International Journal of Gynecology and Obstetrics 126 (2014) 115119

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International Journal of Gynecology and Obstetrics

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CLINICAL ARTICLE

A randomized comparative trial of early initiation of oral maternal

feeding versus conventional oral feeding after cesarean delivery
Shabeen N. Masood a,, Yasir Masood b, Uzma Naim c, Muhammad F. Masood d
a
Sobhraj Maternity Hospital, Karachi Metropolitan Corporation, Karachi, Pakistan
b
Department of Surgery, Ziauddin Medical University, Karachi, Pakistan
c
Department of Surgery, Wayne State University, Detroit, USA
d
Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To compare the effects of two maternal feeding policiesearly versus conventional oral feedingafter
Received 2 October 2013 cesarean delivery. Methods: This prospective multicenter randomized comparative trial was conducted at tertiary
Received in revised form 21 February 2014 care hospitals in Sindh, Pakistan, from 2010 to 2012. Women with an uncomplicated cesarean delivery under spi-
Accepted 20 April 2014 nal anesthesia were allocated to an intervention of early (after 2 hours) or conventional (after 18 hours) initiation
of oral feeding. Outcomes included maternal ambulation, maternal satisfaction, gastrointestinal functions, and
Keywords:
length of hospital stay. Results: In total, 1174 women (n = 587 per group) were included in the nal analysis. Gas-
Day-care cesarean delivery
Early ambulation
trointestinal complications were not signicantly different between the two groups. Lower intensities of thirst and
Early oral maternal feeding hunger and a higher rate of maternal satisfaction were observed in the early feeding group (P b 0.05), and 53.8% of
Length of hospital stay women in this group were able to ambulate within 15 hours of surgery, compared with 27.9% of women in the
Maternal satisfaction conventional feeding group. The frequencies of readmission, febrile morbidity, and wound infection were insignif-
Maternal thirst and hunger icant. Conclusion: Early oral dietary initiation after cesarean delivery resulted in early ambulation, greater maternal
satisfaction, and reduced length of hospital stay, with no detrimental outcomes, making this practice cost-
effective. Hence, day-care cesarean delivery might be an option in resource-constrained settings.
Trial Registration number: ChiCTR-TRC-13003651, http://www.chictr.org
2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction
There are certain trends in postoperative dietary management that
most health providers follow. One common practice is to withhold
uids and foods after cesarean delivery until the return of bowel sounds
or the passage of atus. This practice is based on the belief that all intra-
abdominal surgical procedures are followed by postoperative ileus [1].
Women who are potential candidates for cesarean delivery are usually
kept fasting in the labor ward for a long period of time; however, this
practice is not scientically tested. Evidence supports early oral feeding
after surgery with no signicant increase in gastrointestinal complica-
tions [2]; this is well tolerated with many nutritional advantages over
standard intravenous uids.
Delayed immobilization after surgery is an important reason for
prolonged hospital stay after a cesarean delivery. By contrast, early dis-
charge from hospital after an uncomplicated cesarean delivery may re-
duce the nancial burden and could make cesarean delivery a day-care
procedure. Early intake of an oral diet, as opposed to the conventional
practice of withholding an oral diet for 1224 hours, promotes prompt
Corresponding author at: U-19, Hasan Apartment Extension, Hasan Square, Gulshan-e-
Iqbal, Block-13D, Karachi 75300, Pakistan. Tel.: +92 3332233414; fax: +92 2134856118.
E-mail address: sh_naz@yahoo.com (S.N. Masood).
recovery, reduces the degree of negative protein balance, and makes
women feel energetic.
The objective of the present study was to determine the effects of
early initiation of oral feeding versus conventional feeding in women
with an uncomplicated cesarean delivery under spinal anesthesia on
time to ambulation, discontinuation of intravenous uids and catheter-
ization, maternal satisfaction, thirst and hunger, gastrointestinal func-
tions, and length of hospital stay.
2. Materials and methods
The present study was a prospective multicenter randomized
trial that compared two active feeding policiesearly and conven-
tional maternal feedingafter cesarean delivery. The study centers
were chosen based on convenience and number of obstetric patients
and comprised the departments of Obstetrics and Gynecology at
Countess of Dufferin Fund Hospital in Hyderabad, Liaquat University
Hospital in Hyderabad Noor Hospital in Karachi, and Fatima Bai
Hospital in Karachi, all in Pakistan. The study was conducted from
March 1, 2010, to May 31, 2012. Ethics approval was obtained from
the Ethics Review Board (ERB) of Liaquat University of Medical and
Health Sciences, Jamshoro, Pakistan.

