Bosn l Basic Med Sci 2012, 12 (+).

263-268
Abstract
Te aim ot studv vas to investiate the eect ot postoperative um chevin on the recoverv ot bovel tunction atter cesarean section. Total
+oo vomen delivered bv lover uterine sement section cesarean under local anesthesia (spinal). lliible patients vere randomlv allocated into
tvo roups. a um-chevin roup (n,o) or a control roup (n ,o). Te um-chevin roup participants vho received one stick ot suar-
less um tor one hours, three times dailv immediatelv atter recoverv trom anesthesia and the control roup had the usual postoperative care
until bein dischared. All vomen vere tolloved up reularlv until dischare trom hospital, and recorded the times to the rst bovel sounds
ot normal intestinal sounds, the time to the rst passae ot atus, the time to the rst teelin ot huner, and the time to the rst detecation.
Te operative data, postoperative tolerance ot um chevin, and postoperative complications vere documented. Tere vas no statisticallv
sinicant dierence betveen the tvo roups in terms ot demoraphic characteristics such as ae, bodv mass index, paritv, duration ot surerv,
number ot miscarriaes and curettaes, time to the rst teedin, the amount ot serum intake, and tvpe ot cesarean section. Te mean averae
postoperative interval ot the rst bovel sounds (.+., versus .6.+ hours, p o.o+6), the rst teelin ot huner (++.8 versus +|., hours, p o.o,o),
the rst passae ot atus (.|.8 versus o.o hours, Po.oo.), the rst detecation (o.6 versus 8.| hours, P o.ooo+) vas sinicantlv shorter com-
pared to the control roup. .o+. Association ot Basic Medical Sciences ot lBlH. All rihts reserved
llY WOkDS. um chevin, ileus, cesarean section, postoperative, earlv oral teedin
Chevin ums has stimulatorv eects on
bovel tunction in patients underoin cesarean
section. A randomized controlled trial
larideh Mohsenzadeh ledari
1
, Shanaz Barat
2
, Mouloud Aaani Delavar
3

1
Department of Midwifery, Babol University of Medical Sciences, Ganjafroz street, 47176-47745 Babol, Iran.
2
Fatemezahra Infertility and
Reproductive Health Research Center, Department of Obstetrics and Gynecology, Babol University of Medical Sciences, Ganjafroz street,
47176-47745 Babol, Iran.
3
Fatemezahra Infertility and Reproductive Health Research Center, Department of Midwifery, Babol University
of Medical Sciences, Ganjafroz street, 47176-47745 Babol, Iran.
INTRODUCTION
Cesarean section is the most common surerv amon vom-
en vhich is associated vith central nervous svstem (CNS)
chanes in postoperative, leadin to decreased bovel move-
ments and driven problems amon vomen (+). Postoperative
ileus is dened as transient cessation ot coordinated bovel
motilitv atter surical intervention (.), and is one ot the ma-
or problems ot post-abdominal surerv alon vith delavs
hospital dischare, abdominal pain, abdominal distension,
inabilitv to start oral teedin and, breastteedin, and eventu-
allv increases the cost ot hospital care (). Te pathoenesis
ot postoperative ileus is multitactorial, but it is more common
in cases ot preoperative narcotic and dru interaction and ab-
dominal surerv procedures, especiallv intraoperative bovel
manipulation, and temporarilv contributes to stop peristaltic
(bovel movement), the related mechanism is probablv dvs-
tunction in parasvmpathetic svstem activitv (inhibitorv neu-
rons) (|). Historicallv, protessionals ot vnecolov and obstet-
rics vaited until ut tunction returns allovin oral or entered
teedin, characterized bv svmptoms such as bovel sounds,
rst atus or stool, and teelin ot huner (,). When the rst
passae atus or stool is noted it is not an initial return ot
bovel tunction. Studies have demonstrated that earlv postop-
erative teedin can be sate prior to the return ot atus or stool
(6). Hovever, some investiators reported that earlv teed-
in vas associated vith a hih rate ot intolerance and such
as delaved teedin miht even lead to increased cell break-
dovn, delaved vound healin, elevated risk ot intection and
the need tor more intravenous teedin, and eventuallv addi-
tional costs on healthcare svstem as vell as the tamilv (;, 8).
