Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : QC01 - QC04 Full Version

Early versus Delayed Initiation of Oral Feeds among Mothers after Caesarean Delivery: A Comparative Study


Published: December 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/59075.17193
Rajiv Kumar Saxena, Chaitanya Indrani, P Roshini, Aritra Maji

1. Professor, Department of Obstetrics and Gynaecology, MVJ Medical College and Research Hospital, Bengaluru, Karnataka, India. 2. Assistant Professor, Department of Obstetrics and Gynaecology, MVJ Medical College and Research Hospital, Bengaluru, Karnataka, India. 3. Assistant Professor, Department of Obstetrics and Gynaecology, MVJ Medical College and Research Hospital, Bengaluru, Karnataka, India. 4. Assistant Professor, Department of Obstetrics and Gynaecology, MVJ Medical College and Research Hospital, Bengaluru, Karnataka, India.

Correspondence Address :
Dr. Chaitanya Indrani,
Flat No-232, 13th Cross, Indira Nagar, 2nd Stage, Bengaluru, Karnataka, India.
E-mail: drpcindrani1537@gmail.com

Abstract

Introduction: It is a common practice to keep a patient ‘nil’ per oral, till the return of bowel sounds, after any laparotomy. Enhanced Recovery After Surgery (ERAS) society, now recommends evidenced-based guidelines for postoperative early oral feeding after an uncomplicated Caesarean Delivery (CD), as opposed to the delayed (conventional) initiation of oral feeds.

Aim: To compare the effects of early feeding versus delayed oral feeding in women undergoing CD.

Materials and Methods: This prospective comparative study was conducted in Department of Obstetrics and Gynaecology at MVJ Medical College and Research Hospital, Bengaluru, Karnataka, India, from November 2020 to October 2021. Total of 148 women with uncomplicated singleton pregnancy undergoing CD, under spinal anaesthesia, were allocated into two groups. Early Feeding group (n=70) (EF) where feeding was started within 2-8 hours of surgery and Delayed Feeding group (n=78) (DF) where feeding was started between 18-24 hours of CD. The outcome measures were maternal satisfaction, and the effect on gastrointestinal function (return of bowel sounds, passage of flatus and stool), mobilisation of patient and complications in postoperative period. Student’s t-test and Chi-square test were used as appropriate, and p-value <0.05 was determined to be statistically significant.

Results: The mean age of women in DF was 24.79±4.37 years and in EF group was 25.09±3.86 years. Overall, the maternal satisfaction was high in both the groups; DF (80%) and in EF (98.6%). There was an early return of bowel sounds in EF group 4.71±1.83 hours versus 13.72±3.08 hours in DF group. Participants in EF group recorded. early passage of flatus (9.89±3.00 hours versus 13.72±3.08 hours), and early ambulation (9.57±1.62 versus 14.95±3.9 hours) when compared to DF group participants.

Conclusion: The ERAS strategy is a safe and effective approach for postoperative care for women undergoing caesarean delivery and results in overall high patient satisfaction.

Keywords

Ambulation, Bowel sounds, Feeding, Flatus, Maternal satisfaction

Caesarean Delivery (CD) represents the most significant operative intervention in obstetrics. The frequency with which it is carried out continues to rise (1). As the risk of complications from the surgery have progressively diminished, this operation is being justified for ever widening clinical and social indications. In India, CD rates have been steadily rising with a wide variation in the rates reported from private and public hospitals (2). Caesarean delivery are generally short duration operation involving minimal, if any, bowel manipulation in young healthy women. Postoperative management related to introduction of fluids and solid food, after CD, vary among individual doctors and different institutions. Historically, patients were kept ‘nil per oral’ (fasting), until return of bowel sounds or passage of flatus, this interval could vary anywhere between 8-24 hours (3). Thereafter, clear fluids followed by soft diet were permitted. Regular diet was introduced only after patient passed flatus and or stools (4).

