Asia-Oceania J . Obstet. Gynaecol. Voi. 77, No. 2: 125-129 1991

Immediate Postoperative Oral Hydration after Caesarean Section

Pierre Guedj,l) Joseph Eldor,l) and Michael Stark21 7) D e p ~ t om f . ~4 ~~s ~ h e s ~ o iMo g~~ ,s Ladach g ~ General ~ o s ~ ~Jerusalem, iat, Israel 2) Department of Obstetrics and Gynecology, Misgav Ladach General Hospital, Jerusalem, Israel

Abstract A study was carried out to assess the effects of immediate postoperative oral rehydration in 51 unpremedicated women undergoing caesarean section under epidural anesthesia. The patients were randomly assigned to 2 groups: group 1 (n=22)-fasting at least until 24 hours after the end of the operation, and group 2 (n=29)-receiving immediate oral intake of fluids (water, tea or coffee with sugar) without limitation of quantity. The 2 groups were compared for the occurrence of postoperative nausea and vomiting, onset of peristalsis, rectal gas emission, first bowel movement, and possible complications. The results demonstrate no significant differences between the parturients who drank immediately postoperatively as compared to those in whom oral fluid intake was delayed for 24 hours or more. It is concluded that immediate postoperative oral rehydration had no harmful effect upon peristalsis post-caesarean section.

Key words: caesarean section, epidural anesthesia, oral rehydration, intravenous rehydration, postoperative complications solution (Dioralyte) in 14 patients after cholecystectomy within 6 hours of surgery by nasogastric tube. The solution promoted water Despite reports that gastrointestinal function returns soon after abdominal surgerylr2) uptake from the jejunum in healthy volunteers.4) The patients could be adequately remany patients are unnecessarily maintained on hydrated in the postsurgical course with I. V. fluids long after surgery. enteral fluids. The intravenous route is not without hazGlucose is required to increase sodium ard. It may cause infusion-related phlebitis or chloride and water absorption by the small thrombosis, resisting of infusion sites, extraintestines) and maintain intestinal morphology vasation of fluid into tissue, local pain and and function.6) sepsis. Leiper et aE.8) used a ~ ~ u c o s e ~ e l e c t r o l ~ eI n this study, 29 parturients after under-

Introduction

Received: Aug. 13, 1990 Reprint request to: Dr. P. Guedj, Department o f Anesthesiology, Misgav Ladach General Hospital, Jerusalem, Israel

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going caesarean section were allowed an immediate oral intake of water, coffee, tea with sugar without limitation of quantity. They were compared to another group of 22 parturients after C . S. who were allowed to receive oral fluids only 24 hours at least after the operation. They were compared to the occurrence of postoperative nausea and vomiting, peristalsis, rectal gas emission, and patient convenience.

Materials and Methods

Table 1. Comparison of age, weight and gestational age between groups 1 (fasting) and 2 (immediate oral fluid intake)

Age (years) Weight (kg) age (weeks)

Group 1 (n=22) (Mean+ SD)

Group 2 (n=29) ( M e a n t SD)

31.37f 5.52 70.24f13.17

31.52dZ 5.32 70.75dZ12.68

3 9 . 5 4 t 1.90

39.121 1.92

Table 2. T h e indications for the caesarean section

Fifty-one parturients at a gestational age of 38-42 weeks, who underwent either elective or emergency caesarean section during the period of June 1989 till March 1990 were studied. The operations were done by epidural anesthesia using bupivacaine 0.5%. The patients were randomly assigned to 2 groups: group 1 (n=22) fasted at least for 24 hours after the end of the operation and group 2 (n=29) who received immediate unlimited, oral intake of water, coffee or tea with sugar, in the recovery room. Informed consent was obtained from each patient. The time of the operation was not more than 45 minutes (the average duration was 25 minutes). The 2 groups were compared for the occurrence of postoperative nausea and vomiting, onset of peristalsis, rectal gas emission, first bowel movement and possible complications. The patients were followed for the consecutive 7 days after the operation.