Chevin um can brin on a teel taint because it stimu-
late the stomach, enhances astric secretion, increases
peristaltic bovel movements and tinallv hastens recoverv
trom ileus (,-+.). lt has also been recentlv considered bv
researchers as a stratev tovard ileus reduction. ln some
* Corresponding author: Mouloud Agajani Delavar
Address: Babol University of Medical Sciences, Ganjafroz
street, Babol, Iran, Post No: 47176-47745
Fax: +98-111-2234702; Tel: +98-111-2199593-5
Email: moloodaghajani@yahoo.com
Submitted 20 April 2012/ Accepted 29 September 2012
Bosn l Basic Med Sci 2012, 12 (+). 266-268
lAklDlH MOHSlNZADlH llDAkl lT Al.. CHlWlNG GUMS HAS STlMUlATOkY llllCTS ON BOWll lUNCTlON
lN PATllNTS UNDlkGOlNG ClSAklAN SlCTlON. A kANDOMlZlD CONTkOlllD TklAl
studies, beneticial ettect ot chevin um has been ap-
proved in the resumption ot bovel tunction (+-+,), but in
some others such as Quah et al., (+6) contradictorv tind-
ins have been achieved tor the eects ot um chevin on
peristaltic movements and diestive svstem stimulation. lt
seems that a necessitv is telt tor more investiation on such
a least-expensive phvsioloical method in stimulatin the
return ot bovel tunction. Teretore, the aim ot the present
studv vas to evaluate the eect ot chevin um on the re-
coverv ot bovel tunction atter cesarean section in vomen.
MATERIALS AND METHODS
Tis studv vas approved bv Babol Universitv ot Medical Sci-
ences tor ethics in medical research. A sinle blind random-
ized controlled clinical trial vas conducted on +oo vomen
candidates tor cesarean section vith local anesthesia (spinal)
in vnecolov vard ot Hospital durin lune .o+o to March
.o++. The nature ot the studv did not allov blindin atter
assinment ot the intervention postoperativelv. Written in-
tormed consent vas obtained trom ++o enrolled vomen. All
enrolled vomen vere allocated usin a computer-enerated
random sequence trom a statistics proram. All cesarean
section vere carried out bv a Gvnecoloic Sureon (an au-
thor) in the mornin. A transverse incision on the uterus
and a Ptannenstiel incision on the abdomen vere pertormed.
Demoraphic intormation on all variables vomen in-
cluded, patients ae, bodv mass index, number ot prenan-
cies, miscarriae and uterine curettaes. lxclusion criteria
vere. vomen vith historv ot dru consumption, especiallv
opioids, vater and electrolvte disturbances, pancreatitis or
peritonitis, historv ot abdominal surerv except cesarean
section, no villinness to cooperate, intra- and sever post-
operative complications, inabilitv to chev um, vithdraval,
diabetes, pre-eclampsia, proloned rupture ot membranes,
hvpothvroidism, and muscular and neuroloical disorders.
The operative data vere recorded, includin the presence
ot severe adhesions, the occurrence ot intraoperative com-
plications, estimated blood loss and duration ot surerv.
Data-collection instruments included the interviev
torm, questionnaires, and subects examination. lor
each ot the studv participants, a questionnaire, desined
based on characteristics and the research obective. The
vomen in the chevin um roup cheved suar-tree
um tor at least one hour, three times dailv trom six
hours atter surerv (atter recoverv trom anesthesia) un-
til bein dischared. Commerciallv available suar-tree
um (Wrilev Companv, Poland) vas used in this studv.
The oral intake ot clear uids and sott toods vas initiated
on postoperative dav. Onlv atter documentation ot bovel
tunction, vhich thev vas determined vith the presence
ot anv tvo ot the tollovin three criteria. (+) bovel sounds,
(.) atus, and () tellin ot huner. ln order to reduce the
eects ot other variables, the postoperative teedin reime
vas standardized tor the all vomen. Around |8 hours tol-
lovin operation, the vomen vere dischared vhen thev
had stable vital sins vith no tebrile morbiditv tor at least .|
hours, abilitv to ambulate and urinate independentlv, deteca-
tion, abilitv to tolerate solid tood and absence ot sever other
post surerv complications. lor post-operative analesia,
+oo m rectal sodium suppositorv diclotenac vas routinelv
iven three times dailv. All vomen vere tolloved up reu-
larlv until dischare trom hospital, and recorded the times
to the rst bovel sounds ot normal intestinal sounds, the
time to the rst passae ot atus, the time to the rst teelin
ot huner, and the time to the rst detecation. Also, postop-
erative tolerance ot um chevin and postoperative com-
plications vas documented. Hovever, anv side eects, and
unresolved postoperative complication presented bv the
vomen durin the postoperative period vere to be recorded.
Betore intervention, +o enrolled vomen vere excluded due
to considered bv sureon to be inappropriate tor this studv.
All analvses vere pertormed vith SPSS (version+6.o).
The data vere analvzed bv t test and chi square. A p val-
ue ot o.o, or less vas considered statisticallv siniticant.