http://dx.doi.org/10.1016/j.ijgo.2014.02.023
0020-7292/ 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
116 S.N. Masood et al. / International Journal of Gynecology and Obstetrics 126 (2014) 115119
The study consisted of three consecutive phases, which were all con-
ducted at the recruiting hospitals. In phase I, research staff conducted
focus group discussions on feeding practices after cesarean delivery
with the stakeholders (all pregnant women who attended the hospitals
prenatal clinics, especially those who had previously had a cesarean de-
livery or who were scheduled for elective cesarean delivery, and staff of
the maternity unit) during prenatal clinics. The responses from the par-
ticipants indicated a positive perception toward early oral maternal
feeding. In phase II, the doctors and nurses of the recruiting hospitals
were trained before implementation of the research protocol. Phase III
was the implementation phase of the study.
The primary outcome measures were the time to ambulation and
the level of maternal satisfaction. The secondary outcomes included
gastrointestinal complications and duration of hospital stay.
Initially, 4610 women gave their consent to participate in the study.
The actual study sample was selected based on nonprobability purpo-
sive sampling. The estimated prevalence of cesarean delivery in
Pakistan is 27%45% [36]. Assuming a 45% prevalence of cesarean de-
livery with an 80% power and a 4% margin of error, the estimated sample
size was approximately 1200. This was calculated with the WHO sample
size calculator. After matching for age, parity, and number of previous
cesarean deliveries, a computer-generated randomization list was
used to allocate the women to the early feeding or conventional feeding
group. The research staff at the recruiting hospitals received sealed
envelopes; color-coded les were used to identify the study groups
(red for early feeding and green for conventional feeding). The data
for 587 women per group were included in the nal analysis (Fig. 1).
The study included women who gave informed consent and who
had an uncomplicated cesarean delivery under spinal anesthesia with-
out comorbidity (medical, obstetric, or surgical history of any serious ill-
ness). Informed consent was obtained preoperatively from all eligible
women and their spouses. Once a woman had been recruited, she con-
tinued to be in the trial.
After cesarean delivery, the women were transferred to separate
wards according to their feeding group allocation, in order to obtain
Enrollment
Allocated to early feeding intervention (n=909)
Received allocated intervention (n=596)
Did not receive allocated intervention (n=313)
Noncompliance of patient or attendant (n=56)
Noncompliance of staff (n=15)
Allocation not followed (n=242)
Lost to follow-up (n=9)
Could not be contacted (n=7)
Not satisfied with the intervention (n=2)
Analyzed (n=587)
Fig. 1. Study ow. a No match by age, parity, and number of previous cesarean deliveries.
better compliance and motivation. Women in the early feeding (EF)
group were given 200250 mL of liquid (water, tea, milk, juice in
tetra/tinned packs) 2 hours after surgery. If the liquid diet was well tol-
erated, a solid diet was started 4 hours after surgery. An interval of
2 hours was chosen before initiation of the liquid diet to allow time
for the fourth stage of labor (1 hour) and for logistic adjustments such
as transfer of the patient from the operating room to the ward
(1 hour). Women in the conventional feeding (CF) group received
clear uids after 12 hours and a solid diet after 18 hours. The decision
to deviate from the allocated feeding regime (for example because of
food intolerance, mild/severe ileus, or clinical deterioration) remained
at the clinicians discretion. Any inevitable deviation was recorded.
The duration of surgery was dened as the time from skin incision to
skin closure. All other durations were recorded as hours after the com-
pletion of surgery. Mild ileus was dened as nausea and abdominal pain
in the rst 12 hours, and severe ileus was dened as persistent nausea,
vomiting (more than four times), abdominal pain, and distention of
more than 6 cm at the level of the umbilicus within 1224 hours post-
operatively. The intensities of thirst and hunger and the level of mater-
nal satisfaction were measured on a visual analog scale (VAS). In both
