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					  DOI: 10.1111/j.1471-0528.2007.01591.x
                                                                                                                                General obstetrics

    The effect of early versus delayed postcaesarean
    feeding on women’s satisfaction: a randomised
    controlled trial
    GH Izbizky, L Minig, MA Sebastiani, L Otano
    Division of Obstetrics, Hospital Italiano de Buenos Aires, Potosı, Buenos Aires, Argentina
    Correspondence: Dr GH Izbizky, Division of Obstetrics, Hospital Italiano de Buenos Aires, Potosı 4135 (C1199ACI),
    Buenos Aires, Argentina. Email

    Accepted 13 October 2007.

Objective To evaluate the effect of early versus delayed feeding                      anorexia, abdominal distension, persistent nausea and/or vomiting,
after caesarean section on the woman’s satisfaction.                                  time to the first bowel movement and passage of flatus.
Design Randomised, controlled trial.                                                  Results Two hundred women were recruited, with 103 randomised
                                                                                      to delayed feeding and 97 to early feeding. The woman’s
Setting Tertiary care hospital.
                                                                                      satisfaction (mean VAS ± SD) was similar in both groups; 73 ±
Population Healthy pregnant women were enrolled for the study                         17 mm in the delayed feeding group and 77 ± 13 mm in the early
during antenatal care visits.                                                         feeding group (P = 0.12). A statistically significant difference was
                                                                                      observed in mean postoperative pain: 29 ± 13 mm in the delayed
Methods Uncomplicated singleton pregnancies undergoing
                                                                                      feeding group versus 24 ± 11 mm in the early feeding group
a planned or intrapartum caesarean section performed under
                                                                                      (P = 0.008). No other significant differences in postoperative
regional anaesthesia were randomly assigned to either (1)
                                                                                      variables were recorded, and there were no major postoperative
a ‘delayed feeding’ group who started oral fluids 4 hours after
                                                                                      complications observed in either group.
surgery with diet introduced at 24 hours; or (2) an ‘early
feeding’ group who were offered a regular diet within the first                        Conclusion Early feeding after uncomplicated caesarean in
8 hours.                                                                              low-risk women is equivalent in terms of the woman’s satisfaction
                                                                                      and the reduced perceived pain.
Main outcome measures Primary outcome was the woman’s
satisfaction measured with a visual analogue scale (VAS) before                       Keywords Caesarean section, satisfaction, postoperative early
their hospital discharge. The secondary outcomes were: pain,                          feeding.

Please cite this paper as: Izbizky G, Minig L, Sebastiani M, Otano L. The effect of early versus delayed postcaesarean feeding on women’s satisfaction: a randomised
controlled trial. BJOG 2008;115:332–338.

                                                                                      sive approach. Moreover, some additional benefits have been
                                                                                      reported such as a more rapid return of bowel sounds and
Caesarean section is the most common major hospital surgi-                            regular oral diet and a shorter hospital stay.12,13 Although
cal procedure performed in the industrialised world, account-                         information about the safety of early feeding after caesarean
ing for more than one-fourth of all deliveries in the USA in                          section appears conclusive, the effect of the different post-
20031 and 21% of all deliveries in England in 2001.2 Even                             operative feeding approaches on women’s satisfaction has
higher rates have been reported in Latin America.3,4 An                               not been well evaluated with the only data available being from
increasing number of women are, therefore, being exposed                              one quasi-randomised trial14 and an audit.15 In addition, in
to this procedure.                                                                    2007 Teoh et al. published a randomised trial in which satis-
   Traditionally, women who had a caesarean section had                               faction pertaining to the feeding regimen was measured as
solid food withheld for the first 24 hours in the belief that                          a secondary outcome on a visual analogue scale (VAS).16 The
this would prevent gastrointestinal complications. However,                           aim of the present study was to evaluate the effect of early
several clinical trials5–12 and a systematic reviews13 have                           versus delayed feeding after uncomplicated caesarean section
shown that early feeding is as safe as the traditional progres-                       on the woman’s satisfaction.

