Take-away message

• Analgesia post-caesarean section (CS) is of global importance, as both the most frequently performed surgical procedure, and one that is commonly associated with significant pain, impacting maternal experience.
• Fascial blocks, such as the transversus abdominis plane (TAP) and quadratus lumborum block (QLB), have been advocated for use in reducing post-CS pain. This network meta-analysis confirms the equivalent benefit of either block in improving post-operative pain in the absence of using intrathecal morphine.
• Although the QLB is advocated for its potential to reduce both somatic and visceral pain, unlike the TAP block, comparing studies investigating either block did not reveal any significant benefit of TAP over QLB.
• No analgesic benefit was found for either when intrathecal morphine is used (although TAP block may be associated with lower incidence of nausea, vomiting & sedation, in the presence of IT morphine).
• As is common to many meta-analyses, these conclusions are somewhat undermined by the moderate-to-low levels of evidence in the included studies.

summary

• K El-Boghdadly, N Desai, S Halpern, L Blake, P M Odor, S Bampoe, B Carvalho, and P Sultan.
• Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.
• Anaesthesia. 2021 Mar 1; 76 (3): 393-403.

AbstractCaesarean delivery is the most commonly performed inpatient surgical procedure globally. Pain after caesarean delivery is moderate to severe if not adequately treated, and is a primary anaesthetic concern for patients. Transversus abdominis plane and quadratus lumborum blocks are fascial plane blocks that have the potential to improve analgesia following caesarean delivery. Although proponents of the quadratus lumborum block suggest that this technique may provide better analgesia compared with transversus abdominis plane block, there are limited data directly comparing these two techniques. We, therefore, performed a systematic review and network meta-analysis to compare transversus abdominis plane and quadratus lumborum block approaches, seeking randomised controlled trials comparing both techniques to each other, or to control, with or without intrathecal morphine. In all, 31 trials with 2188 patients were included and our primary outcome, the cumulative intravenous morphine equivalent consumption at 24 h, was reported in 12 trials. In the absence of intrathecal morphine, transversus abdominis plane and quadratus lumborum blocks were equivalent, and both were superior to control (moderate-quality evidence). In the presence of intrathecal morphine, no differences were found between control, transversus abdominis plane and quadratus lumborum blocks (moderate-quality evidence). Similar results were found for resting and active pain scores at 4-6 h, 8-12 h, 24 h and 36 h, although quadratus lumborum block was associated with lower pain scores at 36 h when compared with transversus abdominis plane block (very low-quality evidence). However, transversus abdominis plane block was associated with a reduced incidence of postoperative nausea and vomiting (moderate-quality evidence) and sedation when compared with inactive control following intrathecal morphine administration (low-quality evidence). There are insufficient data to draw definitive conclusions, but transversus abdominis plane and quadratus lumborum block appear to be superior to control in the absence of intrathecal morphine, but provide limited additional benefit over inactive control when intrathecal morphine is also used.© 2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.

This article appears in the collection: Obstetrics.

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