RESULTS
Tere vas no statisticallv sinicant dierence betveen the
tvo roups in terms ot demoraphic characteristics such
as ae, bodv mass index, paritv, duration ot surerv, num-
ber ot miscarriaes and curettaes, time to the rst teedin,
the amount ot serum intake, and tvpe ot cesarean section
(Table +).. ln um-chevin roup, the tirst bovel sounds
vas siniticantlv shorter compared to the control roup
(po.o+6). The tirst detecation vas o.; hours in the um
roup and 8.| hours in the control roup (po.ooo). The
rst passae ot atus vas seen on postoperative hours .|.8
Variables
Gum-chevin
(Mean - SD)
Control
(Mean - SD)
P-value
Ae (vear) 2.9 - 6.+ 28.3-6.2 0.+93
Bodv mass index 30. - +.8 31. - +.1 0.2+6
Duration ot surerv (min) 32.6 - . 30.8 - +.9 0.16
Number ot prenancies 1. - 1.0 2.1 - 1.2 0.16+
Number ot miscarriae 0.3 - 0.3 0.+ - 0.8 0.60
Number ot curettaes 0.1 - 0.2 0.2- 0. 0.291
leedin time (hours) 22.1 - 1. 22. - 3.+ 0.2+8
Te amount ot uid
intake (liter)
2.9 - 0.3 2.9 - 0.3 0.312
Tvpe ot C-section N () N () -
lmerencv 8 (1.6) 6 (+2.9) 0.33
TABLE 1. Participants' characteristics based on the study groups
(n=100)
Bosn l Basic Med Sci 2012, 12 (+). 26-268
lAklDlH MOHSlNZADlH llDAkl lT Al.. CHlWlNG GUMS HAS STlMUlATOkY llllCTS ON BOWll lUNCTlON
lN PATllNTS UNDlkGOlNG ClSAklAN SlCTlON. A kANDOMlZlD CONTkOlllD TklAl
in um chevin roup and on hours o.o in the control
roup respectivelv (po.oo.), and also the tirst teelin ot
huner vere telt on postoperative hours ++.8 in the um-
chevin roup and +|., hours in the control roup (po.o,o).
None ot the participants telt dissatistied vith chevin
um and none vere excluded trom the studv (Table .).
DISCUSSION
Te vomen vere vell toleratin the um and no teelin ot
dissatistaction, and none vere theretore excluded trom the
studv. The studv tindins has shovn reduced time to the
rst bovel sounds, detecation, passae ot atus, and teelin
ot huner tollovin chevin um atter the cesarean section.
ln this studv, the mean time to the rst bovel movement re-
vealed remarkable dierence betveen the tvo roups, vhich
is in accordance vith Dehcheshmeh studv on the eects ot
chevin um atter elective cesarean section on +.o primipa-
rous vomen in Shahrekord in .o++, reportin ;.|-+.;+ hours
and +,.;- .|| hours as the mean time to the tirst bovel
movement in the um and the control roup respectivelv (.,
;, +;), the ndin is also in consistent vith Schuster studv on
the impact ot um chevin atter simoid-colostomv surerv
on | patients in .oo6, in vhich the mean time to the rst
bovel movement vas 6..-,.| hours and 8,.|-..| hours in
the um and the control roup (+o). Nonetheless, in Akhlahi
survev on the eect ot chevin um on the resumption ot
bovel tunction atter cesarean section on +.o patients in
Mashhad in .oo8, the tvo roups vere dierent in terms ot
the teelin ot bovel movement, but not statisticallv sini-
cant, as the mean dierence vas +|.;-6., hours and +6.6-8.|
hours in um-chevin and the control roup respectivelv.
Tis studv is not in areement vith the present research, and
the reason behind such a contradiction mav be due to sam-
plin andor surical conditions (). Other variable examined
in terms ot bovel tunction vas the teelin ot huner vhich
vas hours earlier in the chevin um roup than the other
and vas statisticallv sinicant, this ndin is in consensus
vith Sati results tollovin the caesarean section in .oo6 (+,),
hovever, in Schuster studv, the tvo roups vere dierent on
the teelin ot huner, but not statisticallv sinicant, as the
mean time to the teelin ot huner vas 6.,-+o.| hours and
;..8-+.+ hours in the chevin um and the control roup
respectivelv (+o), such a discrepancv could be ovin to the
small sample size in Schuster studv. ln the present research,
the mean time to the rst detecation displaved sinicant dit-
terence betveen the tvo roups as it happened 8 hours ear-
lier in the um than the control roup, similar to the results
obtained bv Maeboud, Ghatouri, Hiravama, Hocevar and
Abdollahi (+, ., +|, +8, +,). So as, in Maeboud studv on .oo
patients atter elective caesarean section in lvpt in .o+o, the
mean time ot detecation vas .+.+-|.; hours and o.oo-8..