332                                       ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
                                                                                          Randomised controlled trial of postcaesarean feeding

Materials and methods                                                           Allocation concealment was achieved by placing the alloca-
Between December 2003 and 2004, 625 women were enrolled                         tion in sequentially numbered, opaque, sealed envelopes. The
for the study during antenatal care visits at the Obstetric                     envelopes were kept by operating room personnel and opened,
Division of Hospital Italiano de Buenos Aires, and those                        once participant data were written on it, after the end of the
who finally underwent a caesarean section were randomised                        caesarean section.
in the immediate postoperative period if they were eligible                        Women were randomly assigned to one of two interven-
(Figure 1). The study protocol and informed consent were                        tions. The ‘delayed feeding’ group started oral fluids 4 hours
approved by the Institutional Review Board of the Hospital.                     after surgery, followed by regular diet at 24 hours. The ‘early
   The inclusion criteria for randomisation were a term sin-                    feeding’ group was offered regular diet within the first 8
gleton pregnancy with a planned or intrapartum uncompli-                        hours. Both groups were offered the same analgesic regimen
cated caesarean section performed under regional anaesthesia.                   (dextropropoxyphene napsylate 98 mg plus dipyrone 400-mg
Exclusion criteria were use of tocolytic drugs, general anaes-                  tablets, 8-hourly), but had the option not to take the medi-
thesia, history of bowel surgery, prenatal diagnosis of fetal                   cation if they did not need it. Analgesic use was reported as
anomaly, maternal disease and intraoperative or immediate                       the percentage of the total prescribed dose that was used.
postoperative major complications. The allocation sequence                         The primary outcome was patient satisfaction before dis-
was generated by a computer random number list in per-                          charge from hospital, measured using a VAS.17,18 A 10-cm-
muted blocks of ten by staff not involved in patient care.                      long scale was used, with adjectival descriptions at the ends

                                                                                              Multiple pregnancy: 15
                                                                           Patients           Magnesium sulphate requirement: 14
                                                                                              Preterm delivery: 53
                                                                                              Diabetes: 3

                                                                           Reject participation

                                                      Accept participation

                                         Caesarean section                Vaginal birth
                                               206                            419

                     Intraoperative exclusion

                                         Final randomisation               Excluded

                               Delayed                    Early
                               feeding                   feeding                  Analysed as
                                 103                       97                 ‘intention to treat’


                               Delayed                    Early                    Analysed
                               feeding                   feeding                ‘per protocol’
                                  99                       101

Figure 1. Study profile.

ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology                             333
 Izbizky et al.

