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Early oral feeding within two hours for parturients compared with delayed oral feeding after cesarean section: a systematic review and meta-analysis

BMC Pregnancy and Childbirth volume 24, Article number: 623 (2024) Cite this article

Abstract

Background

It is recommended that postpartum women undergo early oral feeding (EOF) after cesarean section (CS). However, the optimal early time for oral feeding after CS is unclear. We performed a meta-analysis to assess whether EOF within two hours is superior to delayed oral feeding (DOF) after CS.

Methods

The PubMed, Embase, Cochrane Library, and Google Scholar databases were searched from inception to February 2024 for randomized controlled trials comparing EOF versus DOF after CS. Primary outcomes included the time to normal bowel function. The secondary outcomes included postoperative complications, the time to ambulation after surgery, the time to removal of the catheter, the time to start of a regular diet, the length of hospital stay and patient satisfaction.

Results

Data from 8 studies involving a total of 2572 women were obtained. EOF within two hours was significantly associated with shorter durations of return bowel movement (WMD, − 2.41, 95% CI, − 3.80–− 1.02; p < 0.001; I2 = 96%), passage flatus after surgery (WMD, − 3.55, 95% CI, − 6.36–− 0.75; p = 0.01; I2 = 98%), ambulation after surgery (WMD, − 0.96, 95% CI, − 1.80–− 0.13; p = 0.02; I2 = 53%), removal of catheters (WMD, − 15.18, 95% CI, − 25.61–− 4.74; p = 0.004; I2 = 100%) and starting a regular diet (WMD, − 7.03, 95% CI, − 13.13–− 0.92; p = 0.02; I2 = 99%) compared with DOF. EOF was not related to increased vomiting (RR, 1.08; 95% CI, 0.74–1.57; p = 0.69; I2 = 0%), nausea (RR, 1.21; 95% CI, 0.83–1.77; p = 0.33; I2 = 37%), abdominal distension (RR, 0.76; 95% CI, 0.31–1.89; p = 0.55; I2 = 54%) or ileus (RR, 0.91; 95% CI, 0.40–2.06; p = 0.81; I2 = 12%).

Conclusions

This meta-analysis provides evidence that EOF within two hours after CS has comparable safety with DOF, and can accelerate the recovery time for normal bowel function.

Trial registration

: INPLASY202320055.

Peer Review reports

Introduction

CS is the most common operation for young healthy women and a life-saving intervention when obstetrics-related complications occur, such as antepartum hemorrhage, gestational hypertension, abnormal fetal presentation and fetal distress [1]. On the other hand, CS may have negative impact on maternal health, which has become a public concern. Among these complications, postoperative gastrointestinal function are particularly common [2,3,4]. This problem can delay postoperative recovery, prolong hospital stay, increase costs, and decrease patient satisfaction [5].

Over the past few decades, patients are fasted after abdominal surgery until bowel sounds return or the passage of flatus [6]. Guidelines focusing on CS enhanced recovery after surgery (ERAS) have also been published [7,8,9]. How to safely and effectively promoting of the recovery of gastrointestinal function after CS has attracted extensive attention from medical professionals. Several previous meta-analysis reviews of patients who underwent CS have demonstrated that early feeding can promote the recovery of bowel function, reduce hospital stays and total postoperative complications [10,11,12]. However, definitions of EOF was different in those meta-analyses. Some studies regard oral feeding 4 h [13], 6 h [14,15,16] or 8 h [17,18,19] after CS as early, while others regard it as 2 h [25, 26] after CS.

Currently, there is still a lack of evidence regarding the optimal timing of the initiation of oral feeding after CS in relation to the recovery of maternal bowel function. Therefore, we undertook a systematic review and meta-analysis of randomized clinical trials (RCTs) to evaluate whether EOF within 2 h is superior to DOF in patients undergoing CS.

Methods

This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [20], and our protocol was preregistered with the INPLASY International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY202320055).

The eligibility criteria

The studies were included if (i) the population included women undergoing planed and/ or emergence CS; (ii) the study design was an RCT; (iii) the intervention group received any oral feeding within two hours and the comparison group received a feeding after two hours. (iv) any of the following outcomes were reported: the time of return of bowel movement, the time to first passing of flatus after surgery and/ or feces after surgery; studies reporting postoperative complications were included. Complications included postoperative nausea, vomiting, abdominal distension, wound infection, urinary tract infection, and fever. The primary outcome indicator was the return to normal bowel function defined as the time of return of bowel movement, the time of passing the first flatus after surgery, and the time of passing the faeces after surgery. The secondary outcome indicator was the various postoperative complications.

