Abdominal nerve blockade for postoperative analgesia after caesarean section. Comparison of the effectiveness of bilateral ilioinguinal nerve block and wound infiltration for postoperative analgesia after caesarean section. Wound infiltration of local anaesthetic after lower segment caesarean section. Combined spinal epidural anaesthesia for caesarean section: a randomised comparison of Oxford, lateral and sitting positions. Postoperative analgesia for Caesarean section using epidural methadone. Iliohypogastric-ilioinguinal peripheral nerve block for post-Cesarean delivery analgesia decreases morphine use but not opioid-related side effects. Clinical study on labor pain relief using the combined spinal-epidural analgesia and inhaling nitrous oxide. [Ilioinguinal nerve blockade with or without epinephrine for analgesia after caesarean section]. Spinal or epidural anaesthesia for elective caesarean section? A Swedish experience.
A prospective study of blocking T10-L1 with local anaesthetic, bilaterally in 30 patients undergoing caesarean section under general anaesthesia has been shown to provide effective postoperative analgesia thus requiring significantly less narcotics (mean 66.6 mg of pethidine) compared to the 30 patients in the control group (mean 163 mg of pethidine). A cocktail of 0.5% of bupivacaine with adrenaline and xylocaine 1% produced analgesia for the duration ranging from 8 to 12 hours (mean 8.4 hours). Patients with abdominal field block were awake, alert and comfortable during the immediate postoperative period. They were pain-free sufficiently to put the babies to the breast early and frequently. We have studied the effects of bilateral ilioinguinal nerve block and wound infiltration with 0.5% bupivacaine on postoperative pain and analgesic requirements in 62 patients undergoing Caesarean section under general anaesthesia. A control group received no local anaesthetic supplementation. Both ilioinguinal block and wound infiltration reduced significantly the pain scores and analgesic requirements in the immediate postoperative period (P < 0.05). The differences in pain scores and analgesic requirements between the study groups were not statistically significant (P > 0.05). The analgesic efficacy of subcutaneous wound infiltration with 20 ml of 0.5% bupivacaine after elective lower segment section Caesarean section was studied in 28 patients in a double-blind randomised controlled manner using a patient-controlled analgesia system. The mean 24-hour morphine consumption of the placebo group and the bupivacaine group was similar (76 mg and 68 mg respectively). Analysis of the cumulative hourly morphine consumption failed to show any statistically significant differences between the groups. However, on a weight-adjusted basis statistically significant differences in morphine consumption were demonstrated, although these may not be clinically important. Subjective experiences of pain, nausea and drowsiness assessed by linear analogue scoring were similar in both groups. Maternal position during induction of intrathecal anaesthesia for caesarean section influences block height and haemodynamic stability. In a randomised study of 90 women presenting for elective caesarean section using combined spinal-epidural anaesthesia, three positions were compared--the Oxford position (group O), the right lateral to supine wedged (group R) and the sitting to supine wedged (group S). Hyperbaric bupivacaine 12.5 mg with fentanyl 12.5 microg was injected intrathecally using a needle-through-needle CSE technique. Intravenous ephedrine 6 mg was given every minute that systolic blood pressure fell below 80% of baseline. Time required for block height to reach T5 as assessed by light touch, was similar in the three groups. There were no significant differences in blood pressure although ephedrine requirements were less in group R. There were no significant differences in the incidence of maternal nausea and vomiting or in neonatal outcome as assessed by Apgar scores and umbilical cord blood gas analysis. Although the study failed to show any significant differences in block height between the groups, no women in group O had a block above T2 compared with three in group R and three in group S. A prospective randomised double blind study was carried out to compare the use of epidural methadone, morphine and bupivacaine for pain relief after Caesarean section. The results indicate that methadone is the most effective agent with few side effects. Subsequently this method was used routinely for postoperative analgesia in all patients undergoing Caesarean section. A retrospective study of 178 patients having this method of analgesia was carried out and indicated that epidural methadone is an effective and safe method of postoperative pain relief. To examine if ilioinguinal-iliohypogastric nerve block could reduce the need for post-Cesarean delivery morphine analgesia and thus reduce the incidence of opioid related adverse-effects.
                A multi-level technique for performing the nerve block with bupivacaine was developed and then utilized in this two-part study. Part one was a retrospective assessment of Cesarean delivery patients with and without ilioinguinal-iliohypogastric blocks to determine if the technique reduced patient controlled analgesia morphine use and thus would warrant further study. The second phase was a randomized double-blind placebo-controlled trial to compare post-Cesarean morphine use and the appearance of opioid-related side effects between the anesthetic and placebo-injected groups.
                Both phases demonstrated that our method of ilioinguinal-iliohypogastric nerve block significantly reduced the amount of iv morphine used by patients during the 24 hr following Cesarean delivery. In the retrospective assessment, morphine use was 49 +/- 30 mg in the block group vs 79 +/- 25 mg in the no block group (P = 0.0063). For the prospective trial, patients who received nerve blocks with bupivacaine had a similar result, self-administering 48 +/- 27 mg of morphine over 24 hr compared to 67 +/- 28 mg administered by patients who received infiltrations of saline. However, despite the significant decrease in morphine use, there was no reduction in opioid-related adverse effects: the incidences of nausea were 41% and 46% (P = 0.70) and for itching were 79% and 63% (P = 0.25) in the placebo and nerve block groups, respectively.