and intermediate positions. Participants were provided with               Table 1. Women’s characteristics, surgical procedures and neonatal
a questionnaire containing the VAS, which was presented                   outcomes according to groups
with a statement explaining what was intended to measure.
This ‘framing’ statement was introduced after initial testing of                                           Delayed         Early feeding
                                                                                                       feeding (n 5 99)      (n 5 101)
the scale yielded a high variability. The variables evaluated as
secondary outcomes were: self-reported pain, time to first                 Maternal age,                  31.9 (Æ5)        32.2 (Æ5)
passage of flatus and bowel movements, incidence of                           mean years (ÆSD)
anorexia, nausea/vomiting and abdominal distension. Pain                  Nulliparity (%)                    52                40
was measured and recorded daily by the woman on a 100-                    Gestational age at delivery,   39.3 (Æ1)        39.3 (Æ1)
mm VAS (0 = minimum pain, 100 = maximum pain)19,20 and                       mean weeks (ÆSD)
was expressed as the mean of the repeated daily measurements              Previous abdominal               48 (48)          54 (54)
                                                                             surgery (%)
for each woman. Anorexia was defined as a lack of appetite or
                                                                          Surgical procedure
reluctance to accept food in the first 24 hours after surgery.             Planned caesarean                64 (64)          69 (68)
Time to first flatus passage and bowel movement was                            section (%)
recorded in hours after the caesarean section, as defined by               Intrapartum caesarean            35 (35)          32 (32)
Patolia et al.8 The women were examined by a staff physician                 section (%)
and an obstetrics/gynaecology resident twice daily. Although              Fasting, mean                  11.6 (Æ4.6)      11.8 (Æ4.6)
they were not told of the woman’s allocation, true blind-                    hours (ÆSD)
                                                                          Surgery length,                36.4 (Æ12)       39.6 (Æ14)
ing was not always possible because of the nature of the
                                                                             mean minimum (ÆSD)
intervention.                                                             Severe abdominal                  4 (4)            8 (8)
   From a previous pilot study, the prior estimate of the var-               adhesions (%)
iance of the VAS satisfaction score in the delayed feeding                Visceral peritoneum              22 (22)          18 (18)
women was 1600. After framing the question, with a clear                     closure (%)
statement of what was intended to measure, the variance                   Parietal peritoneum              31 (31)          36 (36)
was reduced to 250. A difference of 10 mm to each side                       closure (%)
                                                                          Indication for caesarean section as reported by clinicians
between groups was considered clinically relevant according
                                                                          Repeat caesarean                 43 (44)          54 (53)
to this experience. The trial was designed to demonstrate the                section (%)
equivalence between the two groups (defined as <10 mm).                    Malpresentation                   6 (6)            6 (6)
With a power of 90%, a two-sided type I error of 0.05, and                   (including breech) (%)
considering a 10% loss, the sample size was estimated to be 94            Failure to progress              37 (37)          26 (26)
women per group.21,22 The two treatments were considered                     (induction/in labour) (%)
equivalent if the 95% CI of the difference between the means              Presumed fetal                    6 (6)            5 (5)
                                                                             compromise (%)
was within the limits of –10 to +10 and contained the bound
                                                                          Other (%)                         7 (7)           10 (10)
   Normality was checked through graphic methods and the
Shapiro–Wilk test. Differences between continuous variables
were tested for significance by an unpaired t test if normally           The baseline characteristics of women in the two groups were
distributed, and the Wilcoxon rank–sum test otherwise. For               similar (Table 1).
categorical variables, the chi-square test or Fisher’s exact test           Four women in the delayed feeding group received food in
was used. Subgroup analysis by type of caesarean section was             the first eight postoperative hours. No crossover was observed
planned. The primary analysis was based on treatment                     in the opposite direction. Mean satisfaction ± SD was 73 ± 17
received (per protocol), and a secondary ‘intention-to-treat’            mm in the delayed feeding group and 77 ± 13 mm in the early
analysis was performed. For data entry MS Excel (Microsoft               feeding group. The difference was not statistically significant
Corporation, One Microsoft Way, Redmond, WA, USA) was                    (–3.6, 95% CI –7.57 to –0.96, Figure 2). A statistically signifi-
used and STATA version 8.0 (StataCorp., TX, USA) for data                cant difference was observed in the mean pain expressed as
analysis.                                                                VAS: 29 ± 13 mm in the delayed feeding group versus 24 ±
                                                                         11 mm in the early feeding group (P = 0.008, Figure 3). Use
                                                                         of the prescribed analgesia was similar in the two groups.
                                                                         (70 versus 71%, P = 0.48). There were no significant differ-
During the study period, 625 women were enrolled for the study           ences in other postoperative variables recorded, including
antenatally. Two hundred were randomised immediately                     hospital stay (Table 2).
following their caesarean section: 103 were assigned to the                 Subgroup analysis by type of caesarean section showed that
delayed feeding group and 97 to early feeding group (Figure 1).          the early feeding group had a higher satisfaction level than the

334                               ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
                                                                                     Randomised controlled trial of postcaesarean feeding

                                                                                             Margin of equivalence

                                                                                             Overall–3.6 (95% CI –7.57 to 0.96)

                                                                                             Elective caesarean section –6.4
                                                                                             (CI 95% –11.7 to –1.1)

                                                                                             Intrapartum caesarean section
                                                                                             2.4 (CI 95% –4.9 to 9.7)

                                           –10         –5         0           5         10
                      Absolute difference of the mean (VAS in mm) early versus delayed feeding groups

Figure 2. Mean satisfaction according to treatment received. The confidence interval comparison approach is illustrated, in which equivalence
is established when the bounds of the two-sided 95% CI lies within the equivalence zone. Top, margin of equivalence established according to previous
experience. Middle, equivalence is established for the absolute difference (mm VAS) between early feeding and delayed feeding groups. Bottom,
subgroup analysis shows that in the planned caesarean section group the confidence interval covers at least some points that lie outside the
equivalence range, so that differences of potential clinical importance remain a real possibility and equivalence cannot safely be concluded.

