European Journal of Cardiovascular Medicine

Lower Segment Caesarean Section (LSCS) is one of the most common surgical procedures performed worldwide and the most common choice of anaesthesia is subarachnoid block.  Significant pain and discomfort is anticipated after LSCS  and most patients describe this pain as moderate to severe in nature. This has a negative impact on maternal bonding, breastfeeding, ambulation and overall recovery of the parturient.(1,2) Therefore there is a need to ensure a safe and effective analgesic regimen.

Postoperative pain following caesarean delivery essentially has 2 components. Somatic component arising from nociceptors due to abdominal wall incision and visceral component from uterine incision.(3)

Multimodal analgesic techniques have been used to treat postoperative pain. Systemic opiods, NSAIDs, epidural analgesia, local wound infiltration, suppositories, fascial plane blocks are some of the common modes of analgesic techniques in use.(2) Transversus Abdominis Plane block (TAP) was introduced by Rafi in 2001.He described it using anatomical landmark guided technique by first identifying Lumbar triangle of Petit.(4) 

In 2007, Hebbard et al introduced ultrasound guided approach for TAP block. Ultrasound facilitates accurate placement of block needle as well as real time deposition of local anesthetic, thereby increasing margin of safety, precision and block quality.(4) TAP block entails injecting a local anesthetic drug into TAP plane anesthetising the parietal peritoneum, muscle, skin along the anterolateral abdominal wall that is supplied by T7-L3 nerve roots.(5)

A better safety profile has been established with Ropivacaine than with Bupivacaine. Ropivacaine has longer duration of action compared to Lignocaine. Hence its frequent use in peripheral nerve blocks and fascial plane blocks have been documented.

The role of corticosteroids as adjuvants to local anesthetics in different peripheral nerve blocks have been documented.(6) Studies shows that Dexamethasone has prolonged duration of action with Ropivacaine than with other local anesthetic drugs.(4) Dexamethasone is a long acting glucocorticoid with potent analgesic, anti-inflammatory and antiemetic properties with additional advantages of decreased post-operative nausea and vomiting.(4) The postoperative analgesic efficacy of Ropivacaine 0.2% with Dexamethasone for TAP block in LSCS patients has been reviewed in very few literature. This study aims to ascertain whether adding dexamethasone enhances the duration and extent of analgesic effects of 0.2% Ropivacaine.

Parturients admitted under Dept. of Obstetrics and Gynaecology, District hospital, Tumakuru undergoing elective/emergency caesarean section for 01 Year, who satisfy our study criteria will be included. The study was conducted after getting Institutional Ethical committee clearance. Informed written consent was obtained from the patients included in the study.

TAP block is performed at the end of caesarean section using ultrasound guided technique. A linear high frequency ultrasound probe (11MHz) is placed in a transverse plane between the lower costal margin and iliac crest in the midaxillary line, 23 Gauge Quincke Babcock spinal needle is attached to a syringe filled with the study drug.  Inj Ropivacaine 0.2% 19ml+1ml normal saline is injected to parturients of group A and Inj.Ropivacaine 0.2% 19ml+ 4mg(1ml) of dexamethasone is injected to parturients of group B on each side of abdomen, in the fascial plane between the internal oblique and transversus abdominis muscle. The use of ultrasound allows accurate deposition of the local anaesthetic in the correct neurovascular plane.

Group A: 19ml of Ropivacaine 0.2%+1ml of normal saline on each side for TAP block. n=30

Group B: 19 ml of Ropivacaine 0.2% 19ml+4mg (1ml) of dexamethasone on each side for TAP block. n=30

Result values recorded using a pre-set proforma.

Inclusion Criteria:

• Parturients undergoing elective/emergency caesarean section
• Age group of 18 to 35 years.
• American Society of Anaesthesiologists physical status II, II E

Exclusion Criteria:

• Comorbid conditions like Hypertension (including PIH-pregnancy induced hypertension), Diabetes(including GDM-Gestational Diabetes Mellitus), Eclampsia not under control
• Infection at the site of injection
• Coagulopathy and on anticoagulant therapy
• Allergy to the study drug
• Haemodynamic instability
• Major obstetric haemorrhage like APH,PPH
• Body Mass Index (BMI) <18 or >35 Kg/m2

Table 1: Distribution of age by group

Patients receiving Ropivacaine 0.2% were classified as group A while those receiving Ropivacaine 0.2% with 4mg dexamethasone as group B. There was no significant difference in age and sex of patients of both group as shown in table 1 (p>0.05).

