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 Table of Contents  
Year : 2012  |  Volume : 2  |  Issue : 2  |  Page : 67-68

Multimodal analgesia for cesarean section: Evolving role of transversus abdominis plane block

Department of Anaesthesia, Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan

Date of Web Publication17-Dec-2012

Correspondence Address:
Samina Ismail
Department of Anaesthesia, Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi 74800
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2249-4472.104729

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How to cite this article:
Ismail S. Multimodal analgesia for cesarean section: Evolving role of transversus abdominis plane block. J Obstet Anaesth Crit Care 2012;2:67-8

How to cite this URL:
Ismail S. Multimodal analgesia for cesarean section: Evolving role of transversus abdominis plane block. J Obstet Anaesth Crit Care [serial online] 2012 [cited 2022 Dec 4];2:67-8. Available from: https://www.joacc.com/text.asp?2012/2/2/67/104729

There has been a dramatic rise in the rate of cesarean section (CS) in the past two decade making it the most commonly performed procedure worldwide. [1] CS commonly induces moderate-to-severe pain for 48 hours. [2] Although advances have been made in the understanding of pathophysiology of postoperative pain and development of new analgesics and delivery techniques, many patients still suffer from moderate-to-severe postoperative pain after CS. [3]

CS patients have additional compelling reasons to provide adequate pain relief; therefore the analgesic regimen should provide safe, effective analgesia, with minimal side effects for the mother and baby. A multimodal analgesia is most likely to achieve these goals.

As part of a multimodal analgesic regimen, opioids are required initially to achieve effective analgesia. However, opioids are associated with dose-dependent side-effects including nausea, vomiting, pruritus, sedation, and respiratory depression. Techniques that reduce opioid requirements may be of benefit in this population.

McDonnell et al. demonstrated that the transversus abdominis plane (TAP) block reduces morphine use after abdominal surgery, including cesarean delivery. [4],[5] TAP block is a regional anesthetic technique that blocks the abdominal wall neural afferents by introducing local anesthetic into the neurofascial plane between the internal oblique and transversus abdominis muscles. [4] McDonnell et al. showed that landmark-based TAP block can be used successfully to provide postoperative pain relief after cesarean delivery. [5] Ultrasonography-guided nerve blocks offer the advantage of real-time imaging of the needle trajectory and injectate spread, which may improve both safety and effectiveness of TAP block. [6]

A meta-analysis to study the efficacy of TAP block shows that it reduces the need for postoperative opioid, the time for first request for further analgesia, provides more effective pain relief and reduces opioid-associated side-effects. [7] A recent Cochrane review has shown that women undergoing CS who had local anesthetic infiltration or abdominal nerve block had reduction in the use of postoperative opioids. [8]

However, there are conflicting results of TAP block in studies done on post CS patients. [9],[10],[11] Studies using it as part of multimodal analgesia along with long acting intrathecal opioid, did not find any improved quality of analgesia for post CS patients. [9],[10] Studies comparing intrathecal morphine with TAP block showed superior analgesia with intrathecal morphine but reported more side effects when compared with TAP block group. [12],[13],[14] However, Belavy et al. using TAP block as a part of multimodal analgesia without long acting opioid and using intravenous patient controlled analgesia (IV-PCA) morphine postoperatively, showed improved pain score, higher patient satisfaction and opioid sparing effect and reduced use of antiemetic in women undergoing CS. [11] Although neuraxial techniques using long acting opioid administration, produce effective analgesia, they are associated with frequent incidence of side effects, which reduce overall patient satisfaction. [15] Furthermore, there is risk of delayed maternal respiratory depression due to rostral spread of hydrophilic opioids such as morphine requiring strict monitoring. [16]

In addition, it is not always possible to provide neuraxial opioid due to logistic issues. Developing countries face another challenge of limited supply of opioids, lack of long acting intrathecal preservative free narcotic and expertise for its use.

Therefore TAP block may be a reasonable alternative when intrathecal morphine cannot be used as in CS done under general anesthesia, or when intrathecal opioid are contraindicated, not available or not appropriate for patients. In our observational study on the technique of anesthesia, [17] we determined that general anesthesia is still used in 49% of cases and in another study, we determined that continuous opioid infusion was the most common method of postoperative analgesia after CS in our institution and pethidine was the most common opioid used. [3] One study done in rural health district of South Africa has shown pethidine (69%) as the most common opioid prescribed after CS and intramuscular route was the only route of administration. [18] There are also concerns in regard to the potential for systemically administered lipophilic opioids such as pethidine to transfer to breast milk and produce transient adverse neurobehavioral effects in the neonate. [19] Although IV-PCA using opioid improves patient satisfaction, better pain scores and less need for rescue analgesia when compared with continuous infusion of opioid, [20] it is also associated with opioid-related side-effects and incomplete analgesia. [15]

Given these issues, there is considerable potential for TAP block to comprise an effective component of a multimodal regimen for post CS analgesia. This technique holds considerable promise as a part of multimodal analgesia regimen for post CS analgesia as it is easy to perform, have shown to provide effective analgesia, and no reported complication under ultrasound guided technique.