late feeding group when they undergo planned caesarean section               sional hernia, and a second woman was readmitted due to
(absolute difference –6.4, 95% CI –11.7 to 1.1), but no differ-              appendicitis on the 15th postoperative day.
ence in the experience of pain. Conversely, in the emergency                    The intention-to-treat analysis showed a small but statis-
intrapartum caesarean section group, in those who had early                  tically significant difference in the woman’s satisfaction in
feeding there was no difference in satisfaction compared                     favour of early feeding group (difference –4.29, 95% CI
with the late feeding group but significantly less pain. (Table 3,            –8.55 to –0.04). This did not, however, reach the ten points
Figure 2).                                                                   that was defined a priori as clinically relevant. The rest of
   No major postoperative complications were observed prior                  the variables showed similar results to the per protocol
to discharge in either group. In the early feeding group, one                analysis.
obese woman with three previous abdominal operations and
a midline incision was readmitted on tenth day with an inci-
                                                                               Table 2. Trial outcomes

                                                                                                            Delayed         Early         P
                   Delayed                           Early                                                  feeding        feeding

                                                                                                            (n 5 99)      (n 5101)

                                                                               Satisfaction level,          73 (Æ17)      77 (Æ13)     0.12*
                                                                                 mean minimum (ÆSD)

                                                                               Pain, mean                   29 (Æ13)      24 (Æ11)     0.008*
                                                                                 minimum (ÆSD)
                                                                               Time to bowel                15 (Æ11)      12 (Æ11)     0.50**

                                                                                 movement, mean
                                                                                 hours (ÆSD)
                                                                               Time to passage              23 (Æ12)      22 (Æ14)     0.72**

                                                                                 of flatus, mean
                                                                                 hours (ÆSD)
                                                                               Hospital stay,              2.5 (Æ0.5)    2.4 (Æ0.5)    0.16**

                                                                                 mean days (ÆSD)
  Graphs by per protocol                                                       Abdominal                    16 (17)       16 (16)      0.95***
                                                                                 distension (%)
Figure 3. Box plot showing mean pain perception (mm VAS) according
to treatment received. The line inside the box represents the median           * Wilcoxon rank–sum test.
of the distribution. The extremes of that box are the 25th and 75th            ** t test.
percentile. The extremities of the whiskers are the minimum and
                                                                               ***Chi-square test.
maximum values of the data.

ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology                                   335
 Izbizky et al.