Postoperative ileus is a self-limiting event that follows all abdominal surgeries including CD. Although the exact mechanism of arrest and disorganisation of gastrointestinal motility is unknown, it appears to be associated with the opening of peritoneal cavity, bowel manipulation, duration of surgical procedure, and bowel adhesions. Those with intraoperative adhesions and postpartum haemorrhage were excluded as extensive intra-abdominal dissection prolongs the duration of surgery, causing increase in fat and tissue catabolism and retention of free fluid in response to altered level of antidiuretic hormone and aldosterone, causing electrolyte disturbance and predisposing to paralytic ileus (5). From a clinical standpoint, most clinicians consider that an ileus has resolved when bowel sounds are heard and flatus is passed, hence, feeding is not allowed until this has happened.

In recent years, these traditional practices of oral feeding after abdominal surgery, have been challenged by many studies, some offered a regular diet within the first 8 hours, whereas in delayed feeding group diet was introduced at 24 hours (6), and in the study by Tan PC et al., the participants were randomised to a sandwich meal served immediately on return to the ward or on demand (7). In 2019, the Enhanced Recovery After Surgery (ERAS) society, published evidenced-based recommendations for postoperative care after CD, to enhance patient satisfaction and early recovery. One of the key element of the recommendations is early feeding with regular diet within two hours after CD. The evidence suggests that earlier resumption of solid food, accelerated return of bowel activity and reduced length of hospital stay with no evidence of higher complication rates. This also resulted in early ambulation, lower costs and higher overall maternal satisfaction (8),(9),(10). Early oral feeding is associated with reduced protein store depletion, improved wound healing and faster recovery (11). The economic impact of early discharge from the hospital after uncomplicated caesarean section cannot be overlooked (12).

There is an inherent resistance to change any conventional practice that has stood the test of time. The contrasting ERAS recommendation of early feeding versus the conventional delayed feeding after CD is one such area that needs implementation and audit. Hence, this novel study was designed to audit the current practice of Delayed Feeding (DF), and implement the evidence based practice of Early Feeding (EF) after CD. The primary objective was the overall maternal satisfaction with the procedure and the secondary objective was to assess the effect on gastrointestinal function (i.e. time to return of bowel sounds, passage of flatus and stool), time taken for ambulation of the patient and associated complications, if any. The hypothesis of the study being that there is no difference in the above mentioned parameters with EF or DF after CD.

Material and Methods

This prospective comparative study was conducted in Department of Obstetrics and Gynaecology at MVJ Medical College and Research Hospital, Bengaluru, Karnataka, India, from November 2020 to October 2021. Institutional Review Board and Ethical Committee approval was taken prior to the study (MVJMC&RH/IEC-04/2019).

Sample size calculation: Sample size estimated was 69 for each group, considering the time for first flatus as 30.7±15.3 and 37.5±16.5 for the two groups with 5% level of significance and 80% statistical power (13). In the present study, a total of 148 patients were recruited. On admission the patients were explained about the study protocol and informed consent was taken after which they were randomly allocated to two groups, i.e., EF group or DF group, using random number table.

Inclusion criteria: The study population included women with term, singleton pregnancy undergoing uncomplicated elective or emergency CD under spinal anaesthesia.

Exclusion criteria: Women treated with magnesium sulphate, tocolytic drugs, previous history of bowel surgery or bowel injury or general anaesthesia were excluded from the study.

This study comprised of 148 women participants, assigned to two groups:

• Group DF (n=78): Participants received conventional postoperative care i.e. nil per oral for 18-24 hours postoperatively, then allowed clear oral fluids after bowel sounds were heard, followed by soft diet.
• Group EF (n=70): Participants received ERASS recommended early oral feeds, that is, water within 2-8 hours of CD, followed by soft or regular diet. Clear oral fluids included sips of water, tender coconut water, fruit juice, tea, coffee. Soft diet included porridge, soup, idli, fruits, milk products followed by regular diet consisting of vegetables and chapatti or rice or ragi ball; as per patient’s preference.

