American Society of Regional Anesthesia and Pain Medicine May 2018 - 26
Truncal Blocks for Cesarean Pain: Filling a Void in Obstetric Pain
Management
CESAREAN SECTION PAIN
Approximately one-third of all neonates in the United States are
delivered by Cesarean section. The most common indications
include elective repeated Cesarean delivery, failure to progress,
malpresentation, or alarming fetal heart rate tracings.1 The most
recent American College of Obstetricians and Gynecologists (ACOG)
committee opinion on optimizing postpartum care published in
2016 cited pain as a considerable challenge for postpartum women,
yet no current standard exists for optimizing post-Cesarean pain
management.2
Although ACOG recommends a postpartum clinic visit, 60% of
patients are estimated to be lost to follow-up; yet, approximately
40% of mothers are reported to have persistent pain at 3 months.2,3
Furthermore, estimates suggest that 10-20% of parturients have
persistent post-Cesarean pain up to a year following delivery that
can be severe enough to interfere with their quality of life on a
near-daily basis.2-4 With such high rates of acute transitioning to
chronic pain in conjunction with poor postdelivery follow-up, a
tremendous gap remains between patient suffering and health care
outreach and delivery.
ACOG recognizes that the postpartum period is stressful and
many women suffer from fatigue, depression, and urinary
incontinence in addition to battling preexisting health issues
or difficult home social situations in the midst of caring for a
new infant.2 These stressors, compounded with a desire to limit
systemic medications for breastfeeding, are possible reasons
why women may leave their postpartum pain untreated. What
remains for discussion is how we as regional anesthesiologists
can intervene to address and
treat the problem of acute
post-Cesarean pain to optimize
patients' quality of life during an
incredibly challenging time and
possibly prevent the transition to
chronic pain extending beyond 3
months. Although techniques such as morphine via epidural and
intrathecal (IT) routes have traditionally been used, the undesired
side-effect profile has created an opportunity for truncal blocks to
gain momentum.
Beth VanderWielen, MD
Regional Anesthesia and Pain
Fellow/Clinical Instructor
University of Wisconsin School of
Medicine and Public Health
Madison, Wisconsin
Rafael Blanco, MBBS, FRCA
Lecturer and Senior Consultant
Anesthetist, FRCA, DEAA
Corniche Hospital
Abu Dhabi, United Arab Emirates
adjuncts, the role of regional anesthesia in improving Cesarean pain
requires additional exploration.
TRANSVERSUS ABDOMINIS PLANE BLOCK
The transversus abdominis plane (TAP) block targets the anterior
rami of spinal nerves, which include the intercostal, subcostal,
iliohypogastric, and ilioinguinal nerves that travel between
the internal oblique (IO) and the transversus abdominis (TA)
muscles (Figure 1). It provides a sensory and motor block from
approximately T10-L1 (Figure 2).7,8 Several approaches have been
described, including the lateral and posterior approach, which
entails deposition of local
anesthetic between the IO and
TA muscles at the midaxillary
line or triangle of petit,
respectively.7
"We must continue to strive for
opioid-minimizing techniques in
post-Cesarean section patients."
INTRATHECAL MORPHINE
Although IT and epidural morphine remain the most popular form
of acute pain control for Cesarean pain, more than 70% of patients
require additional analgesia.1,5 Furthermore, the side-effect
profile should not be underestimated; as many as 87% of patients
experience pruritus and up to 70% experience urinary retention.
Nausea and vomiting have also been well-established side effects,
leading to significant discomfort for a new mother trying to provide
acute infant care.6 Although nonsteroidal anti-inflammatory
drugs and acetaminophen are helpful opioid-sparing multimodal
26
Randomized controlled
trials and meta-analysis literature have reported controversial
outcomes with the traditional lateral TAP technique, demonstrating
no difference in total morphine consumption at 48 hours when
compared with wound infiltration of local anesthetic for postCesarean pain.7,9 When compared to IT morphine, patients receiving
a TAP block experienced higher pain scores on movement, higher
total 24-hour morphine consumption, and less time to first rescue
analgesic, although opioid-related side effects such as nausea,
vomiting, pruritus, and sedation were all higher in the IT morphine
group.10 The results have been corroborated by multiple other
studies.11-13
QUADRATUS LUMBORUM BLOCK
The definition of the quadratus lumborum block (QLB) requires
a nomenclature discussion. It was first described by Blanco14
American Society of Regional Anesthesia and Pain Medicine
2018
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