Search strategy

The PICO principle (population, intervention, comparator, and outcome) was used to search for relevant literature. The PubMed, Embase, and Cochrane Library databases were searched for available papers published up to February 2024 using the MeSH term “cesarean section”, as well as other relevant key words. In addition, we searched the Google Scholar database for relevant research literature. The search strategy was developed and executed by Bingchen Lang and Shouming Chen (Supplementary Appendix 1).

Data extraction

Study characteristics (authors, year of publication, study design, sample size, ages, and feeding protocol in the EOF and DOF groups), bowel function returns (the time of return of bowel movement, the time of flatus after surgery, the time of feces after surgery), postoperative complications (nausea, vomiting, abdominal distension, wound infection, urinary tract infection and fever), and ERAS-related parameters (time to ambulation after surgery, time to removal of catheter and length of hospital stay) were extracted by two authors (Dongxu Chen and Shengping Zhou) using a standardized form. If the continuous variable is expressed as the median (quartiles), the formula of Wan et al. [21] was used to convert it to the mean (standard deviation). Disagreements that arose during the data extraction process were discussed to reach consensus.

Assessment of risk of bias

The risk of bias was assessed by two reviewers (Dongxu Chen and Bingchen Lang) independently, using the Cochrane risk of bias tool, which considers the methods of random sequence generation, allocation concealment, blinding of participants and the outcome estimator, incomplete reporting of outcome data, selective reporting of outcomes and other sources of bias risk. There are three levels of risk bias: low risk, unclear risk and high risk. Disagreements were resolved through arbitration by a third reviewer.

Quality of evidence

The Recommendations, Assessments, Developments, and Evaluations (GRADE) working group system was used in this study to evaluate the quality of the results. Two reviewers (Shouming Chen and Lan Wu) assessed the quality of each outcome independently. The GRADE quality assessments are organized into five categories: design limitations, inconsistency, indirectness, imprecision and publication bias. Our team members used GRADE profiler (GRADEpro) software to create a GRADE summary of findings table, which includes the following outcomes: return of bowel movement, passage of flatus after surgery, passage of feces after surgery, vomiting, nausea, abdominal distension and ileus.

Statistical analysis

The data collected in this study were analyzed with Review Manager 5.4.1 software provided by The Cochrane Collaboration in London, UK. Dichotomous outcomes were presented as risk ratios (RR) and 95% confidence intervals (CI); and continuous variables were presented as weighted mean differences (WMD). The heterogeneity of the outcomes was weighed by the I-squared (I2) test. If I2 > 50%, we used a random-effects model, and conducted a sensitivity analysis by omitting each study individually. If I2 ≤ 50%, the fixed-effects model was employed. A p value < 0.05 was considered to indicate statistical significance.

Results

Literature search

Figure 1 shows the search process. A total of 761 relevant items were initially identified from databases, and 148 duplicates were excluded after screening. Among the remaining 613 records, 543 were excluded because they were noneligible (i.e., reviews, case reports, or not in English). Sixty-two items were excluded after a full-text assessment: 59 because of inappropriate comparisons (i.e., EOF not within 2 h), two because of non-RCTs, and one because they were inaccessible. Finally, eight studies were fulfilled the predefined criteria and selected for the analysis [22,23,24,25,26,27,28,29].

Fig. 1
figure 1

Prisma flow diagram

Full size image

Study characteristics and patient populations

The included studies were undertaken from 2000 to 2022, and a total of 2572 women who were scheduled for CS under general anesthesia or regional anesthesia were involved. All included studies were RCTs. Among them, one included item received EOF with 200 ml of sugar-free water within 1 h after CS [29], and the other seven items received EOF at 2 h after CS. The characteristics of the included RCTs, type of anesthesia and feeding protocol are summarized in Table 1.

Table 1 The general characteristics of the enrolled studies
Full size table

Quality of the included studies

The risk of bias assessment is shown in Fig. 2A and B. In total, 75% (6/8) of the studies used appropriate methods for random sequence generation [22,23,24,25, 28], and five studies specifically described the details of allocation concealment [23,24,25,26, 28]. Three studies described the blinding procedure of participants and personnel [24, 27, 28], and one study reported the blinding procedure of outcome assessment [27].