Study Procedure

Relevant information was collected to study the outcomes in both the groups. This included independent variables of demographic data like maternal age, parity, gestational age, previous abdominal surgery, whether emergency or elective CD. Postoperative parameters included assessment of ‘maternal satisfaction’ with postoperative care, which was recorded after 48 hours of CD, using the Visual Analogue Scale (VAS) (6). The same scale was used to evaluate patient satisfaction on a scale from 0-10, minimum satisfaction was given a score of 0 and maximum satisfaction was given a score of 10. The scores of 0-3 denoted ‘not satisfied at all’, scores of 4-7 denoted ‘low satisfaction’ and scores 8-10 represented ‘highly satisfied’. Time elapsed between end of CD and first maternal ambulation (walking with support), time of return of gastrointestinal motility (passing of flatus and motions), postoperative gastrointestinal complications (nausea or vomiting) and any other complications (abdominal distension, loose stools etc) were documented.

Postoperative intravenous fluid was given to all groups until the women tolerated oral intake well. Intravenous (i.v.) hydration was discontinued when patient successfully completed a meal without nausea or vomiting. All participants received prophylactic antibiotics. Early breast feeding was encouraged in both the groups. Duration of surgery was defined as the time from onset of skin incision to skin closure. Cessation of i.v. fluids and removal of i.v. cannula were recorded in hours after completion of surgery.

Statistical Analysis

Continuous variables were presented as Mean±Standard Deviation (SD) and these variables between the two groups were compared by using Student’s t-test. Categorical variables were presented as absolute numbers and percentage and these variables were compared using Chi-square test. A p-value <0.05 was determined to be statistically significant.

Results

Both the groups were comparable with respect to demographic parameters as presented in (Table/Fig 1).

There was no difference in duration of surgery, amount of blood loss or intraoperative adhesions between the two groups (Table/Fig 2).

Group EF received early oral sips of water within 2-8 hours (4.71±1.83 hours) of CD, whereas the mean time to start oral fluids in the DF group was 13.72±3.08 hours. Women in group EF ambulated early, when compared to DF group. Group EF women passed flatus early, when compared to DF group. Similar findings were noted in relation to passage of stools. These differences were statistically significant (Table/Fig 3).

No difference was observed between both the groups with respect to immediate postoperative nausea and vomiting. Group EF patients received lesser intravenous fluids postoperatively, which also facilitated early removal of urinary catheter in group (Table/Fig 3).

Both groups did not display any other complication before discharge.Statistically significant difference was also noted in woman’s satisfaction, in favour of the early feeding protocol.

Discussion

Globally rising trends of caesarean delivery rates have ignited concerns regarding improving postoperative care, which is vital for multiple surgical disciplines. Enhanced Recovery After Surgery (ERAS) society (2019) has recommended evidence-based guidelines for improving quality of postoperative care and safety after CD (14).

Most clinicians believe that maternal satisfaction is based on the psychological response of the patient to life events (15). It is influenced by several factors for example effective management of postoperative intravenous fluids, nausea and vomiting, duration of fasting status (16).

In present study, high level of maternal satisfaction was observed in both the groups, 98.6% in EF group and 80.7% in DF group, respectively. Similar observations were made by Teoh WH et al., who conducted a RCT in Singapore population, in 196 women and reported higher maternal satisfaction (90 versus 60) in EF group as compared to the control group (3). In a study conducted in Pakistan by Arif N et al., 80% of EF group had higher level of maternal satisfaction due to less thirst and hunger as compared to 49% in DF group (17). In another study, 362 pregnant women were randomly assigned to EF (n=183) and DF (n=179) groups, and the maternal satisfaction was significantly greater in EF group (16).

