European Journal of Cardiovascular Medicine

Caesarean section is a common obstetrics surgery with incidence of 21% till today globally.1 Postoperative ileus is one of the expected consequences of any abdominal surgery including Caesarean section. Post operative ileus is an impaired condition of gastrointestinal motility defined as the interval from surgery until the passage of flatus or stool and the tolerance of an oral diet, that should occur within the fourth postoperative day and complicates up to 20% of caesarean delivery.2 It can lead to abdominal distension, vomiting, postoperative pain, discomfort and prolongation of hospital stay thus resulting in significant morbidity.3 Many methods have been advocated to speed bowel recovery after caesarean delivery such as ambulation, early hydration and chewing gum.4Chewing gum acts similar to sham feeding and activates the cephalic vagal pathway which results in both humoral and nervous stimulation of bowel motility. It has been proven to hasten return of gastrointestinal motility in non-obstetric abdominal surgery5

Few studies in the recent past have shown the efficacy of chewing gum in increasing bowel motility in caesarean section patients6,7. Very few studies were done in India so this study was proposed to determine whether chewing gum in immediate postoperative period facilitates early recovery from ileus following caesarean section.

Aim and Objectives: -

Aim: To determine the efficacy of chewing gum on recovery of bowel function following caesarean section

Objective

1. To determine the efficacy of chewing gum on recovery of bowel function following caesarean section.
2. To assess the time interval of first feeling of hunger, time of first passage of flatus, time of first passage of faeces after chewing gum following caesarean section 

This was a hospital based single-blind prospective cohort study carried out at IGMC&RI. After obtaining institutional research & ethics approval, 82 pregnant women who underwent caesarean section both emergency & elective were recruited into the study from September 2023 to November 2023

Inclusive criteria

woman above 18 years of age who underwent caesarean section under spinal                        

Anaesthesia  

• women who are willing to give consent for the study

Exclusive criteria

• General Anaesthesia
• Patients with obstructed labour
• Diabetes
• Hypothyroidism,
• Intra operative complications such as bowel injury,
• History of gastrointestinal surgery, and
• Water and electrolyte disturbances
• Women who are not giving consent

A written informed consent was obtained from all patients at which demographic data, age, parity, education, employment status was collected

All women included in the study were allocated and randomized into one of the two groups using computer generated numbers concealed in a sealed envelope into group A (intervention group) and group B(control group)The women were notified of their  group to which they belong to  in the postoperative period.

Commonly available sugar free orbit chewing gum was used in this study.

Patients in the chewing gum group were given a pellet of sugar free chewing gum 6 hours after the surgery for 3 times daily till the passage of flatus.

They were asked to chew the chewing gum for 30 mins without swallowing. The chewing gums were given at fixed interval to monitor complaints

Patients assigned to control group received standard postoperative care.

The patients were asked to notify the nursing staff at first passage of flatus and time of feeling of hunger. All patients were followed up through discharge 

Statistical Analysis

Sample size was calculated based on previous study.With the latest study done in similar demography as reference, and confidence level    of 95% with margin of error as 5% ,

Taking the mean of the reference group as 30

Mean of the test group as 24.8

Standard deviation 8.4

The mean and standard deviation of first flatus was considered, So the final    sample size is 82 ,41 in each group.

Statistical analysis of the clinical trial was calculated using SPSS version 20. The obtained data was tabulated in a data form & analyzed in SPSS version 20 software for statistical analysis. Continuous variable is summarized as mean (± STD).

Students T test was used for the comparison of continuous variables between the 2 groups. The chi square test was used to check for differences between proportion and to analyze demographic variables.

P ≤0.05 was considered as statistically significant.

The study end point were time to first feeling of hunger, time to passage of flatus & time to first defecation and duration of stay in the hospital & side effects of chewing gum.

82 subjects were recruited for the study. The mean age was 26.78 & 25.92 in the interventional and control group respectively. There was no statistically significant difference in their demographic variables.

The gum chewing group had a statistically significant earlier onset of feeling of hunger than the control group (P= 0.002)

The first passage of flatus was significantly earlier in the gum chewing group than the control (P= 0.001)

The first passage of feces was also earlier in the gum chewing group than control group (P = 0.001).

Majority of subjects stay in the hospital for less than 7 days. (P = 0.08) None of the subjects had side effects to chewing gum.

Group A

Group B

Distribution of the Obstetric score of the Study participants, N=82

More than half of the study participants (57.3%) had undergone Emergency LSCS and the rest 42.7% underwent Elective LSCS

*10-20 hours and >20 hours were grouped for the purpose of analysis

*10-20 hours and >20 hours were grouped for the purpose of analysis

Postoperative ileus (POI) after CD is the most severe type of intestinal dysfunction, causing complete constipation and intolerance to oral intake. It primarily occurs due to non-mechanical damage disrupting the normal motor activity of the gastrointestinal tract. 8Furthermore, many surgeons view POI, regardless of its severity, as an expected physiological response and occasionally a necessary outcome of any open abdominal surgery