Fig. 2
figure 2

(A) Risk of bias assessment results for individual studies. (B) Summary plot for risk of bias assessment for individual studies

Full size image

The time to return to normal bowel function

The results of the potential effects of EOF versus DOF on gastrointestinal function after CS are displayed in Fig. 3. Compared with those in the DOF group, the time of return bowel movement significantly earlier (WMD, − 2.41, 95% CI, − 3.80–− 1.02; p < 0.001; I2 = 96%) and the time of passage flatus after surgery sooner (WMD, − 3.55, 95% CI, − 6.36–− 0.75; p = 0.01; I2 = 98%) in the EOF group. However, the duration of fecal passage after surgery (WMD, − 2.19, 95% CI, − 6.01–− 1.62; p = 0.26; I2 = 97%) was similar in both groups.

Fig. 3
figure 3

The time to return of normal bowel function

Full size image

Postoperative gastrointestinal complications

The effects of EOF and DOF on postoperative gastrointestinal complications after CS are showed in Fig. 4. Compared with the DOF group, EOF within two hours did not show a significant association with increases in vomiting (RR, 1.08; 95% CI, 0.74–1.57; p = 0.69; I2 = 0%), nausea (RR, 1.21; 95% CI, 0.83–1.77; p = 0.33; I2 = 37%), abdominal distension (RR, 0.76; 95% CI, 0.31–1.89; p = 0.55; I2 = 54%) or ileus (RR, 0.91; 95% CI, 0.40–2.06; p = 0.81; I2 = 12%).

Fig. 4
figure 4

Postoperative gastrointestinal complications

Full size image

Other postoperative complications

The effects of EOF within two hours and DOF on non-gastrointestinal postoperative complications after CS are showed in Fig. 5. Compared with the DOF group, EOF within two hours was not associated with fever (RR, 0.87; 95% CI, 0.53–1.44; p = 0.59; I2 = 0%), wound infection (RR, 2.64; 95% CI, 0.71–9.85; p = 0.15; I2 = 0%), urinary tract infection (RR, 0.56; 95% CI, 0.12–2.58; p = 0.45; I2 = 48%) or readmission (RR, 1.75; 95% CI, 0.52–5.91; p = 0.37; I2 = 3%).

Fig. 5
figure 5

Other postoperative complications

Full size image

ERAS

Figure 6 presents the potential effects of EOF within two hours on ERAS compared with those of DOF. The time to ambulation after CS significantly earlier (WMD, − 0.96, 95% CI, − 1.80–− 0.13; p = 0.02; I2 = 53%), the time to removal of catheter significantly sooner (WMD, − 15.18, 95% CI, − 25.61–− 4.74; p = 0.004; I2 = 100%), and the time to start a regular diet much earlier (WMD, − 7.03, 95% CI, − 13.13–− 0.92; p = 0.02; I2 = 99%) in the EOF group. Length of hospital stay was assessed in five studies and no significant difference between groups (WMD, − 4.57; 95% CI, − 9.63–0.49; P = 0.08; I2 = 98%).

Fig. 6
figure 6

ERAS

Full size image

Patient satisfaction

Only two of the included studies reported patient satisfaction levels [24, 26]. One study [24] reported that patients in the EOF and DOF groups had no difference in patient satisfaction level (p = 0.14). The findings of Masood et al. [26] showed that hunger and thirst would be more pronounced in the DOF patients compared to the EOF group (p ≤ 0.001 and p ≤ 0.001, respectively), which could account for the decrease in patient satisfaction (34.4% vs. 48.2%).

Quality of evidence

Details regarding our GRADE assessment of pooled effect estimates can be found in Table 2.

Table 2 GRADE summary of findings table
Full size table

Discussion

The current meta-analysis indicated that EOF within 2 h after CS has comparable safety with DOF, without increasing gastrointestinal morbidities (vomiting, nausea, abdominal distension and ileus) or other non-gastrointestinal postoperative complications (fever, wound infection, urinary tract infection, readmission). Even faster recovery of bowel function was observed in the patients oral intake within 2 h compared with DOF. These include a shorter time to the return of bowel movement, a shorter time to the passage of flatus and a shorter time to start a regular diet. Importantly, EOF was associated with reduced time to ambulation and removal of the catheter after CS. On the other hand, inconsistent findings were noted because the meta-analysis by Charoenkwan [30] indicated that EOF significantly reduced the length of hospital stay, whereas in the present systematic review it was shown that EOF and DOF had no significant effect on the length of hospitalization.