Findings of maternal satisfaction have not been consistently high in the EF group. Izbizky GH et al., and Esra Ozbasli E et al., documented maternal satisfaction in the two groups as equivalent (6),(18). In present study, time for return of bowel sounds, passage of flatus and stool were earlier in the EF group when compared to DF group. Similar findings have been consistently reported by different researchers. In the study by Arif N et al., time for return of bowel sounds in hours was 7.8±0.93 in EF group and 11.75±0.91 in DF group. Mean time for passage of flatus was 12.38±0.66 hours in the EF group versus 15.12±0.54 in DF group (17). Hsu YY et al., reported early return of gastrointestinal function in EF group (19). Jalilian N and Ghadami MR, also reported early return of bowel movement in the EF group compared to DF group. The time to mobilisation was reported as 10.7±7.7 hours and 13.5±5.9 hours in EF and DF groups. They concluded that early oral feeding reduces the time required for return of normal bowel function, without significant increase in incidence of gastrointestinal complications (20).

Early resumption of fluids and food motivated the participants to ambulate early and also led to discontinuation of i.v. earlier than in the DF group. In the present study, the mean requirement for i.v. fluids in EF group was 1.76±0.3 litres and 2.52±0.414 in DF group. Masood SN et al., reported requirement of 1-1.5 L i.v. fluids in the EF group and 3-3.5 L in the DF group. They also compared the time to discontinue i.v. fluids in hours (25.27±8.75 in EF group and 30.24±14.21 in the DF group) (21).

In the present study, participants ambulated early in the EF group as compared to the DF group. This was probably influenced by early discontinuation of intravenous fluids and early removal of urinary catheter in the EF group. Arif N et al., reported only 77% of their participants ambulated within 15 hours in EF group and 65% of participants in their DF group (17). Masood SN et al., reported that 53.8% women in EF group were mobilised within 15 hours of surgery as compared to 27.9% women in the DF group (21).

Early return of bowel sounds and early ambulation aided bowel movement and passage of stool earlier in the EF group. Time taken for bowel movement and passage of stool in EF group was 47.31 hours as compared to 55.15 hrs in DF group. In the randomised control trial by Orji EO et al., 200 women were randomly assigned to EF and DF groups mean time for bowel movement was 58.30±5.91 hours in EF group, when compared to 72.76±4.25 hours in DF group (p-value <0.001) (22). Teoh WH et al., reported in EF group bowel evacuation time as 44.4 hours and 65.6 hours in the DF group (p-value <0.05) (3). Studies by Senanayake H and Nasar AM et al., demonstrated shortened mean time to ambulate and void urine and stool in EF group (23),(24).

In the present study, removal of indwelling foley’s catheter was 11.51±1.43 hours in EF group and 18.09±2.68 hours in the DF group, and this difference was statistically significant. ERAS society emphasised on removal of catheter in those who do not need strict monitoring of urine output (14).

Limitation(s)

The present study focused only on one element of ERAS, namely early feeding. There are other important attributes that also contribute to the overall maternal satisfaction like postoperative pain relief and care of the neonate, which have not been studied. All the study participants included in the study had low risk uncomplicated CD, hence, the results cannot be extrapolated to complicated CD.

Conclusion

The ERAS protocol can be implemented safely in any tertiary care hospital. It is an effective approach to improve the quality of postoperative care after caesarean delivery. The benefits of this strategy also include higher level of patient satisfaction. Once full feeding is established early in the postoperative period, in future, there exists the possibility of setting a trend for earlier discharge from hospital, especially in a resource constrained setting.

Acknowledgement

The author thanks the effort, assistance and co-operation of the Consultants, Residents of Department of Obstetrics and Gynaecology, as well as nurses and healthcare providers of M.V.Jayaram Medical College and Research Hospital.

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DOI and Others

DOI: 10.7860/JCDR/2022/59075.17193

Date of Submission: Jul 16, 2022
Date of Peer Review: Aug 10, 2022
Date of Acceptance: Nov 14, 2022
Date of Publishing: Dec 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 16, 2022
• Manual Googling: Nov 01, 2022
• iThenticate Software: Nov 12, 2022 (10%)

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