Gastrointestinal activation post-elective cesarean birth: Paula method versus standard care

Liebergall M1, Shafir A1, Hochner-Celnikier D1

Research Type


Abstract Category

Anorectal / Bowel Dysfunction

Abstract 784
Non Discussion Abstract
Scientific Non Discussion Abstract Session 37
Bowel Evacuation Dysfunction Clinical Trial Nursing Female
1.Hadassah Hebrew University Medical Center


Hypothesis / aims of study
Caesarean section births are associated with post-operative complications, including poor peristalsis, causing discomfort, pain and in extreme cases, paralytic ileus. Several treatments are known to accelerate post-operative peristalsis such as early drinking and eating, early ambulation, and bowel evacuation treatments (glycerin suppositories and micro enemas). Another effective treatment to advance peristalsis is chewing gum [1]. Since the known methods are not always effective and not suitable for all women undergoing Caesarean delivery, there was a need to find alternative treatments to accelerate peristalsis and promote bowel movements. The method examined in this study is the ''Paula method", the circular muscles exercise method. According to this method, the contracting and releasing of one circular muscle causes other involuntary circular muscles to be activated, including those of the intestinal tract. The effectiveness of the method was reported in a large randomized controlled trial (RCT) that included 240 women with stress incontinence [2].  However, acceleration of gastrointestinal system smooth muscles by the Paula method was not investigated. 
The aim of this study was to examine the effectiveness of the “Paula Method” compared with standard care to women after elective Caesarean delivery. Gastrointestinal (GI) activation is defined as the initial appearance of intestinal sounds, defined as first flatus and first defecation after the surgery.
Study design, materials and methods
This RCT pilot study examined the effectiveness of the “Paula Method” to accelerate gastrointestinal activity in women after elective Caesarean section, compared with standard care. Inclusion criteria were: women aged 18-45, who underwent elective Caesarean section under regional anesthesia. We excluded women with chronic GI illness and those who had general anesthesia. The participants were randomized according to a statistical table into an exercise group and a control group. Women in the exercise group received standard care and performed circular muscle exercises according to the “Paula Method”. The control group was treated with the standard protocol: early drinking of water, early ambulation, and bowel evacuation treatments (glycerin suppositories and micro enemas). Participants, nurses and other healthcare providers were not blinded to group assignment. Nurses were trained in auscultation of bowel sounds in order to ensure inter rater reliability.  Nurses were also taught the Paula method, including practice exercises during a training session and were also provided with written instructional material. Women in the exercise group were instructed to practice 5 minutes of exercise, 6 times a day, while lying on their back. Subjects also received a pamphlet with illustrations and an explanation of the exercises. Women could choose which exercise to perform and how long they performed it.  (See table). 
The primary outcomes were first appearance of bowel sounds, first passage of flatus and first defecation after surgery. In addition, use of analgesia during hospitalization was also recorded.  
Sample size calculation was based on previous data of first passage of flatus, comparing a chewing gum and a control group [1], with 29 women in each group. Another 20% of subjects were added (32 women in each group) in case of complications such as severe bleeding, or use of general anesthesia
Seventy five women were recruited, 11 (14.6%) refused to participate and 64 (85.3%) agreed to participate and were randomized to group. Due to surgical complications, thirty one women in the exercise group and 29 in the control group were analyzed for the first passage of flatus, 25 women for first defecation in the exercise group, as 6 women asked for bowel evacuation, and 28 women in the control group. Both groups were similar in terms of socio-demographic factors. A significant difference was found in time to first passage of flatus in favor of the exercise group (mean 24.07 ± 6.85 hours compared to 39.07 ± 10.37 hours in the control group p>0.0001).  No other statistically significant differences on outcomes were found  between the groups.
Interpretation of results
In this study we examined the efficacy of the “Paula Method” on women  undergoing elective Caesarean delivery on the activation of the gastrointestinal system, compared with standard care. We can conclude that performing “Paula” exercises following elective Caesarean delivery can serve as sham eating. The Enhanced Recovery after Surgery (ERAS) guideline recommended sham feeding or chewing gum for improving postoperative maternal quality and safety [3]
Concluding message
This study added a natural and convenient alternative to standard conservative treatment of accelerating GI activity post cesarean section. Earlier GI activation can alleviate discomfort, pain and paralytic ileus. It is recommended that the effectiveness of “Paula” training to enhance postoperative GI activity be further examined following other abdominal surgeries.
Figure 1 Examples of Paula Method exercises used in the current study
  1. Hochner, H, Tenfelde, S, Abu Ahmad, W, Liebergall-Wischnitzer, M. (2015). Gum chewing and gastrointestinal function following cesarean delivery: a systematic review and meta-analysis. Journal of Clinical Nursing, 24,1795–1804.
  2. Liebergall-Wischnitzer, M , Hochner- Celnikier, D , Lavy, Y , Manor, O Svieky, D , Paltiel, O . (2009) Randomized trial of circular muscle versus pelvic floor exercises for stress urinary incontinence in women. Journal of women's health, 18(3):377-85.
  3. Wilson, R.D., Caughey, A. B., Wood, S.L., Macones, G.A Ian J. Wrench, I.J., Huang, J., Norman, M., Pettersson, K., Fawcett, W.J., Shalabi, M., Metcalfe A., Gramlich, L., Nelson, G. (2018). Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1). American Journal of Obstetrics & Gynecology, 219 (6), 523-522.
Funding None Clinical Trial Yes Registration Number clinical trials website: NCT03761147. RCT Yes Subjects Human Ethics Committee Institutional Review Board (IRB). Institution Name: HADASSAH MEDICAL ORGANIZATION. Helsinki Yes Informed Consent Yes