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Post-Cesarean Delivery Analgesia and the Role of Peripheral Nerve Blocks: A Review

Feb 6, 2023, 10:12 AM by Beth VanderWielen, MD; Unyime Ituk, MBBS, FCARCSI; Ruth Landau, MD; Pervez Sultan, MBChB, FRCA, MD; and Ashraf Habib, MBBCh, MSc, MHSc, FRCA


Cite as: VanderWielen B, Ituk U, Landau R, Sultan P, Habib A. Post-cesarean delivery analgesia and the role of peripheral nerve blocks: a review. ASRA Pain Medicine News 2022;47.  




Optimizing post-cesarean delivery (CD) analgesia is essential to the quality of postpartum recovery.1,2 Severe acute pain is associated with increased risk of chronic pain and postpartum depression.3 Furthermore, adequate analgesia is associated with improved maternal-neonatal bonding and higher breastfeeding success.4 The Society for Obstetric Anesthesia and Perinatology (SOAP)5 and the PROSPECT guidelines6 recommend a multimodal approach to post-cesarean analgesia. This includes the administration of long-acting neuraxial opioids such as morphine, scheduled non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, and rescue oral opioids for breakthrough pain. SOAP guidelines also recommend consideration of local anesthetic (LA) techniques, including regional nerve blocks, in situations when long acting neuraxial morphine is not used. This article will review the current data on methods to optimize post CD pain. Data at this time suggest peripheral nerve blocks provide analgesic benefit in cases where intrathecal morphine cannot be utilized or as a rescue technique for refractory pain.     

Neuraxial Morphine

Neuraxial morphine is associated with lower pain scores, longer time to first rescue analgesia, reduced postpartum opioid consumption and less sedation following CD, compared to parenteral opioids, though the risk of pruritus and nausea may be higher.7 An analgesic ceiling effect and dose related side-effects with the use of neuraxial morphine have previously been described.8,9 Higher doses of intrathecal morphine (ITM) (>100-250 mcg) are associated with a prolonged time until first analgesia request (by 4.5 hours) with a higher risk of opioid related side-effects such as pruritus and postoperative nausea and vomiting (PONV) when compared with lower doses (50-100 mcg). Therefore a balance between analgesia and side-effects must be considered for each patient when deciding individual neuraxial morphine dosing strategies.9 For epidural administration, a 1-3 mg dose is recommended by SOAP.5,6,10

Multimodal Analgesia

In addition to neuraxial morphine, NSAIDs and acetaminophen should be administered on a scheduled basis,11 starting preoperatively or intraoperatively,12 and should be given concurrently.13 Furthermore, acetaminophen should be administered in a scheduled rather than as needed manner, with preference for sole agents rather than acetaminophen-opioid combination preparations, as these provide comparable analgesia with significant opioid sparing effects.14,15 This regimen avoids the risk of exceeding the maximum recommended dose of acetaminophen and restricts the use of oral opioids to only in the event of breakthrough pain. 

Data at this time suggest peripheral nerve blocks provide analgesic benefit in cases where intrathecal morphine cannot be utilized or as a rescue technique for refractory pain.

In addition to its antiemetic effects, intravenous dexamethasone might provide a useful analgesic effect after CD16 and can be considered as a component of the multimodal analgesic regimen.

Transversus Abdominis Plane Block (TAPB)


The transversus abdominis plane block (TAPB) has been the most investigated regional anesthesia technique in this patient population. Several meta-analyses have concluded that TAPB provides postoperative opioid-sparing and improved analgesia in patients who do not receive ITM. This is not surprising given that TAPB is less effective for treating visceral pain, compared to ITM which treats visceral and somatic components. When ITM is used, additional analgesic benefit from TAPB has not been demonstrated.17-19 TAPB should therefore mostly be considered when long-acting neuraxial opioids are not used, as occurs with CD performed under general anesthesia or if long-acting neuraxial opioids are contraindicated or not available. TAPB may be useful as a rescue technique, such as in cases of severe breakthrough postpartum pain or in women requiring escalating doses of opioids.20 

Local Anesthetic and Dosing

Doses of ≤50 mg bupivacaine equivalents (20 ml 0.25% bupivacaine on each side, for example) are recommended on each side to balance analgesia efficacy with risk of local anesthetic systemic toxicity (LAST).21 The role of liposomal bupivacaine, which provides longer duration of analgesia, shows some promise in the CD setting. A recent study reported that TAPB with liposomal bupivacaine was associated with 52% reduction in postoperative opioid consumption compared with TAPB with immediate-release bupivacaine, when used in the context of multimodal analgesia involving neuraxial morphine with scheduled NSAIDs and acetaminophen.22 However, further studies are needed to corroborate these findings prior to recommending its routine use.


Significantly longer time to request supplemental analgesia by about 6.5 hours and a decrease in opioid consumption by 30% were reported in patients receiving a TAPB with the posterior compared to lateral approach following CD performed under an opioid-free spinal anesthetic.23 This may be explained by broader dermatomal coverage provided by a more posterior technique (Table 1).24 


Table 1: Approaches to the transversus abdominis plane block (TAPB).

