A review of peripheral nerve blocks for cesarean delivery analgesia

Abstract

Peripheral nerve blocks have a unique role in postcesarean delivery multimodal analgesia regimens. In this review article, options for peripheral nerve blocks for cesarean delivery analgesia will be reviewed, specifically paravertebral, transversus abdominis plane, quadratus lumborum, iliohypogastric and ilioinguinal, erector spinae, and continuous wound infiltration blocks. Anatomy, existing literature evidence, and specific areas in need of future research will be assessed. Considerations for local anesthetic toxicity, and for informed consent for these modalities in the context of emergency cesarean deliveries, will be presented.

Keywords: QLB; anesthetics, local; cesarean section; ilioinguinal; nerve block; neuroaxial; postoperative analgesia; quadratus lumborum; regional block; trans abdominis plane; wound infiltration; wound infusion.

Conflict of interest statement

Competing interests: None declared.

© American Society of Regional Anesthesia & Pain Medicine 2019. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1

Overview of peripheral nerve blocks for postcesarean delivery pain management. PCEA, patient-controlled epidural analgesia.

Figure 2

Schematic illustration of tissue planes and related anatomy for (A) transversus abdominis plane (TAP) and (B) quadratus lumborum (QL) blocks. QLT, quadratus lumborum transmuscular.

Figure 3

Ultrasound images comparing tissue planes for transversus abdominis plane (TAP) and quadratus lumborum (QL) blocks in non-pregnant patient (A) and immediately postcesarean delivery (B). Note the tissue distortion (flattened-appearing muscular planes) and air artifacts (arrows) that occur after cesarean delivery, which may introduce visualization and technique challenges for abdominal wall nerve blockade in this patient population. *Target for TAP block. **Target for QL block (QL1). ***Target for QL block (QL2). EOM, external oblique muscle; IOM, internal oblique muscle; QL, quadratus lumborum muscle; TA, transversus abdominis muscle.