Results The patient groups were similar as regards maternal age, weight and gestational age (Table 1). The indications for the caesarean section are described in Table 2. Three patients in the first group (fasting) had nausea postoperatively and 2 of the second group i in king). The bowel sounds were heard in everyone between the 12th and the 24th hour following the operation. I n group 1 (fasting) the emission of the first flatus (Fig. 1) occurred 1 time on day 3 and 21 times on day 4; while in group 2 (drinking freely)-1 time on day 2, 7 times on day 3, 18 126

Elective C. S. Non-progressive labour Fetal distress Severe preeclampsia ~aIpresen~tion Placental causes

Group 1 (Fasting) (n=22)

Group 2 (Drinking) (n=29)

4

15 3 3 1 5 2

7 6 2 I 2

times on day 4, 2 times on day 5 , and 1 time on day 6. Return of bowel movements occurred for the first time on: group 1-4 times on day 4,15times on day 5 , 3 times on day 6. Group 2-one time on day 2, one time on day 3,lO times on day 4, 16 times on day 5 and 1 time on day 6. Furthermore, we have noted abdominal pain due to abdominal distention 13 times in group 1 (68.4%) and 12 times (57.1%) in group 2.

Discussion The results demonstrate no significant differences between those parturients who drank immediately postoperatively as compared to those in whom oral fluid intake was delayed for 24 hours or more. Patient’s comfort was much greater in the group who drank immediately, These parturients were also not connected to the I. V. line, with less incidence of local pain and t~ombophlebitis, Possible mechanisms for postoperative dis-

ORAL HYDRATION AFTER CAESAREAN SECTION

EASES

R

F

18

12

I

r

Fig. 1. Day of first flatus appearance postoperatively. R=oral rehydrated patients; F=Fasting patients

F I

1st BOWEL MOVEfdENT

Fig. 2. Day of the first bowel movement postoperatively.R=oral rehydrated patients; F=Fasting patients

turbance of gut function have been suggested. These include: Reflex increase in sympathetic activity following abdominal incision17+3) handling and exposure of the gut to air,**Q)peritoneal irritation,lO*ll)sympathetic overactivity due to an increase in circulatingl*J3) or local cat echo la mines^*) cholinergic inactivity following cholinergic nerve damage,ls) side effect of various drugs administered in the perioperative period,l6-lSf general body distur-

bance such as cold, hypoxic and electrolyte disturbance180-aa)and administration of opiate ana1gesics.l) All these factors can contribute to postoperative paralytic ileus. A study of women in labour found a marked delay in gastric emptying in those receiving narcotic analgesics.23) Thoren et tat,**) assessed the duration of postoperative ileus in patients after hysterectomy analgesiced either with epidural mor127

P. GUEDJ ET AL.

phine or epidural bupivacaine 0.25% postoperatively. They allowed the patients in the epidural bupivacaine group to have oral fluid intake after 18f5 hours postoperatively, and the patients in the epidural morphine group28+. 13 hours postoperatively. The time of the first passage of flatus was 2 2 k 16 in the epidural bupivacaine group and 56k22 in the epidural morphine group. The time until the first postoperative passage of feces was shorter in the bupivacaine group (57+44 hrs) than in the morphine group (92k22 hrs). However, glucose has a stimulatory effect on intestinal ion ~ an sp o rt'~ 6Optimal ) water and sodium absorption is achieved with solutions containing approximately 60 mrnol/Z sodium and 90 mmol/Z glucose.a6) The earIy oral intake of fluids can by itself stimulate gut peristalsis. However, in our patients it didn't delay the time of appearance of peristalsis or of rectal gas emission. It is also more economical in terms of materials and nursing time. It is concluded that immediate postoperative oral rehydration after caesarean section in our patients had no harmful effect upon peristalsis. Its clinical value has to be further evaluated in a larger group of parturients.

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