Authors (including presenting author) :
WONG SK, LAM COC, TSANG SL, MA WLT
Affiliation :
Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital
Introduction :
Caesarean section (C/S) is one of the most common obstetric operations around the world. Rates of C/S are rising worldwide. The average C/S rate in the Hospital Authority birthing hospitals increased from 28.0% in 2017 to 30.3% in 2020 and the one in Queen Elizabeth Hospital (QEH) was 33.7% in 2020.
It is a common practice to keep women fasting after the operation until clinical signs of bowel function return. It is to prevent the occurrence of paralytic ileus following a main abdominal surgery. However, this approach has been challenged. C/S are generally short operations involving minimal, if any, bowel manipulation in young healthy women. Systematic reviews revealed that there was no evidence on early oral feeding after C/S, regardless mode of anaesthesia, increase incidence of ileus or other post-operative and gastrointestinal complications. There were no significant differences identified on early feeding with respect to nausea, vomiting and abdominal distention to delayed oral feeding. On the contrast, early feeding promoted the earlier return of gastrointestinal functions as evidenced with the presence of bowel sounds, passage of flatus and bowel opening. There was early ambulation and reduced hospital stay after the operation. Moreover, maternal satisfaction was rated higher in the early feeding group in several studies.
International guidelines suggest for early normal diet resumption after C/S. The National Institute for Health and Clinical Excellence (NICE) stated that women can eat and drink as normal if they recover well after C/S without any complications. Enhanced Recovery After Surgery Society (ERAS) recommends resuming a regular diet within 2 hours after C/S and Society of Obstetric Anesthesia and Perinatology (SOPA) endorses advancing to a normal diet within 4 hours post C/S.
Women undergone uneventful C/S in QEH were kept fasting for 6 hours and then resumed sips of water, fluid to full diet gradually, depending on the presence of bowel sound upon doctors’ assessment. Most women could have full diet on post-operation day two (at around 48 hours). To promote women’s general well-being and satisfaction, a new regimen with the early introduction of oral diet for women undergo uneventful C/S was proposed.
Objectives :
To measure and compare the general well-being and physical status among uneventful C/S women with early introduction of normal diet.
Methodology :
Two groups of women who gave birth in uneventful C/S in two different months were given questionnaires to measure well-being and physical status in different aspects. The control group followed the conventional dietary regimen and the intervention group was given an early oral feeding arrangement.
A survey was conducted before and after the change of dietary regimen. In the postnatal period, women’s vomiting was recorded. They were invited to complete a self-replied questionnaire which consisted seven statements to evaluate their physical conditions and general well-beings at 6 hours and 24 hours after C/S. These statements consisted of Visual Analogue Scale for women to rate the followings:
• Thirst
• Hunger
• Tiredness
• Wound pain
• Activity level
• Ability in taking care her newborn
• General well-being (and at 48 hours)
Inclusion Criteria
• All women undergo elective or emergency lower segment C/S with regional or general anesthesia
Exclusion Criteria
• Placenta previa, placenta accreta
• Classical C/S
• Blood loss 1000ml or above
• Intra-operative or immediate post-operative major complications
• Required Maternal Special Care/ Intensive Care immediately after C/S
• Severe adhesion from previous abdominal surgery
Dietary Regimen
The introduction of early oral feeding as tolerated:
• Early fluid upon arrival postnatal ward (water to rice water)
• Soft diet (congee, bread, light sandwich) from 6 hours post-operation
• Full diet at 18-24 hours post-operation if bowel sound present/ passage of flatus
For women who are categorized as high risks or in the exclusion criteria, dietary regimen will be prescribed by obstetricians in the post-operation order.
Study Period
For the conventional group, the above stated survey was conducted from 2nd to 31st August 2021. With the start of the new dietary regimen, the survey was conducted from 1st to 30th September 2021 for the intervention group.
Statistical Analysis
With effect size 0.5 was estimated, a sample size of 64 subjects in each group was required in order to have 80% power and 5% level of significance by independent t-test. Sub-group analysis with sample size less than 30, data were assessed for normality using the Shapiro-Wilk test. Chi-Square test & One-way ANOVA test were used for categorical variables while independent t-test & Mann-Whitney U test were used for continuous variables as appropriate. A p value of ≤0.05 was considered statistically significant.
Result & Outcome :
A total of 180 completed questionnaires were collected in the stated period (95 in the conventional group and 85 in the intervention group).
Results
Baseline demographic and clinical characteristics, intrapartum and birth outcomes were not different between the two groups.
In the intervention group with early dietary regimen, there was no report of adverse outcomes in their postnatal period. No significant differences with respect to vomiting, number of anti-emetic and analgesic doses usage between the two groups (p > 0.05 for all of above). Women resumed a full diet 13 hours sooner (p < 0.001) than the conventional group.
There were significant improvements in women’s general well-beings and physical status in the early dietary regimen group when compared with the conventional group: mean score of thirsty level at 6 hours (6.3 versus 5.1, p = 0.004) and 24 hours (3.5 versus 2.8, p = 0.018); mean score of hungry level at 24 hours (4.5 versus 3.0, p < 0.001), mean score on degree of tiredness at 24 hours (5.1 versus 4.2, p = 0.007) and mean score in general well-being at 48 hours (6.7 versus 7.4, p < 0.001).
Elective and Emergency C/S groups were analysed separately. For women experienced labour process before emergency C/S, the following status improved in the interventional group: mean score on thirsty level at 6 hours (7.2 versus 5.6, p = 0.025) and 24 hours (3.8 versus 2.6, p = 0.024); mean score on hungry level at 24 hours (4.0 versus 2.4, p = 0.005) and mean score on general well-being at 24 hours (4.9 versus 5.7, p = 0.032) and 48 hours (6.2 versus 7.1, p < 0.001).
Discussion
Women’s general well-being and physical status were improved with resuming early normal diet. It was a sustainable practice without increasing manpower and cost.
Although women could start diet earlier post-operation, the duration of having intravenous fluid infusion (IVF) remained unchanged. Without increasing pain level and use of analgesic in these two groups, score on “ability to move” rated the same. It is suggested early removal of IVF and urinary catheter after diet is resumed. This facilitates early mobilization to promote physical health and morale, as recommended in the international guidelines.
With the goal of promoting better maternal outcomes, midwives should keep abreast of updated evidence-based practices, identify practice gaps and to translate evidences into clinical practices.
