Caesarean most surgeons accept the idea that

Caesarean section (CS) becomes
one of the commonest major surgical operations performed daily worldwide. 1
However, gastrointestinal dysfunction has a major con­tributing role in the
abdominal discomfort following CS as it can cause accumulation of intestinal
secretions and gases, resulting in nausea, vomiting, abdominal pain or distension.
Thus, it can lead to prolonged postoperative hospital stay after CS. 2

Postoperative ileus (POI),
which is the worst form of intestinal dysfunction, leads to absolute
constipation and oral intake intolerance. It is widely believed it can be
resulting from a non-mechanical injury that disturbs the normal gastrointestinal
tract motor activity. Also, most surgeons accept the idea that POI of any
degree is a predicted physiological and sometimes mandatory response to any open
abdominal procedure. 3

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In the USA, POI is known to
cost between $5000 and $10 000 which reaches a total of $1 billion annually due
to abdominal discomfort, hospital stay prolongation and high treatment costs. 4
Thus, several techniques were tested as trials to enhance the gastrointestinal
motility resumption after CS. These include early oral intake, early
ambulation, chewing gum and coffee consumption. 5, 6

 The mechanism of enhanced postoperative
gastrointestinal recovery by the chewing gum is believed to be due to stimulation
of digestion through the cephalic-vagal pathway as it stimulates the several
neural and humoral factors that modulate the functions of different parts of
the gastrointestinal tract. 2 Recently, a series of randomized
controlled trials were conducted to confirm the benefits of gum chewing in managing
gastrointestinal dysfunction following CS. 7, 8 Their results
suggested that gum chewing improved the early resumption of bowel functions and
can be implemented for enhanced recovery after surgery (ERAS) program. 2

Our hypothesis

To assess the
effects of chewing gum to reduce the duration of postoperative ileus and to
enhance postoperative recovery after a CS.

 This randomized controlled
trial was conducted at Armed Forces Hospital Southern Region, khamis Mushayt,
Saudi Arabia in the period from April 2015 to June 2017 after being approved by
the local research ethics committee and prospectively registered at (NCT02386748).The primary outcome measure was the time to first passage
of stool, while secondary outcomes were the time of the first flatus, the first
hearing of normal intestinal sounds, the duration of hospital stay, the
duration of parenteral therapy either intravenous antibiotics or fluids, the
time of initiation of breast feeding and the cost of hospital stay. Also, the secondary outcome measures
included tolerance of gum chewing, complications in all groups entailing febrile morbidity, blood
transfusion, the
occurrence of vomiting, abdominal distension or postoperative paralytic ileus
requiring nasogastric tube placement or hospital re-admission.Eligibility
criteria: participant follow chart:600 women aged between 20 and
35 years scheduled for elective CS; either first or repeated, with term,
singleton, viable and healthy pregnancy were assessed for enrolment in this
trial. Our exclusion criteria were emergency caesarean section, multiple
pregnancies, polyhydramnios, abnormal placentation (placenta praevia andor
accreta), and past history of medical disorders, bowel disease or gastrointestinal
operations. All eligible women were fully counselled about the trial potential
side effects before an informed written consent was signed by each participant.Randomization:400 eligible and consented
women were enrolled and divided randomly into three groups through sealed
envelope method which was withdrawn by the patient herself. Each envelope was
marked with a serial number and had a card defines the intervention type. Once
participant had been allocated, it could not be changed. The ratio of one to
one was determined as the allocation ratio during the allocation process. The
study nature did not allow blinding after application of the assigned intervention postoperatively. Intervention:Women in group (A) received
sugarless gum (Nova gum, Batook chewing gum IND. LTD, Saudi Arabia) two hours
after their operating room (OR) discharge. They were instructed to chew it at
least for half an hour and at two hours interval during daytime. Gum chewing
was stopped all over the night (12:00 PM) to allow the women to sleep. Counting
and recording the number of empty sticks were done during the routine vital
signs observations in order to assure the women’s compliance to gum use. Women
were instructed to stop chewing gum with the passage of stool and they were
allowed to start regular oral intake.   Group (B) women started oral
clear fluids after OR discharge by six hours. Group (C) was the control group;
women of this group were kept on intravenous fluids for 24 hours, unless
resumption of intestinal function took place. Then, clear fluids and soft foods
were allowed orally to start with their first bowel motion. Intestinal sounds
for all groups were checked at six to eight hours intervals postoperatively by
two of the authors (WA, MA). All the operations were performed in the
morning under general anaesthesia using Pfennanstiel’s incision. The time when
surgery was ended discharging the woman from the operating theatre (OR) after
full recovery marked as the zero hour. For analgesia, two rectal doses of 100
mg diclofenac sodium
(Voltaren, Novartis Pharma, Saudi Arabia), if not contraindicated. The need for
additional use
of pethidine was recorded. No oral or rectal bowel stimulants were used after CS. The same
postoperative program for ambulation was used for all groups. Data collection:Women demographic data were
collected including
their age, body mass index (BMI), obstetric history, past medical and surgical histories,
gestational age at delivery and caesarean section indications. The operative data were also
recorded, including the operative time, need of blood transfusion, operative complications and the
presence of
severe adhesions or uterine extension. Moreover, the postoperative data like feeding time, time
of hunger feeling, time of passing flatus, time of passing stool, absent or
hypoactive intestinal sounds,
inability to pass flatus or stool, vomiting, abdominal distension with or without pain and tolerance of gum chewing were recorded. The criteria to
consider the woman fit for hospital discharge were stable vital signs for at least 24 hours, full
ambulation without assistance, passage of a stool and urine, tolerance to solid food and absence of
postoperative complications.

The women were followed till
the final discharge from hospital and on outpatient basis. However, any events presented by the participants
during the postpartum period were recorded. Operative and postoperative
exclusion criteria were caesarean hysterectomy, extensive adhesions, uterine
extensions, bowel injury and any operative complication that can affect the woman normal recovery
or plan of the trial. The past history and demographic
characteristics were similar in all groups without any statistical significant
difference in the age, BMI, gestational age, past obstetric, medical and
surgical histories. The only operation rather than CS encountered in the past
surgical history was appendectomy.

The time of gastrointestinal
recovery was significantly shorter in group (A) as women included in this group
showed statistically significant earlier onset of normal bowel sounds, passing
flatus and stool. Table (2, 3) Also, they have significantly shorter duration
of intravenous therapy and hospital stay as well as lower amount of intravenous
fluids due to earlier resumption of regular oral intake. The operative time and
the need for intravenous pethidine showed no significant statistical difference
between all groups.

Although the abdominal
distension was exactly similar among gum chewing and conventional groups, the
occurrence of vomiting and PI was significantly higher in the later group. On
the other hand, the only statistical significant difference noticed between the
conventional and control groups was that fewer women suffered from abdominal
distension among the former group. Otherwise, no other significant differences
were detected. Table (4)


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