groups, intravenous hydration was discontinued and the Foley catheter
was removed after the woman had taken her rst full meal without
nausea or vomiting. Approximately 1.01.5 L and 3.03.5 L of uid
were given postoperatively in the EF and CF groups, respectively. All
women received three doses of intravenous antibiotics. Mobilization
was encouraged in both groups. The study did not alter/interfere with
any treatment/care given routinely to the women except for the inter-
ventions to be evaluated.
Demographic data were collected at recruitment. The research staff
or the duty doctor collected the remaining data during the womens
stay in the postoperative ward and at the 1-week follow-up at the hos-
pital, using structured questionnaires. The duty doctor was expected to
report serious adverse events.
The data were analyzed with SPSS version 15.0 (IBM, Amonk, NY,
USA). Continuous variables were reported as mean standard
Assessed for eligibility (n=4610)
Excluded (n=2792)
Did not meet inclusion criteria (n=2770)
Vaginal birth (2728)
Intraoperative complications (n=42)
Refused to participate (n=22)
Randomized (n=1818)
Allocation
Allocated to conventional feeding intervention (n=909)
Received allocated intervention (n=851)
Did not receive allocated intervention (n=58)
Noncompliance of patient or attendant (n=9)
Noncompliance of staff (n=7)
Allocation not followed (n=42)
Follow-up
Lost to follow-up (n=20)
Could not be contacted (n=14)
Not satisfied with the intervention (n=6)
Analysis
Analyzed (n=587)
a
Excluded (n=244)
 S.N. Masood et al. / International Journal of Gynecology and Obstetrics 126 (2014) 115119
deviation and compared with the t test. Categorical variables were re-
ported as number and percentage and analyzed using the 2 test. The
Fisher exact test was used if there were fewer than ve occurrences in
any group. P b 0.05 was considered statistically signicant.
3. Results
In total, data for 1174 women were available (EF group, n = 587;
CF group, n = 587). The mean age of the study participants was
25.90 4.42 years and the parity was 2.22 1.57 (Table 1). Elective
cesarean delivery was performed in 971 (82.7%) of the women, and
203 (17.3%) of the women underwent emergency cesarean delivery.
A history of previous cesarean delivery was present in 619 (52.9%) of
the women. The frequencies of nausea, vomiting, mild or severe
postoperative ileus, and abdominal distention were not statistically
signicant between the two groups. Nausea was found in 40 (6.8%)
versus 27 (4.6%) women in the early and conventional feeding
groups, respectively (Fig. 2). Vomiting was observed in 14 (2.4%)
women in each group, mild ileus was noted in 58 (9.9%) versus 55
(9.3%) women in the early and conventional feeding groups, and
severe ileus in 5 (0.9%) versus 7 (1.2%) women. Abdominal disten-
tion was present in approximately 12 (2%) of the women in each
group (P N 0.05).
The time to rst auscultation of bowel sounds, time to rst percep-
tion of bowel sounds by the woman, time to passing atus, and abdom-
inal girth at the level of the umbilicus 1 hour after the cesarean delivery
were similar in the two groups (Table 2). However, discontinuation of
intravenous uid and removal of the catheter occurred signicantly ear-
lier in the EF group than in the CF group (P b 0.05).
Twice as many women in the EF group were able to ambulate
15 hours after surgery compared with the CF group (316 [53.8%] vs
164 [27.9%]) (Fig. 3). The intensities of thirst and hunger were signi-
cantly higher in the CF group (P = b 0.001 and P = b0.001, respectively).
One week after discharge, 4 (0.7%) women in the EF group had been
readmitted (Fig. 4); 2 because of wound infection and 2 because of high-
grade fever secondary to endometritis. In the CF group, one patient had
been readmitted because of severe secondary postpartum hemorrhage.
Wound infection was rare (EF group, 2 [0.3%]; CF group, 0 [0.0%]. Febrile
morbidity was seen in 18 (3.0%) women in each group.
4. Discussion
In the present study, 53.8% of the women in the early feeding group
were able to ambulate within 15 hours postoperatively compared with
27.9% of the participants in the conventional feeding group. Similar re-
sults were reported in a study conducted in India [7].
Although the frequency of nausea was higher in the EF group, no sig-
nicant differences between the groups were observed in terms of ab-
dominal distention, paralytic ileus, and wound dehiscence. Similarly, a