TAPB TypeLocal Anesthetic TargetDermatomal Coverage
LateralBetween the IO and TA musclesT10-12*
PosteriorInjection after the TA tapers, within the IO/EO aponeurosis and anterior to QL muscleT9-T12*

*The lateral approach reliably covers T10-T11, with less predictable coverage to T12, while the posterior approach reliably covers T10-T12, with frequent coverage of T9 and occasional coverage to L1.24

TAPB, transversus abdominis plane block; TA, transversus abdominis; IO, internal oblique; EO, external oblique; QL, quadratus lumborum


Quadratus Lumborum Block (QLB)


The quadratus lumborum block (QLB) has gained popularity due to the promise of paravertebral spread and thereby visceral coverage. However, when compared to or in combination with ITM, the QLB does not provide additional analgesic benefit.19,25-28  In the absence of ITM, studies have reported that both the posterior and anterior QLB approach provides superior analgesia in comparison to either a posterior or lateral TAPB approach.29-31 Conversely, a recent network meta-analysis concluded no difference in analgesia when TAPB was compared to QLB.19 Since all QLB approaches (lateral, posterior, and anterior/transmuscular) and TAPB approaches (posterior and lateral) were combined and several indirect comparisons were included, more studies directly comparing the different approaches of QLB vs TAPB are needed to assess if there is a superior technique and approach based on location of local anesthetic deposition. 


There are three common approaches to the QLB including the lateral, posterior, and anterior (Table 2).32 There is limited data on a fourth type which refers to intramuscular injection of local anesthetic into the QLB muscle itself.33 Lower opioid consumption for CD pain with the anterior versus posterior approach was reported in one study,34 while another concluded that combined anterior and posterior blocks provide superior analgesia than either block alone (Table 3). 35 The optimal approach for CD pain remains to be determined.


Table 2: Approaches to the quadratus lumborum block (QLB).

QLB TypeLocal Anesthetic TargetDermatomal Coverage32
LateralBetween the IO and TA musclesT12-L1
PosteriorLumbar interfascial triangle which is posterior to the QL an deep to the erector spinae muscleT4-L1
AnteriorAnterior to the QL muscle at the level of L4 vertebrae (between psoas major muscle and QL muscle)T4-L1

QLB; quadratus lumborum block; TA, transversus abdominis; QL, quadratus lumborum.


Table 3: Summary of the randomized controlled trials for QLB approaches for CD pain.

AuthorBlock ApproachStudy DesignITM (Y/N)Outcomes
Kang et al, 201935


94 participants; all received cesarean epidural at L2-3 with 1.3-1.7 mL of 0.75% bupivacaine; PQLB and AQLB groups, 30 mL/side of 0.2% ropivacaine; PQLB+AQLB group, 15 mL of 0.2% ropivacaine at each point of injection/side; EA group, 6-mL saline solution containing 9 mg.

Ropivacaine (0.15%) and 2 mg morphine via the epidural.

Catheter was given; a PQLB was performed in addition with saline injected as placebo.

NVAS scores (at rest and with movement) and morphine consumption in PQLB + AQLB group significantly lower than those in PQLB or AQLB*;  Total morphine consumption significantly lower in EA than any QLB group.*
Koksal et al, 202134PQLB vs AQLB80 participants; 10-11.5 mg 0.5% hyperbaric bupivacaine; PQLB and AQLB; 20 ml of 0.25% bupivacaine/side.NMorphine consumption and pain scores (at rest and with movement) significantly lower in AQLB vs PQLB group.*
Yoshida et al, 202033iQLB  vs placebo36 participants; spinal anesthesia with 10-11 mg hyperbaric bupivacaine and 15 mcg fentanyl; iQLB 0.4 mL/kg 0.25% ropivacaine injected bilaterally vs placebo saline group.15 mcg spinal fentanyl 

There were no significant differences between the iQLB and placebo groups regarding elapsed time to first postoperative analgesic use.

*P <0.001

ITM, intrathecal morphine; PQLB, posterior quadratus lumborum block; AQLB, anterior quadratus lumborum block; iQLB, intramuscular quadratus lumborum block; EA, epidural analgesia; VAS, visual analog score


Erector Spinae Plane Block (ESPB)

Data regarding the ESPB are encouraging but limited. The block is typically performed at T9 using an in-plane approach under ultrasound guidance. A recent meta-analysis concluded that ESPB may be associated with reduced postoperative opioid consumption compared to control, but the quality of evidence was very low.36 Similar to QLB, the analgesia provided with ESPB may be superior to that provided by TAPB in the absence of neuraxial morphine, but data are limited.37,38

Ilioinguinal-Iliohypogastric Nerve Block (II-IH)

A recent network meta-analysis concluded that the use of the II-IH nerve block was associated with a significant reduction of 24-hr opioid consumption and a decrease in PONV compared to either systemic analgesia alone or a placebo block.39 The authors also reported a reduction in pain scores and a longer time to first request for rescue analgesics. However, the quality of evidence was low due to significant heterogeneity among the included trials. Furthermore, only two of the included trials administered ITM to the study participants. 

