or vomiting, or both (RR 0.94, 95% CI 0.66 to 1.33; I² = 67%; random-effects model; 6 studies, 742 women; very low-certainty evidence); nausea (RR 1.24, 95% CI 0.51 to 3.03; I² = 74%; 3 studies, 453 women; low-certainty evidence); vomiting (RR 0.83, 95% CI 0.52 to 1.32; I² = 0%; 4 studies, 559 women; low-certainty evidence), abdominal distension (RR 0.99, 95% CI 0.75 to 1.31; I² = 0%; 4 studies, 559 women; low-certainty evidence); need for postoperative nasogastric tube placement (RR 0.46, 95% CI 0.14 to 1.55; 3 studies, 453 women; low-certainty evidence); or time to the presence of bowel sounds (MD -0.20 days, 95% CI -0.46 to 0.06; I² = 71%; random-effects model; 3 studies, 477 women; low-certainty evidence). There is probably no difference between the two feeding protocols for the onset of flatus (MD -0.11 days, 95% CI -0.23 to 0.02; I² = 9%; 5 studies, 702 women; moderate-certainty evidence). Early feeding probably results in a slight reduction in the time to the first passage of stool (MD -0.18 days, 95% CI -0.33 to -0.04; I² = 0%; 4 studies, 507 women; moderate-certainty evidence), and may lead to a slightly sooner resumption of a solid diet (MD -1.10 days, 95% CI -1.79 to -0.41; I² = 97%; random-effects model; 3 studies, 420 women; low-certainty evidence). Hospital stay may be slightly shorter in the early feeding group (MD -0.66 days, 95% CI -1.17 to -0.15; I² = 77%; random-effects model; 5 studies, 603 women; low-certainty evidence). The effect of the two feeding protocols on febrile morbidity is uncertain (RR 0.96, 95% CI 0.75 to 1.22; I² = 47%; 3 studies, 453 women; low-certainty evidence). However, infectious complications are probably less common in women with early feeding (RR 0.20, 95% CI 0.05 to 0.73; I² = 0%; 2 studies, 183 women; moderate-certainty evidence). There may be no difference between the two feeding protocols for wound complications (RR 0.82, 95% CI 0.50 to 1.35; I² = 0%; 4 studies, 474 women; low-certainty evidence), or pneumonia (RR 0.35, 95% CI 0.07 to 1.73; I² = 0%; 3 studies, 434 women; low-certainty evidence). Two studies measured participant satisfaction and quality of life. One study found satisfaction was probably higher in the early feeding group, while the other study found no difference. Neither study found a significant difference between the groups for quality of life (P > 0.05).

AUTHORS' CONCLUSIONS

Despite some uncertainty, there is no evidence to indicate harmful effects of early feeding following major gynaecologic surgery, measured as postoperative ileus, nausea, vomiting, or abdominal distension. The potential benefits of early feeding include a slightly faster initiation of bowel movements, a slightly sooner resumption of a solid diet, a slightly shorter hospital stay, a lower rate of infectious complications, and a higher level of satisfaction.

Immediate vs on-demand maternal oral full feeding after unplanned cesarean section during labor: a randomized controlled trial

BACKGROUND

The adoption of Enhanced Recovery After Cesarean is increasing, but evidence supporting individual interventions having a specific benefit to Enhanced Recovery After Cesarean is lacking. A key element in Enhanced Recovery After Cesarean is early oral intake. Maternal complications are more frequent in unplanned cesarean delivery. In planned cesarean delivery, immediate full feeding enhances recovery, but the effect of unplanned cesarean delivery during labor is not known.

OBJECTIVE

This study aimed to evaluate immediate oral full feeding vs on-demand oral full feeding after unplanned cesarean delivery in labor on vomiting and maternal satisfaction.

STUDY DESIGN

A randomized controlled trial was conducted in a university hospital. The first participant was enrolled on October 20, 2021, the last participant was enrolled on January 14, 2023, and follow-up was completed on January 16, 2023. Women were assessed for full eligibility on arrival at the postnatal ward after their unplanned cesarean delivery. The primary outcomes were vomiting in the first 24 hours (noninferiority hypothesis and 5% noninferiority margin) and maternal satisfaction with their feeding regimen (superiority hypothesis). The secondary outcomes were time to first feed; food and beverage quantum consumed at first feed; nausea, vomiting, and bloating at 30 minutes after first feed, at 8, 16, and 24 hours after the operation, and at hospital discharge; parenteral antiemetic and opiate analgesia use; first breastfeeding and satisfactory breastfeeding, bowel sound, and flatus; second meal; cessation of intravenous fluid; removal of a urinary catheter; urination; ambulation; vomiting during the rest of hospital stay; and serious maternal complications. Data were analyzed using the t test, Mann-Whitney U test, chi-square test, Fisher exact test, and repeated measures analysis of variance as appropriate.