 Table 3. Trial outcomes stratified by type of caesarean section             clinical endpoints but also incorporate individuals’ preferen-
 (planned versus intrapartum)                                               ces in order to offer a more individually oriented outcome. In
                                                                            this context, the definition of a ‘clinically significant benefit’ is
                            Delayed          Early           P              a matter of a woman’s personal judgement as well as that of
                            feeding         feeding
                            (n 5 99)       (n 5 101)
                                                                               Caesarean section rates have been rising progressively dur-
 Satisfaction level, mean mm (6SD)                                          ing recent decades all over the world. Many reasons have been
 Planned caesarean        71.5 (13)        78.0 (17)      0.01*             described for the increasing rate, including women’s choice.20
    section (n 5 133)                                                       Facilities and human resources necessary for perinatal care
 Intrapartum caesarean    76.1 (14)        73.8 (15)      0.51*             could be significantly influenced by this trend, in addition
    section (n 5 67)                                                        to healthcare costs. It is important, therefore, to try and
 Pain, mean mm (6SD)
                                                                            reduce morbidity and increase satisfaction rates from this
 Planned caesarean        27.3 (614)       24.5 (611)     0.22*
    section (n 5 133)
                                                                            common procedure. Teoh et al.16 randomised 196 women
 Intrapartum caesarean    30.8 (611)       22.9 (611)     0.005*            undergoing caesarean section under spinal anaesthesia, to
    section (n 5 67)                                                        compare the incidence of ileus in early and late feeding
                                                                            groups. As a secondary outcome, they measured maternal
 *Wilcoxon rank–sum test.                                                   satisfaction. Although they used a slightly different outcome
                                                                            measurement from ours, they found a higher rate of satis-
                                                                            faction in the early-fed group (90 versus 60 on the VAS scale
                                                                            P < 0.001). They also reported a very low incidence of ileus
                                                                               The strengths of this trial are the noninferiority design, the
This study shows that the satisfaction rates obtained following             comparison of two active policies,21,22 the high acceptance
early feeding after caesarean section are equivalent to those               rate (which minimised selection bias) and the minimal cross-
obtained following delayed feeding. However, those in the                   over between the study branches. To focus only on variables
early feeding group reported lower levels of postoperative                  of physical discomfort is a limitation of this study. Some other
pain, especially when the caesarean section was conducted                   attributes of woman’s satisfaction would deserve evalua-
as an emergency. To our knowledge this is the first rando-                   tion in further trials. Another limitation is the external
mised control equivalence trial to evaluate the impact of                   validity of our findings because our participants may repre-
postpartum medical care recommendations on women’s sat-                     sent a limited socio-economic and cultural population. This
isfaction and perceptions as a primary outcome.                             trial was performed on low-risk, middle-income, educated
   We are aware that satisfaction is a complex and multidi-                 women.
mensional psychological response to life events.23 Although                    The primary estimate of equivalence results from a per
there is no such thing as a single index of satisfaction, the               protocol analysis; however, the ‘intention-to-treat’ analysis
approach used in this trial has been previously validated.                  showed a small but statistical significant difference in favour
Several studies have assessed satisfaction using VAS16,24,25                of early feeding. Our rationale for using a per protocol analysis
and these have also been adopted in quality-of-life instru-                 was that in a comparative trial, where the aim is to decide if
ments.18 Health professionals are increasingly encouraged to                two treatments are different, an intention-to-treat analysis is
involve women in treatment decisions, recognising them as                   generally conservative: the inclusion of protocol violators and
experts with a unique knowledge of their own health and their               withdrawals will tend to make the results from the two treat-
preferences for treatments,26 and recent evidence supports                  ment groups more similar. However, for an equivalence trial
this view.27,28 Although women may wish to be more involved                 this effect is no longer conservative: any blurring of the dif-
in the decisions concerning their obstetric interventions,                  ference between the treatment groups will increase the chance
information is lacking on the experiences and perceptions                   of declaring equivalence.
concerning postoperative caesarean birth care.                                 This trial shows that a programme of early feeding after
   This clinical trial places the focus upon equivalence                    a caesarean delivery in low-risk women is clinically equivalent
between the randomised groups. The next step is to determine                in terms of women satisfaction, is as safe as the traditional
whether the observed results are clinically relevant. The inter-            approach and has beneficial effects on women’s perceived
pretation of ‘satisfaction’ or ‘quality-of-life’ scores is not              pain. These findings add to the already robust literature on
always straightforward, and it is not easy to identify a single             the safety and benefits of early feeding after uncomplicated
value that will serve as a clinically relevant measurement.                 caesarean section. We believe that there is now enough
However, it is important that in assessing the benefits of                   evidence for clinicians worldwide to safely implement early
healthcare interventions, researchers should not only include               feeding following caesarean section.29

336                                  ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
                                                                                         Randomised controlled trial of postcaesarean feeding