Ilioinguinal-TAP Block (i-TAP)

The ilioinguinal-TAP (i-TAP) block is a combination of an II-IH nerve block with a TAP block to address sparing of the L1 dermatome in a significant proportion of TAPBs.40 In a randomized controlled trial comparing the i-TAP block plus ITM to ITM alone as part of a multimodal analgesia strategy in women who underwent CD, opioid consumption and pain scores were lower in the i-TAP plus ITM group.41 Further studies are needed to confirm these findings.

Wound Infiltration

Local anesthetic wound infiltration or infusion through a wound catheter have also been shown to provide opioid sparing effects following CD in women who do not receive ITM.18,42 In the presence of ITM, these techniques do not provide analgesic benefit in the first 24 hours. A recent study, however, reported an almost 50% reduction in median opioid consumption with wound infusion from 24-48hr in women who received a multimodal regimen incorporating ITM, but the study was not powered for this endpoint and the results were not statistically significant.43 Placement of the wound catheter below the fascia is associated with 40% less opioid consumption compared to placement above the fascia.44 A recent network meta-analysis reported comparable analgesia with the use of local anesthetic infiltration/infusion to that provided with TAPB in the absence of ITM.18 

Special Circumstances 

It has previously been determined that up to 15% of patients experience severe acute post-cesarean pain in the first 24 to 48 hours, despite multimodal analgesia including neuraxial long-acting opioids (usually preservative free morphine).3,45 For these specific patients and under special circumstances, enhanced approaches to tailor the intraoperative anesthesia and postoperative analgesia are beneficial.46

Enhanced dosing of ITM (up to 300 mcg) has been shown to be effective in patients predicted to experience severe pain after CD,47 and such dosing requires adherence to SOAP Monitoring Recommendations for respiratory depression,48 with hourly monitoring in the first 12 hours. 

Additional strategies to consider may include neuraxial clonidine, either epidurally (50-100 mcg) or intrathecally (30-60 mcg or 0.5mcg/kg), with benefits including increased duration of surgical block and time to first analgesia rescue, anti-hyperalgesia, and reduced opioid consumption in patients with opioid use disorder.49-52 However, clonidine is associated with increased risk of sedation and it should be noted that there is a Food and Drug Administration (FDA) black box warning against the use of clonidine due to the risk of maternal hypotension. Similarly, dexmedetomidine, given intravenously or intrathecally as off-label use, appears to be an effective analgesic adjuvant,53-55 but may cause maternal bradycardia and sedation, warrants further study, and is not currently FDA-approved for intrathecal use.


ITM as part of a stepwise multimodal analgesia strategy remains the gold standard for post-CD analgesia. In clinical scenarios where ITM is not utilized, regional nerve block techniques (TABP and QLB are the most-well studied) can be a beneficial opioid-sparing analgesic strategy. In the absence of ITM, QLB shows the most promise but due the multiple different possible approaches, further investigation on the optimal technique and LA dose is required before further conclusions can be made. Much remains to be learned about ESPB, II-IH, and i-TAP blocks, and future study is needed to determine how these blocks or combinations of blocks perform against the QLB when ITM cannot be given. Additionally, more data on optimal LA dose, combination of blocks, and the role of liposomal bupivacaine are needed. Enthusiasm for peripheral nerve blocks must be balanced with the current evidence that demonstrates the unequivocal superiority of ITM, therefore the authors recommend prioritizing ITM whenever able in concert with scheduled non-opioid oral analgesics.

Dr. Beth VanderWielen
Beth VanderWielen, MD, is a staff anesthesiologist and clinical adjunct assistant professor in the department of Anesthesia at the University of Wisconsin School of Medicine and Public Health, Gundersen Health System in Madison, WI.

Dr. Unyime Ituk
Unyime Ituk, MBBS, FCARCSI, is the obstetrical anesthesia division chief and clinical associate professor in the department of Anesthesia at the University of Iowa Carver College of Medicine in Iowa City, IA.

Dr. Ruth Landau
Ruth Landau, MD, is the immediate past president of SOAP, a Virginia Apgar professor of anesthesiology, and director of obstetric anesthesia at Columbia University Irving Medical Center in New York, NY.

Disclosure: Dr. Landau serves on the Research Advisory Board of Pacira Pharmaceuticals and serves on the Executive Editorial Board of Regional Anesthesia and Pain Medicine.

Dr. Pervez Sultan
Pervez Sultan, MBChB, FRCA, MD (Res), is an associate professor of anesthesiology at Stanford University School of Medicine in Stanford, CA.

Disclosure: Dr. Sultan is an Arline and Pete Harman Endowed Faculty Scholar of the Stanford Maternal and Child Health Research Institute.

Dr. Ashraf Habib
Ashraf Habib, MBBCh, MSc, MHSc, FRCA, is women’s anesthesia division chief and professor of anesthesiology and obstetrics and gynecology at Duke University Medical Center in Durham, NC.

Disclosure: Dr. Habib has received research support from Haisco USA and Pacira Pharmaceuticals. He is also a consultant for Vertex Pharmaceuticals and has served on the Advisory Board for Heron Therapeutics and MDoloris.


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