RESULTS

Overall, 501 participants were randomized into immediate or on-demand oral full feeding (sandwich and beverage). Vomiting in the first 24 hours were reported by 5 of 248 participants (2.0%) in the immediate feeding group and 3 of 249 participants (1.2%) in the on-demand feeding group (relative risk, 1.7; 95% confidence interval, 0.4-6.9 [0.48%-8.28%]; P=.50), and the maternal satisfaction scores from 0 to 10 were 8 (6-9) for the immediate feeding group and 8 (6-9) for the on-demand feeding groups (P=.97). The times from cesarean delivery to the first meal were 1.9 hours (1.4-2.7) vs 4.3 hours (2.8-5.6) (P<.001), first bowel sound 2.7 hours (1.5-7.5) vs 3.5 hours (1.8-8.7) (P=.02), and second meal 7.8 hours (6.0-9.6) vs 9.7 hours (7.2-13.0) (P<.001). These intervals were shorter with immediate feeding. The participants were more likely to agree to recommend immediate feeding to a friend (228 [91.9%] in the immediate feeding group vs 210 [84.3%] in the on-demand feeding group; relative risk, 1.09; 95% confidence interval, 1.02-1.16; P=.009). However, at first feed for food, ate "nothing at all" rates were 10.4% (26/250) in the immediate group and 3.2% (8/247) in the on-demand group, and "eaten all" rates were 37.5% (93/249) in the immediate group and 42.8% (106/250) in the on-demand group (P=.02). Other secondary outcomes were not different.

CONCLUSION

Compared with on-demand oral full feeding, immediate oral full feeding after unplanned cesarean delivery in labor did not increase the maternal satisfaction score and was not noninferior on postoperation vomiting. On-demand feeding with its emphasis on patient autonomy could be preferred, but the earliest full feeding should be encouraged and provided.

Comparison of Post-Cesarean Pain Perception of General Versus Regional Anesthesia, a Single-Center Study

Background and Objectives: Pain during and after the procedure remains the leading concern among women undergoing cesarean section. Numerous studies have concluded that the type of anesthesia used during a cesarean section undoubtedly affects the intensity and experience of pain after the operation. Materials and Methods: This prospective cohort study was conducted at the Clinic for Gynecology and Obstetrics, Clinical Center "Dragisa Misovic-Dedinje", Belgrade, Serbia. Patients at term pregnancy (37-42 weeks of gestation) with an ASA I score who delivered under general (GEA) or regional anesthesia (RA) by cesarean section were included in the study. Following the procedure, we assessed pain using the Serbian McGill questionnaire (SF-MPQ), Visual Analogue Scale (VAS) and the pain attributes questionnaire at pre-established time intervals of 2, 12, and 24 h after the procedure. Additionally, time to patient's functional recovery was noted. We also recorded the time to the first independent mobilization, first oral intake, and lactation establishment. Results: GEA was performed for 284 deliveries while RA was performed for 249. GEA had significantly higher postoperative sensory and affective pain levels within intervals of 2, 12, and 24 h after cesarean section. GEA had significantly higher postoperative VAS pain levels. On pain attribute scale intensity, GEA had significantly higher postoperative pain levels within all intervals. Patients who received RA had a shorter time to first oral food intake, first independent mobilization, and faster lactation onset in contrast to GEA. Conclusions: The application of RA presented superior postoperative pain relief, resulting in earlier mobilization, shorter time to first oral food intake, and faster lactation onset in contrast to GEA.

[Effects of Early Oral Feeding versus Delayed Oral Feeding on Bowel Function, Gastrointestinal Complications and Surgical Recovery after Cesarean Section under Regional Anesthesia: Systematic Review and Meta-Analysis]

PURPOSE

This study aimed to assess combined effects of early oral feeding after Cesarean section (C/S) under regional anesthesia on bowel function, gastrointestinal complications and surgical recovery.

METHODS

A systematic literature search was conducted using KISS, RISS, PubMed, CINAHL, EMBASE, CENTRAL and Google Scholar to identify randomized clinical trials comparing early oral feeding (EOF) with delayed oral feeding (DOF) after C/S. Outcome variables were bowel function and gastrointestinal complications and surgical recovery. Effect size was calculated using weighted mean differences (WMDs) and relative risks (RRs), with 95% confidence intervals (CIs).