In previous clinical practice, women after CS were prohibited from eating via the mouth until bowel activity resumed, despite they were feeling hungry [16]. Anesthesiologists and obstetricians use this approach because of the fear of maternal harm from postoperative complications such as nausea, vomiting, asphyxia, and intestinal obstruction due to EOF; however, the veracity of this theory has been questioned in recent years. There are now many studies on the safety of EOF after CS. The timing of the early feeding regimes varied from immediately to 8 h after the operation [14, 17, 25, 31]. Almost all studies have shown that EOF does not increase postoperative complications. However, the optimal time for oral feeding after CS is unclear. A research group summarized a series of studies and composed standardized ERAS guidelines (parts 1–3) for preoperative and postoperative care in patients with CS. [6, 7] Oral intake of a regular diet within 2 h after CS was recommended [7]. The Society for Obstetric Anesthesia and Perinatology (SOAP) committee recommended that oral intake of ice chips and/or water within 60 min postcaesarean admission to the post anesthesia care unit (PACU) and advance to a regular diet ideally within 4 h postcaesarean, as tolerated [32]. In the present review, our results support EOF 2 h after CS.

The length of hospitalization not only reflects the quality of the patient’s recovery but also correlates with the cost of medical. However, our results showed that EOF did not reduce the postoperative hospital stay following CS, which is not consistent with the findings of previous systematic reviews [10,11,12]. There may be several reasons for this. First, CS is less invasive compared to other abdominal surgeries, and patients recover quickly after surgery. Some medical centers have a fixed postoperative discharge time unless the patient has other complications that require treatment. In addition, the promotion of ERAS in recent years has greatly shortened the postoperative hospitalization time, making it difficult to further shorten the hospitalization time.

High maternal satisfaction was expected in the EOF group due to early gastrointestinal tract function, early ambulation after surgery, early removal of the catheter and early initiation of a regular diet without increasing complications. However, the results of this review showed no significant difference in maternal satisfaction between the EOF and DOF groups, which is not consistent with a previous review [8], suggesting that more clinical trials are needed to be performed.

Limitations

This meta-analysis had limitations. First, most studies were unblinded, severely limiting the quality of the information. Second, we found that clinical heterogeneity existed in analyses of all continuous variables among studies, such as the time to ambulation after surgery, the time to removal of the catheter, the time to start a regular diet, and the length of hospital stay. Third, the number of patients included in this study was still small. Caution is required when interpreting our results. Therefore, well-controlled randomized studies are still required to compare EOF within 2 h and DOF after CS.

Conclusions

In conclusion, this systematic review and meta-analysis suggest that EOF within 2 h after CS has a comparable safety profile compared with DOF group, accelerates patient recovery, but does not shorten hospitalization or improve maternal satisfaction.

Data availability

Data is provided within the manuscript and supplementary information file.

Abbreviations

EOF:

Early oral feeding

CS:

Cesarean section

DOF:

Delayed oral feeding

ERAS:

Enhanced recovery after surgery

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Authors and Affiliations

  1. Department of Anesthesiology, West China Second University Hospital, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan Province, 610041, China

    Dongxu Chen, Lan wu & Shouming Chen

  2. Department of Pharmacy, West China Second University Hospital, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan Province, China

    Bingchen Lang

  3. Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan Province, 610041, China

    Shengping zhou

  4. Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan Province, China

    Dongxu Chen, Bingchen Lang, Lan wu, Shengping zhou & Shouming Chen

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Contributions

DXC: study conception and design, analyses and interpretation of the data; performed the quantitative analysis; drafted the article; approved the final version to be published; and agreed to be accountable for all aspects of the work.BCL: analyses and interpretation of the data; perform quantitative analysis; literature review; final approval of the version to be published; agreement to be accountable for all aspects of the work; LW: literature review; quantitative analysis; final approval of the version to be published; and agreement to be accountable for all aspects of the work; SPZ: literature review; analyses and interpretation of the data; final approval of the version to be published; agreement to be accountable for all aspects of the work; SMC: study conception and design, analyses and interpretation of the data; quantitative analysis; final approval of the version to be published; and agreement to be accountable for all aspects of the work.

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Correspondence to Shouming Chen.

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Chen, D., Lang, B., wu, L. et al. Early oral feeding within two hours for parturients compared with delayed oral feeding after cesarean section: a systematic review and meta-analysis. BMC Pregnancy Childbirth 24, 623 (2024). https://doi.org/10.1186/s12884-024-06838-9

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BMC Pregnancy and Childbirth

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