The cause of postoperative ileus remains a subject of debate. Following surgery, bowel motility is suppressed due to increased sympathetic activity and higher levels of circulating catecholamines. 9Some suggest that dysfunction of pacemaker cells resulting from bowel manipulation could also contribute to postoperative ileus.10 Additionally, electrolyte imbalances, irritation of the peritoneal or retroperitoneal areas, and the effects of narcotic pain relief may play a role in its development. 11Recent studies have focused on neural and humoral factors, with vasoactive intestinal peptide being identified as directly inhibiting intestinal smooth muscle contraction, with its levels rising after surgery.12 Pain can also trigger the release of substance P, which further inhibits bowel motility. Surgical procedures also suppress the activity of promotive hormones such as gastrin, neurotensin, and pancreatic polypeptide 13

It is crucial to explore strategies aimed at reducing the duration of postoperative ileus. While therapies such as motility agents, early postoperative feeding protocols, and physical therapy have been investigated in clinical trials, they are not commonly utilized due to their limited effectiveness in clinical practice. Currently, surgeons have few options to offer patients aside from reassurance that normal bowel function will eventually resume.

The process of chewing gum, similar to sham feeding which is believed to aid in gastrointestinal recovery, is thought to work by activating the cephalic-vagal pathway, thereby stimulating various neurogenic and hormonal factors that regulate gastrointestinal function.14 Recent randomized controlled trials have investigated the advantages of gum chewing in addressing gastrointestinal issues post colorectal surgery. The findings indicate that gum chewing promotes quicker restoration of bowel function and could be incorporated into Enhanced Recovery After Surgery (ERAS) protocols to facilitate better recovery.8

This research revealed that there were no notable statistical variances in demographic characteristics such as age, education status type of LSCS and parity between the groups of participants who chewed gum and those who did not. Similar findings were reported by Abd El Maeboud et al 15. To ensure consistency in the study, only consultant gynecologists performed all the caesarean sections using the Pfanennstiel incision technique. This standardization was crucial since the proficiency of the surgeon and the extent of bowel manipulation could potentially influence differences among participants.

Our data showed that bowel function after caesarean section was enhanced in gum chewing group. In our patients the time to first feeling of hunger was higher I gum chewing group which is statistically significant (P= 0.002)

The time to passage of flatus and feces was signicantly higher in gum chewing group compared to control group (P= 0.001) These results are similar to RCT study conducted by Altraigey et al., on 372 women and concluded that chewing gum significantly improved intestinal recovery with the passage of feces and flatus16 (P= 0.0001)

Asao et al., conducted a randomized prospective study of gum chewing after laproscopic colectomy for colorectal cancer in 19 patients. The time to the passage of first flatus was 1.1 days earlier in the gum chewing group than in the control group17 (P <0.01).

In a meta-analysis of 17 randomized clinical trials by Li et al., patients in the chewing gum treatment group, compared with the reference group, experienced a significant reduction of 0.31 days for time to first flatus, 0.51 days for time to first bowel movement, 0.72 days for length of hospital stay.18

Shang H et al., in 2008 conducted a RCT trail on chewing gum among 388 patients who underwent caesarean section. Patients in Gum chewing group experienced an earlier onset of both flatus (34.6 ± 12.6 hours versus 39.9 ± 13.5 hours, p < 0.01) and bowel sounds (18.2 ± 9.8 hours versus 23.2 ± 11.9 hours, p < 0.01) compared to those in Control Group. The occurrence of mild ileus symptoms differed between the two groups, with 12% in Group G and 21% in Group C (p < 0.01); however, neither group had any cases of severe ileus. There were no significant disparities in the timing of the first stool passage (67.4 ± 19.4 hours in gum chewing Group versus 68.6 ± 16.4 hours in control Group), lactation initiation (40.0 ± 18.3 hours in Gum chewing Group versus 39.8 ± 19.8 hours in control Group), or hospital discharge 19(4.9 ± 0.9 days in gum chewing Group versus 4.9 ± 1.0 days in control Group)

Kafali et al., conducted a RCT study on influence of gum chewing on post caesarean patients among 150 patients in 2010 and concluded that, In the study group, bowel sounds were detected significantly earlier, with a mean time of 5.9 hours compared to 6.7 hours in the control group (p < 0.01). Similarly, the first passage of flatus postoperatively occurred at 22.4 hours in the gum-chewing group and 31 hours in the control group (p < 0.001). Although the length of hospital stay was shorter in the gum-chewing group (2.1 days) than in the control group (2.3 days), this difference was not statistically significant (p > 0.05). The requirement for postoperative analgesics was comparable between both groups, but the gum-chewing group exhibited a lower need for postoperative antiemetics compared to the control group (p < 0.01) 20

The primary limitation of our study is its small sample size. Consequently, any disparities in bowel function recovery outcomes and complications between the study groups might not be evident.

To gain a deeper understanding of these mechanisms, future studies could investigate levels of catecholamine, vasoactive intestinal peptide, substance P, gastrin, neurotensin, and pancreatic polypeptide in patients who chew gum following gastrointestinal surgery.

Chewing gum significantly improves bowel motility in caesarean patients and can be added to post caesarean care on early post operation feeding as a low cost, safe & tolerable in early intestinal stimulation to reduce ileus associated complications.

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