RESULTS

Seven studies involving 1,911 patients from 568 studies, 7 studies were included in meta-analysis. EOF was significantly associated with shorter time to recover bowel movement compared with DOF (WMD, -2.50; CI, -3.50~-1.50). EOF was not associated with nausea (RR, 1.15; CI, 0.87~1.53) and vomiting (RR, 0.96; CI, 0.65~1.42), but lower incidence of abdominal distension (RR, 0.70; CI, 0.50~0.98). EOF was significantly associated with shorter time to discontinuation of intravenous fluids (WMD, -8.88; 95% CI, -16.65~-1.11) and removal of urinary catheter (WMD, -15.23; CI, -25.62~-4.85).

CONCLUSION

This meta-analysis provides evidence that EOF after C/S under regional anesthesia not only accelerates return of bowel function and surgical recovery but also reduces gastrointestinal complications. These results suggest that EOF should be offered to women who have undergone C/S to improve the recovery experience and reduce overall medical costs.

Enhanced Recovery after Surgery: Cesarean Delivery

This review summarizes the importance of enhanced recovery after surgery (ERAS) implementation for cesarean deliveries (CDs) and explores ERAS elements shared with the non-obstetric surgical population. The Society for Obstetric Anesthesia and Perinatology (SOAP) consensus statement on ERAS for CD is used as a template for the discussion. Suggested areas for research to improve our understanding of ERAS in the obstetric population are delineated. Strategies and examples of anesthesia-specific protocol elements are included.

Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean

The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.

Effect of Closure of Anterior Abdominal Wall Layers on Early Postoperative Findings at Cesarean Section: A Prospective Cross-sectional Study

OBJECTIVE

 To investigate the effect of closure types of the anterior abdominal wall layers in cesarean section (CS) surgery on early postoperative findings.

METHODS

 The present study was designed as a prospective cross-sectional study and was conducted at a university hospital between October 2018 and February 2019. A total of 180 patients who underwent CS for various reasons were enrolled in the study. Each patient was randomly assigned to one of three groups: Both parietal peritoneum and rectus abdominis muscle left open (group 1), parietal peritoneum closure only (group 2), and closure of the parietal peritoneum and reapproximation of rectus muscle (group 3). All patients were compared in terms of postoperative pain scores (while lying down and during mobilization), analgesia requirement, and return of bowel motility.

RESULTS

 The postoperative pain scores were similar at the 2^nd, 6^th, 12^th, and 18^th hours while lying down. During mobilization, the postoperative pain scores at 6 and 12 hours were significantly higher in group 2 than in group 3. Diclofenac use was significantly higher in patients in group 1 than in those in group 2. Meperidine requirements were similar among the groups. There was no difference between the groups' first flatus and stool passage times.

CONCLUSION

 In the group with only parietal peritoneum closure, the pain scores at the 6^th and 12^th hours were higher. Rectus abdominis muscle reapproximations were found not to increase the pain score. The closure of the anterior abdominal wall had no effect on the return of bowel motility.

Cesarean delivery: an evidence-based review of the technique

The cesarean section is utilized to deliver babies since the late 19^th century. Nowadays, the frequency of cesarean section is increased, mainly because of the low rate of complications and for the increasing demand from future mothers, scared by the idea of painful labor. Although the technique to perform cesarean section has been refined over time, infections, hemorrhage, pain and other consequences still represent matter of debate. To try to reduce the incidence of these complications many trials, randomized or not, have been performed, with the aim to analyze different technical aspects of this surgery. The aim of our review was to resume all the evidence-based instructions on how to best approach to cesarean section practice, in a step-to-step fashion, considering pre-operative actions, opening and closing steps, and postoperative prophylaxis.

A randomized controlled trial comparing early versus late oral feeding after cesarean section under regional anesthesia

Objective

To compare the return of bowel movements in regionally anesthetized women undergoing cesarean section (C-section) given Early Oral Feeding (EOF) to that of women given Late Oral Feeding (LOF). Secondary outcomes of maternal satisfaction and gastrointestinal complications were also examined.

Methods

In a single-blinded randomized controlled trial (TCTR20181202001), 148 singleton pregnant women undergoing elective C-sections with regional anesthesia were assigned to receive either EOF or LOF. Participants began to sip water at 6–8 hrs or more than 12 hrs post-operation, for EOF or LOF respectively. Participants were then placed onto a stepping diet as tolerated. Participants failing to tolerate the stepping diet or those having surgical complications were excluded from the study.