study from Thailand [8] found no signicant difference in gastrointestinal
adverse effects between women with early (after 8 hours) versus delayed
(after 24 hours) rst meal intake after cesarean delivery. In other studies
Table 1
Demographic and other characteristics of women with uncomplicated cesarean delivery.
Characteristic Early feeding
(n = 587)
Age, y 26.07 4.51
Parity 2.26 1.61
Previous cesarean delivery(s)
Yes 312 (53.2)
No 275 (46.8)
Elective cesarean delivery 486 (82.8)
Emergency cesarean delivery 101 (17.1)
a
t test.
b
2 test.
117
[2,9], there were also no signicant differences in the rates of abdominal
distention, ileus, and wound dehiscence and in the times to passage of a-
tus and return of bowel sounds, despite an increase in postoperative nau-
sea and vomiting after early introduction of oral feeding.
Cesarean delivery is the most commonly performed operation
worldwide [10]. It generally involves minimal bowel manipulation
and the duration of surgery is relatively short, allowing a rapid postop-
erative return of bowel functions even before this is clinically detectable
[11]. Early oral feeding is associated with less depletion of protein
stores, a decreased infection rate, and improved wound healing, and if
adequate calories are administered, it prevents weight loss by maintain-
ing serum electrolytes and a positive nitrogen balance [12].
Lower intensities of thirst and hunger with higher rates of maternal
satisfaction were observed in the EF group in the present study, without
an increase in vomiting. An audit of an early feeding program in France
[13] showed that postoperative thirst was a bigger problem for patients
than hunger. After the introduction of early oral feeding, signicantly
fewer mothers experienced hunger and thirst on the rst two postoper-
ative days [13]. Maternal satisfaction was higher in the EF group
(48.2% vs 34.4%), because the women were less hungry and thirsty
given that feeding was introduced earlier. Similar rates of maternal sat-
isfaction have been reported in most other studies [14,15].
Women in the EF group were given 1.01.5 L of uid postoperatively
compared with women in the CF group, who were given 3.03.5 L be-
fore they were allowed full meals. The early introduction of uids and
food was associated with an increased rate of early ambulation, earlier
discontinuation of intravenous uids, and earlier removal of the cathe-
ter. Guidelines from the National Institute for Health and Clinical Excel-
lence [16] recommend that the urinary catheter should be removed
once a woman is mobile after regional anesthesia. The fact that EF
kept women in their hospital bed for a shorter period of time may result
in a signicant reduction in both tangible costs (cost of medications and
hospital utilities) and intangible costs (nursing care and paramedical
services). Similar ndings were reported in a study from Mulago,
Kenya [17], where women in the EF group were also able to leave the
bed earlier (15.1 hours vs 17.8 hours).
Length of hospital stay and cost-effectiveness are important factors
to take into account when considering the possibility of making cesare-
an delivery a day-care procedure. The authors of a Canadian study [18]
recommended early feeding because it was associated with a shorter
hospital stay, compared with delayed feeding; the median length of
hospital stay was 6.0 days for the traditional feeding group and 4.0
days for the early feeding group (P b 0.001). Similarly, a study from
the USA [2] found that women who received EF had a shorter hospital
stay, and this had a signicant impact on hospital charges. Studies
from India [19] and Nigeria [20] also reported shorter hospital stays
with early feeding (mean 59.0 7.3 hours versus 88.0 9.5 hours, re-
spectively; P b 0.001) [19]. In the present study, the lengths of hospital
stay in the two groups differed by only 3 hours. The women in the EF
group could have been discharged sooner, but they were kept in hospi-
tal for the same duration of time as the women in the CF group to ob-
serve the effects of early oral diet introduction.
Conventional feeding Total P value
(n = 587) (n = 1174)
25.72 4.33 25.90 4.42 0.18a
2.17 1.52 2.22 1.57 0.36a
307 (52.3) 619 (52.9) 0.791b
280 (47.7) 555 (47.3)
485 (82.6) 971 (82.7) 0.938b
102 (17.4) 203 (17.3)
118 S.N. Masood et al. / International Journal of Gynecology and Obstetrics 126 (2014) 115119