Funding                                                                          12 Kovavisarach E, Atthakorn M. Early versus delayed oral feeding after
                                                                                    cesarean delivery. Int J Gynaecol Obstet 2005;90:31–4.
This trial was supported with the Division’s own funds for                       13 Mangesi L, Hofmeyr GJ. Early compared with delayed oral fluids and
research.                                                                           food after caesarean section. Cochrane Database Syst Rev 2002:
                                                                                 14 Soriano D, Dulitzki M, Keidar N, Barkai G, Mashiach S, Seidman DS.
Acknowledgements                                                                    Early oral feeding after cesarean delivery. Obstet Gynecol 1996;87:
The authors thank the effort of the Residents of Obstetrics                                           ´
                                                                                 15 Benhamou D, Tecsy M, Parry N, Mercier FJ, Burg C. Obstetrical and
and Gynecology, Department of Nurses and labour and deliv-                          pediatric anesthesia audit of an early feeding program after cesarean
ery room personnel of the Hospital Italiano in the execution                        delivery: patient wellbeing is increased. Can J Anaesth 2002;49:
of this trial. j                                                                 16 Teoh W, Shah M, Mah C. A randomised controlled trial on beneficial
                                                                                    effects of early feeding post-Caesarean delivery under regional anaes-
                                                                                    thesia. Singapore Med J 2007;48:152–7.
                                                                                 17 Robinson PN, Salmon P, Yentis SM. Maternal satisfaction. Int J Obstet
 1 Hamilton BE, Martin JA, Sutton PD. Births: Preliminary Data for 2003.            Anesth 1998;7:32–7.
   National Vital Statistics Reports; Vol. 53. Hyattsville, Maryland: National   18 The EuroQol Group. EuroQol-a new facility for the measurement of
   Center for Health Statistics, 2004.                                              health-related quality of life. Health Policy 1990;16:199–208.
 2 Thomas J, Paranjothy S; Royal College of Obstetricians and Gynaecol-          19 Huskisson EC. Measurement of pain. Lancet 1972;2:1127–31.
   ogists Clinical Effectiveness Support Unit. National Sentinel Caesarean       20 Minkoff H, Chervenak FA. Elective primary cesarean delivery. N Engl J
   Section Audit Report. RCOG Press. 2001. [              Med. 2003;348:946–50.
   public/pdf/nscs_audit.pdf] Accessed 1 July 2007.                              21 Jones B, Jarvis P, Lewis JA, Ebbutt AF. Trials to assess equivalence: the
 3 Belizan JM, Althabe F, Barros FC, Alexander S. Rates and implications            importance of rigorous methods. BMJ 1996;313:36–9.
   of caesarean sections in Latin America: ecological study. BMJ 1999;           22 Siegel JP. Equivalence and noninferiority trials. Am Heart J 2000;
   319:1397–402.                                                                    139(Suppl):S167–70.
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   WHO 2005 global survey on maternal and perinatal health research                 review and analysis. Eval Program Plann 1983;6:185–210.
   group. Cesarean delivery rates and pregnancy outcomes: the 2005               24 Swart M, Sewell J, Thomas D. Intrathecal morphine for caesarean
   WHO Global survey on maternal and perinatal health in Latin America.             section: an assessment of pain relief, satisfaction and side effects.
   Lancet 2006;367:1819–29.                                                         Anaesthesia 1997;52:373–7.
 5 Burrows WR, Gingo AJ, Rose SM, Zwick SI, Kosty DL, Dierker LJ, et al.         25 Murphy JD, Henderson K, Bowden MI, Lewis M, Cooper GM. Bupiva-
   Safety and efficacy of early post operative solid food consumption after          caine versus bupivacaine and fentanyl for epidural analgesia: effect on
   caesarean section. J Reprod Med 1995;40:463–7.                                   maternal satisfaction. BMJ 1991;302:564–7.
 6 Kramer RL, Van Someren JK, Qualls CR, Curet LB. Postoperative man-            26 Charles C, Gafni A, Whelan T. Decision-making in the physician-patient
   agement of cesarean patients: the effect of immediate feeding on the             encounter: revisiting the shared treatment decision-making model. Soc
   incidence of ileus. Obstet Gynecol 1996;88:29–32.                                Sci Med 1999;49:651–61.
 7 Hilliard R, Patolia DS, Toy EC, Baker B. Early feeding after cesarean         27 Montgomery AA, Emmett CL, Fahey T, Jones C, Ricketts I, Patel RR,
   delivery. Obstet Gynecol 2000;95(4 Suppl):44S.                                   et al. Two decision aids for mode of delivery among women with pre-
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                                                                   Journal club
 It has been a strongly ingrained part of the hospital doctor’s ritual to listen for bowel sounds in the immediate postoperative
 days following any abdominal surgery. The thought of giving women food on the same day as their caesarean irrespective of
 whether bowel sounds are present or not will horrify many traditionalists. But there is now increasing evidence that early
 feeding is not only safe but also may actually improve outcomes. This randomised trial from Brazil adds further weight to that
 argument. Although the two regimens were equivalent in terms of maternal satisfaction, there were some secondary beneficial

ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology                                          337
 Izbizky et al.

 Discussion points
 1 Background: In your hospital, how long is the average woman starved preoperatively for a routine caesarean? What effect
   does perioperative starving have on maternal and fetal/neonatal health? What are the potential risks of early postoperative
   feeding of women who have had caesarean sections?
 2 Technical: What were the two regimens compared in this study? Would you have chosen the same two regimens to
   compare? The researchers chose the women’s satisfaction at their main outcome: do you think that this is the most
   important question? What is an equivalence trial? Do you think that its use was appropriate in this study?
 3 Clinical practice: What is the current practice in your hospital regarding restarting fluids and diet after a caesarean? Do you
   know of any national or local recommendations? Do you think that the evidence is now strong enough for you to give
   routine early feeding?
 4 Hypothetical: Do you think that day case caesareans will ever be possible? What would be the advantages and what are the
   obstacles in the way of achieving this?

 Correspondence: Dr A Weeks, School of Reproductive and Developmental Medicine, University of Liverpool, Crown Street,
                                                               Liverpool L8 7SS, UK. Email j

338                             ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology

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