Table 2: ASA grade distribution by group

Table 3: Mean duration of first dose of rescue analgesia in both the intervention group.

              *Statistically significant

Table 4: Mean dose of rescue analgesia (Paracetamol) required in 24 hours in both the intervention group

In the present study it was seen that the mean time taken for the first rescue dose was quicker in group A than B. It took 3.75 hours (CI: 3.36 - 4.13) for those given ropivacaine alone while it was 8.41 hour (CI: 8.01 – 8.81) for those on combination of ropivacaine and dexamethasone. This difference was found to be statistically significant (<0.05). The least time take for first dose in group A was 1 hour while for group it was 6 hours.

Transversus abdominis plane (TAP) block is a localized anesthetic technique that blocks the anterolateral abdominal wall sensory nerves to provide good post-operative analgesia. Banerjee et al. were the first to describe it, and method involves using the triangle of Petit as a landmark to inject a local anesthetic agent into the plane between the internal oblique and transversus abdominis muscles. Ultrasound guided TAP blocks have been found to be a feasible method with satisfactory analgesia following LSCS, laparoscopic abdominal surgeries such as cholecystectomy, colectomy, hysterectomy and hernia repair during the immediate post-operative period.(7-8)

In our study, 10% of parturients belonged to age group below 20 years of age, 61.7 %  belonged to 21-25 yrs age group , 18.3% in age group 26- 30 yrs age and 10% of parturients belonged to more than 30 yrs of age with p value 0.327 which was statistically not significant.

A systematic review by mangilal deganwa et al. on effects of dexamethasone as an adjuvant to ropivacaine on duration and quality of post-operative analgesia in ultrasound-guided transversus abdominis plane block in patients undergoing lower-segment cesarean section has found that compared to patients receiving 0.1% ropivacaine alone, those receiving dexamethasone with 0.1% ropivacaine have a longer analgesic duration of TAP block. Additionally, it possesses antiemetic and opioid sparing qualities that enhance post-operative recovery and maternal satisfaction.

Cummings et al in his study has reported that dexamethasone provides prolonged analgesia when used as an adjuvant with ropivacaine more than bupivacaine while performing interscalene block.(9)

A meta-analysis of randomized controlled trials by De Oliveira et. Al(10) identified that low dosage (less than 0.1 mg/kg) of dexamethasone lowered post-operative nausea and vomiting, while high doses (more than 0.2 mg/kg) and moderate doses (0.11 to 0.2 mg/kg) decreased opioid use and post-operative pain score. Dexamethasone is commonly used as an adjuvant for various peripheral nerve blocks like interscalene, supraclavicular and other lower limb blocks and have been found to prolong the duration of the nerve block (11-13).We have chosen Dexamethasone as the adjuvant in our study since very few studies are available which shows the prolonged duration of action of dexamethasone when used in TAP block following LSCS. 

Sharma et. al. had conducted a study among patients undergoing hernia repair under spinal anesthesia, comparing the efficacy of ropivacaine (0.5%) with and without 8 mg of dexamethasone. This study also found a prolonged duration of analgesia of 9.11 hours among the dexamethasone group versus 6.55 hour among those given only ropivacaine. Similar findings were also documented by Ammar et. al (14) among patients undergoing open abdominal hysterectomy. But this study had compared the effect of bupivacaine 0.25% with 8 mg dexamethasone versus bupivacaine 0.25% with saline using TAP block.

We conclude that the study of ultrasound-guided TAP blocks performed for LSCS postoperatively led to a reduction in consumption of analgesics as well as an improvement in patient satisfaction. We suggest that the TAP block provides an additional tool in the anesthesiologist's armamentarium for treating pain following caesarean section or in patients who are not candidates for intravenous or neuraxial opioids.

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2.       Mankikar MG, Sardesai SP, Ghodki PS. Ultrasound guided transversus abdominis plane block for post operative analgesia in patients undergoing caesarean section. Indian J Anaesth 2016;60:253 7.

3.       Srivastava U, Verma S, Singh TK, Gupta A, Saxsena A, Jagar KD, et al. Efficacy of trans abdominis plane block for post cesarean delivery analgesia: A double-blind, randomized trial. Saudi J Anaesth 2015;9:298-302.

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9.       Cummings KC, 3rd, Napierkowski DE, Parra-Sanchez I, Kurz A, Dalton JE, Brems JJ, et al. Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine. Br J Anaesth. 2011;107:446-53.

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