Results

After exclusion, 69 women remained in the EOF group and 67 in the LOF group. The ages of participants ranged from 19 to 42, with a mean of 32.07. There was no-loss follow up and no significant difference in patient characteristics, except the site of the surgical incision. Participants given EOF were more likely to experience bowel sound the next morning than patients given LOF (EOF 87.0%, LOF 44.8%, P-value<0.001). However, there was no difference in time to passing flatus and time to passing stool. Maternal satisfaction regarding hunger (EOF 3.78±0.91, LOF 3.24±1.01, P-value 0.002) and maternal satisfaction with postoperative consumption (EOF 4.38±0.64, LOF 4.13±0.48, P-value 0.049) were significantly higher in the EOF group. There was no difference in gastrointestinal complications between the groups (P-value 0.978).

Conclusion

The EOF group experienced an earlier return of bowel movement and greater maternal satisfaction than the LOF group, with no difference in gastrointestinal complications. These findings support the recommendation of EOF for women who undergo uncomplicated C-sections under regional anesthesia.

Enhanced recovery after cesarean delivery

Enhanced recovery after surgery is a concept initially developed for patients undergoing colorectal surgery but has been adopted by other surgical specialties with similar positive outcomes. The adoption of enhanced recovery after surgery in the obstetric patient population is rapidly gaining popularity. This review highlights perioperative interventions that should be considered in an enhanced recovery after surgery protocol for women undergoing cesarean delivery.

Early Versus Delayed Oral Feeding after Uncomplicated Cesarean Section under Spinal Anesthesia: A Randomized Controlled Trial

Objective:

The objective of this study is to compare the safety of early versus delayed oral feeding after uncomplicated cesarean section (CS) under spinal anesthesia.

Methods:

This was a randomized, controlled trial that enrolled 152 women who had uncomplicated CS under spinal anesthesia between January 2014 and June 2014. Women in the early feeding group had sips of oral fluid 6 h postoperatively while those in the delayed feeding group were on nil per oral for the first 24 h after surgery before commencement on liquid diet. Primary outcome measure was development of symptoms of paralytic ileus while secondary outcome measures included time interval to return of bowel sound, duration of hospital stay, and patients satisfaction which was determined using a visual analog score.

Results:

The incidence of mild ileus symptoms was similar in both groups. Early-fed group had significantly shorter mean postoperative time intervals to return of bowel sound, (7.3 h vs. 11.5 h [P = 0.005]), passage of flatus, (30.7 h vs. 37.5 h [P = 0.009]). Hospital stay was also significantly shorter in the early feeding group, (4.2 days vs. 4.9 days [P < 0.001]). Early-fed women had higher levels of satisfaction.

Conclusion:

Early initiation of oral feeding after uncomplicated CS under subarachnoid block is not associated with increased incidence of gastrointestinal symptoms or paralytic ileus.

Early Maternal Feeding Versus Traditional Delayed Feeding After Cesarean Section: A Pilot Study

BACKGROUND

Cesarean section is on the rise all over the world; it has become a safe surgery due to better anesthesia, asepsis, blood transfusion and antibiotics. Traditionally, the patients are kept nil orally till they pass flatus. This study was performed to find out acceptance and tolerability of early feeding, its side effects and complications if any.

METHODS

This comparative study was conducted in a service hospital. There were two groups of 70 cases each where one was administered early feeding and the second group was put on standard delayed feeding as is traditionally done in most of the hospitals. Gastrointestinal outcomes and other parameters were noted in both the groups and analyzed.

RESULTS

During the study period, every alternate willing case without any exclusion criteria was allotted to each group. Early feeding was started 6 h after surgery in the study group, whereas it was withheld till passage of flatus in the control group. Appearance of bowel sounds and passage of flatus were earlier in study group (21.6 and 34.5 h, respectively) as compared with control group (31.7 and 49.2 h, respectively). There were no complications or side effects of early feeding.

CONCLUSION

There is no justification to withholding oral feeds as is traditionally done. Early feeding should be initiated without fear of any side effects. Patients have an early postoperative recovery; it is cost-effective and results in higher patient satisfaction.

Development of Consensus-Based Best Practice Guidelines for Postoperative Care Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Delphi process with multiple iterative rounds using a nominal group technique.

OBJECTIVE

The aim of this study was to use expert opinion to achieve consensus on various aspects of postoperative care following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Significant variability exists in postoperative care following PSF for AIS, despite a relatively healthy patient population and continuously improving operative techniques. Current practice appears based either on lesser quality studies or the perpetuation of long-standing protocols.

METHODS

An expert panel composed of 26 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting (one electronic and two face-to-face). Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible.

RESULTS

Consensus was reached to support 19 best practice guideline (BPG) measures for postoperative care addressing non-ICU admission, perioperative pain control, dietary management, physical therapy, postoperative radiographs, surgical bandage management, and indications for discharge.

CONCLUSION

We present a consensus-based BPG consisting of 19 recommendations for the postoperative management of patients following PSF for AIS. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research.

LEVEL OF EVIDENCE

5.