Fig. 2. Gastrointestinal outcomes after early or conventional feeding.

Table 2
Postoperative ndings among women with an uncomplicated cesarean delivery.

Postoperative event Early feeding Conventional feeding Total P valuea

(n = 587) (n = 587) (n = 1174)

Time to rst auscultation of bowel sounds, h 17.09 12.9 16.15 11.15 16.62 12.05 0.19
Time to rst perception of bowel sounds by the woman, h 18.33 11.87 17.29 10.74 17.81 11.32 0.13
Time to passing atus, h 19.78 11.57 19 10.35 19.4 10.99 0.25
Abdominal girth at the level of the umbilicus 1 hour after cesarean delivery, cm 82.65 17.5 83.45 17.12 83.05 17.31 0.475
Time to discontinuation of intravenous uids, h 25.27 8.75 30.24 14.21 27.75 12.06 b0.001
Time to removal of catheter, h 13.21 2.78 33.71 6.35 23.46 11.37 b0.001
Length of hospital stay, h 74.63 13.85 77.4 16.13 75.83 15.08 0.006
a
t test.

No signicant detrimental effects on postoperative clinical outcomes
were seen among women who were allowed early oral feeding. Early
postoperative recovery is an important factor that can enable women
to ambulate earlier and reduce their hospital stay. Therefore, initiation
of EF seems to be safe for women with an uncomplicated cesarean deliv-
ery and is more acceptable to women and their families.
In the present study, a larger number of women was recruited than
in previously published trials [21,22] and no signicant maternal ad-
verse event was seen as a result of post cesarean early feeding. In a pre-
vious study [23], 142 (38.9%) providers of obstetric care said that EF is
cost-effective, whereas 106 (29%) participants felt that it may increase
costs because of complications or readmissions. In the present study,

Fig. 3. Factors inuencing maternal satisfaction with early or conventional feeding. a P b 0.005.
 S.N. Masood et al. / International Journal of Gynecology and Obstetrics 126 (2014) 115119
Fig. 4. Outcomes 1 week after discharge from hospital.
postoperative follow-up after 1 week did not show a signicant increase
in the rates of maternal readmission and infectious morbidities.
The present participants came from a wide range of socioeconomic
backgrounds; this further strengthens the external validity of the trial.
The present study is limited by a high rate of protocol violations by
patients and their attendants, the use of self-reported outcome mea-
sures, and compliance difculties among the attendants related to the
early initiation of oral feeding.
In conclusion, the early initiation of oral feeding after cesarean
delivery under spinal anesthesia resulted in early ambulation and
greater maternal satisfaction. This feeding regime can reduce the
length of hospital stay without any detrimental effects on postoper-
ative clinical outcomes in uncomplicated cesarean deliveries. Early
oral feeding also reduces the tangible and intangible costs of services
provided to the patients. National recommendations regarding early
oral feeding after cesarean delivery are required. Day-care cesarean
delivery could become a future option in resource-constrained set-
tings if mothers are allowed to drink and have oral food sooner
after surgery.
Conict of interest
The authors have no conict of interest to declare.
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