  References Top

1.Villar J, Valladares E, Wojdyla D, Zavaleta N, Carroli G, Velazco A, et al. Caesarean delivery rates and pregnancy outcomes: The 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006;367:1819-29.  Back to cited text no. 1
2.Bonnet MP, Mignon A, Mazoit JX, Ozier Y, Marret E. Analgesic effect and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: A systemic review. Eur J Pain 2010;14:894-9.  Back to cited text no. 2
3.Ismail S, Shahzad K, Shafiq F. Observational study to assess the effectiveness of postoperative pain of patients undergoing elective cesarean section. J Anaesthesiol Clin Pharmacol 2012;28:36-40.  Back to cited text no. 3
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4.McDonnell JG, O'Donnell B, Curley G, Heffernan A, Power C, Laffey JG. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: A prospective randomized controlled trial. Anesth Analg 2007;104:193-7.  Back to cited text no. 4
5.McDonnell JG, Curley G, Carney J, Benton A, Costello J, Maharaj CH, et al. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: A randomized controlled trial. Anesth Analg 2008;106:186-91.  Back to cited text no. 5
6.Barrington MJ, Ivanusic JJ, Rozen WM, Hebbard P. Spread of injectate after ultrasound-guided subcostal transversus abdominis plane block: A cadaveric study. Anaesthesia 2009;64:745-50.  Back to cited text no. 6
7.Siddiqui MR, Sajid MS, Uncles DR, Baig MK. A meta-analysis on the clinical effectiveness of transverse abdominis plane block. J Clin Anesth 2011;23:7-14.  Back to cited text no. 7
8.Bamigboye AA, Hofmeyr GJ. Local anaesthetic wound infiltration and abdominal nerves block during cesarean section for postoperative pain relief. Cochrane Database Syst Rev 2009;3:CD006954.  Back to cited text no. 8
9.Costello JF, Moore AR, Wieczorek PM, Macarthar AJ, Balki M, Carvalho JC. The transversus abdominis plane block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve analgesia after cesarean delivery. Reg Anesth Pain Med 2009;34:586-9.  Back to cited text no. 9
10.McMorrow RC, Ni Mhuircheartaigh RJ, Ahmed KA, Aslani A, Ng SC, Conrick-Martin I, et al. Comparison of transversus abdominis plane blocks vs. spinal morphine for pain relief after Caesarean section. Br J Anaesth 2011;106:706-12.  Back to cited text no. 10
11.Belavy D, Cowlishaw P J, Howes M, Phillips F. Ultrasound guided transverse Abdominis plane block for analgesia after caesarean delivery. Br J Anaesth 2009;103:726-30.  Back to cited text no. 11
12.Kanazi GE, Aouad MT, Abdallah FW, Khatib MI, Adham AM, Harfoush DW, et al. The analgesic efficacy of subarachnoid morphine in comparison with ultrasound -guided transversus abdominis plane block after cesarean delivery: A randomized controlled trial. Anesth Analg 2010;111:475-81.  Back to cited text no. 12
13.Loane H, Preston R, Douglas MJ, Massey S, Papsdorf M, Tyler J. A randomized controlled trial comparing intrathecal morphine with transversus abdominis plane block for post-cesarean delivery analgesia. Int J Obstet Anesth 2012;21:112-8.  Back to cited text no. 13
14.Kanazi GE, Aouad MT, Abdallah FW, Khatib MI, Adham AM, Harfoush DW, et al. The analgesic efficacy of subarachnoid morphine in comparison with ultrasound-guided transversus abdominis plane block after cesarean delivery: a randomized controlled trial. Anesth Analg 2010;111:475-81.  Back to cited text no. 14
15.Farragher RA, Laffey JG. Postoperative pain management following cesarean section. In: Shorten G, Carr D, Harmon D, et al., eds. Postoperative pain management: An evidence-based guide to practice. 1 st ed. Philadelphia, PA: Saunders Elsevier; 2006. p. 225-38.  Back to cited text no. 15
16.Dahl JB, Jeppesen IS, Jorgensen H, Wetterslev J, Moiniche S. Intraoperative and postoperative analgesic efficacy and adverse effects of intrathecal opioids in patients undergoing cesarean section with spinal anesthesia: A qualitative and quantitative systematic review of randomized controlled trials. Anesthesiology 1999;91:1919-27.  Back to cited text no. 16
17.Ismail S, Shafiq F, Malik A. Technique of anaesthesia for different grades of Caesarean section: Cross sectional study. J Pak Med Assoc 2012;62:363-7.  Back to cited text no. 17
18.Khan MF, Omole OB, Marincowitz GJ. Postoperative analgesia following caesarean deliveries in a rural health district of South Africa. Trop Doct 2009;30:217-21.  Back to cited text no. 18
19.Wittels B, Scott DT, Sinatra RS. Exogenous opioids in human breast milk and acute neonatal neurobehavior: A preliminary study. Anesthesiology 1990;73:864-9.  Back to cited text no. 19
20.Ismail S, Afshan G, Monem A, Ahmed A. Postoperative analgesia following caesarean section: Intravenous patient controlled analgesia versus conventional continuous infusion. J Anesthesiol 2012;2:120-6.  Back to cited text no. 20

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