                A multi-level ilioinguinal-iliohypogastric nerve block technique can reduce the amount of systemic morphine required to control post-Cesarean delivery pain but this reduction was not associated with a reduction of opioid related adverse effects in our study group. To study the pain relief effectiveness of the combined spinal-epidural analgesia (CSEA) and the inhalation of nitrous oxide, and the influences on the mothers and infants.
                The 300 cases of pregnant women were randomly divided into 3 groups: CSEA group, nitrous oxide group and control group. The nitrous oxide group was that pregnant women inhaled nitrous oxide premixed with oxygen (50%:50%), the pregnant women of the CSEA group were injected fentanyl and bupivacaine in the subarachnoid and epidural space, analgesic was not used in the control group. The degree of labor pain, duration of the labor, way of delivery, bleeding volume, rate of anoxia of newborn, blood gas analysis to maternal radius artery and fetal umbilical blood among 3 groups were observed.
                The effect for analgesia labor of the CSEA group was much better than that of the nitrous oxide group (P < 0.01). In the first stage of labor and total stage of labor, the CSEA group was shorter than the others (P < 0.05), but there was no difference between the nitrous oxide group and the control group (P > 0.05). In the second stage of labor, the 3 groups were alike to each other. The bleeding volume of caesarean section (373 +/- 77) ml in the nitrous oxide group was much more than the other 2 groups, there was no difference between the CSEA group (259 +/- 78) ml and the control group (239 +/- 89) ml. The rate of obstetric forceps of CSEA group was higher than the control group (P < 0.01), and the rate of caesarean section of the nitrous oxide group was much higher than the CSEA group. The blood gas analysis to maternal radius artery and fetal umbilical blood and the rate of anoxia of newborn of 3 groups revealed no significant difference.
                The effectiveness of the combined spinal-epidural analgesia CSEA for analgesia labor is confirmed and has rarely side-effect, and it can be the first choice, and the inhalation of nitrous oxide can safely provide effective labor analgesia, too. The analgesic effect of bilateral ilioinguinal nerve blockade with or without epinephrine after caesarean section with Pfannenstiel incision was investigated in 36 ASA class 1-2 parturients. They were randomly classified into 3 groups of 12 each. Before the patients were extubated from standard general anesthesia, bilateral ilioinguinal nerve blockade was performed. Group A patients were the control group. Group B patients received 0.375% plain marcaine 10 mL to each side. Group C patients received 0.375% plain marcaine with 1:200000 epinephrine 10 mL to each side. The pain scores and requirement for post operative analgesia of group B and C were compared with the control group A. The pain scores of group B and C were decreased 30% and 37% respectively during the first eight hours after operation. However, group C patients had lower pain scores during the first day after operation. There was an increased time from anesthesia to the first injection of pethidine in group B and C when compared with group A (4.57 +/- 2.94, 4.38 +/- 2.72 and 1.8 +/- 0.9 hr, respectively). However, no significant difference between group B and C. The total pethidine requirement were decreased in group B and C although the mean pethidine dose was not statistically significant. The results suggest that bilateral ilioinguinal nerve blockade improve the quality of postoperative analgesia. The adding epinephrine can prolong the duration of nerve blockade. Ninety seven women undergoing elective lower segment caesarean section were randomly divided into two groups, group 1 received spinal anaesthesia with hyperbaric bupivacaine and group 2 received mepivacaine 20 mg/ml with adrenaline 5 microg/ml via an epidural catheter. All patients were given a preload of Ringer acetate and Macrodex prior to onset of anaesthesia. Ephedrine 5 mg was given if the systolic blood pressure fell below 100 mmHg. There was a small (<30%) but significant (P<0.01) fall in blood pressure in both groups of women. Six women in the epidural group required supplemental analgesics during the operation compared to only 1 patient in the spinal group (P<0.01). Muscle relaxation was judged to be inadequate in 3 patients in the spinal group and in 5 patients in the epidural group. One patient in the spinal group had a characteristic post-spinal headache lasting 3 days. The injection-delivery time was shorter (P<0.01) in the spinal group compared to the epidural group. The Apgar scores at 1 and 5 min were similar in both groups. The results from our study suggest that spinal anaesthesia is a good alternative to epidural anaesthesia for elective caesarean section. A fall in blood pressure, which is equally possible in both groups of patients, should be prevented by adequate fluid preload and treated immediately by intravenous ephedrine.
Local analgesia infiltration and abdominal nerve blocks as adjuncts to regional analgesia and general anaesthesia are of benefit in caesarean section by reducing opioid consumption. Nonsteroidal anti-inflammatory drugs as an adjuvant may confer additional pain relief.