hours earlier in um-chevin and the control roup, and in
Hiravamai and Ghatouri studies, respectivelv on ,o patients
vith upper astrointestinal tract surerv in .oo8 in Tehran
and colorectal surerv on .. patients in .oo6 in lapan, det-
ecation time vas +, hours earlier in um-chevin than the
control in both studies, vhich vas statisticallv meanintul. ln
Abdollah investiation on |6 patients tollovin appendec-
tomv surerv in Goran in .o++, the time to the rst deteca-
tion vas .| hours earlier in the um than the control roup
and vas statisticallv sinicant. Hovever, in a research on
8 patients atter lett colon cancer surerv in lnland in .oo6,
no statistical dierence vas observed in the time to the rst
detecation betveen the um (..-+., hours) and the control
(.,-+., hours) roup (+6), about vhich small sample size
and tvpe ot surerv mav be the reasons tor such a dierence.
Te mean passae ot atus vas the other variable evaluated
on intestinal tunction, happenin, on averae, , hours earlier
in the um than the control roup, this ndin is in consis-
tence vith louba investiation on +o. patients underoin
bladder radical surerv in .oo; in America, in vhich the
time to the rst passae ot atus vas respectivelv ..| and ..,
davs in the um and the control roup, shovin acceleration
ot as passae tollovin chevin um atter bladder surerv
(.o). ln Nove studv in .o+o on |6 patients vith open ap-
pendectomv, the mean time ot as passae vas ... and .o
davs in the um and the control roup (.+). ln Choi survev
on 6o patients in .o++, the mean time to the passae ot a-
tus vas 6o h and |8 hours in um-chevin and the control
roup and statisticallv sinicant (..), vhilst, Quah reported
no remarkable dierence betveen the tvo roups in terms
ot as passae. There is not vet an independent investia-
tion on the exact chevin um mechanism ot action. Hov-
ever, some theories discuss um as a torm ot sham teedin
that chevin resultin in propulsive astrointestinal activitv
throuh cephalic-vaal stimulation (., .|). lt is suested
that cephalic-vaal mechanism bein less eective in vomen
underoin cesarean section under local anesthesia (.,). ln
addition, suar tree chevin um that contains the articial
sveetener sorbitol and other hexitols miht be havin side et-
tects such as bloatin, as, and abdominal cramps. Hovever
there is no reported about the possible eects ot the inre-
dients ot these ums (.6). Moreover, in this studv vas tound
Variables
Gum-chevin
(Mean - SD)
Control
(Mean - SD)
P-value
Te rst bovel sounds (hours) 21.9 - .8 26.1 - 9.3 0.016
Te rst passae ot atus (hours) 2+.8 - 6.+ 30.0 - 9. 0.002
Te rst teelin ot huner (hours) 11.8 - 6.1 1+.3 - . 0.030
Te rst detecation (hours) 30.- 3.9 38.+ - 8.9 0.0001
TABLE 2. Resumption of bowel function following the operation
in both groups (n=100)
Bosn l Basic Med Sci 2012, 12 (+). 268-268
lAklDlH MOHSlNZADlH llDAkl lT Al.. CHlWlNG GUMS HAS STlMUlATOkY llllCTS ON BOWll lUNCTlON
lN PATllNTS UNDlkGOlNG ClSAklAN SlCTlON. A kANDOMlZlD CONTkOlllD TklAl
suar tree chevin um sate and tolerated bv all patients.
Teretore, it is suested that the content ot maxitols in su-
ar-tree chevin ums mav plav a role in the amelioration ot
ileus atter surerv and tuture studies are needed to investiate
probable mechanisms involved in the observed phenomena.
CONCLUSION
The results ot the present studv indicate that chevin is
acceptable and inexpensive phvsioloic method tor de-
creasin the time to the passae ot tlatus, bovel move-
ments, and teelin ot huner in patients underoin ce-
sarean section. lt can be added to post-caesarean care
vithout anv concern on earlv post-operation teedin as
a lov-cost, sate and tolerable treatment in earlv intesti-
nal stimulation to reduce ileus associated complications.
ACKNOWLEDGMENTS
The present studv is a research proect, Contract
No.88.;,.+ and lkCT reistration No. .o+oo8o,,o.N.,
approved bv Babol Universitv ot Medical Sciences,
herebv, the authors vould like to appreciate the uni-
versitv authorities, and Ms. Shokat Ashari, and also
respected personnel ot the surical vard ot kou-
hani Hospital ot Babol tor their sincere cooperation.
DECLARATION OF INTEREST
The authors declare that there is no contlictin interest.
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