الفهرس 
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Abstract
Severe acute pain occurs in more than 10% of patients within the first 36 h after caesarean section1 and significantly impacts women’s satisfaction. Reluctance to administer opioids to breastfeeding women sometimes leads to insufficient administration of postoperative analgesia. However, inadequate pain management can lead to delayed breastfeeding and ambulation, or impairment of respiration with potential complications such as thrombosis, ileus, atelectasis or pneumonia. Furthermore, the severity of acute pain at 2-week postpartum is an independent risk factor for persistent pain at 3 months and postpartum depression (2.5-fold and three-fold risk increase, respectively, in the case of severe acute postoperative pain).
Today, a widely used technique for the management of post-caesarean section pain is the addition of 100 to 200 μg of intrathecal morphine (ITM) to the spinal anesthetic as part of a multimodal analgesia strategy.8,9 However, the gain in analgesic efficacy is accompanied by adverse effects.10 The most frequent adverse effect is postoperative nausea and vomiting (PONV), which also has the greatest negative impact on maternal satisfaction. The transversus abdominis plane (TAP) block is an established alternative technique to reduce pain after caesarean section, with a potential reduction of adverse effects compared with ITM.
This study aimed to compare the TAP block for postoperative pain relieve following caesarean section operations to the most famous analgesia (intrathecal morphine) used for caesarean section regarding efficacy and complications.
In our study, sixty cases that underwent elective caesarean delivery, were included in the study and divided into 2 groups; patients were randomly allocated by closed envelope randomization; group M (N= 30): Patients in this group received intrathecal 150 mic morphine in a 0.5 ml volume, mixed with 10 mg of hyperbaric bupivacaine 0.5 % in a 2 ml volume (total volume 2.5 ml).group B (N= 30): Patients in this group received intrathecal 10 mg hyperbaric bupivacaine 0.5% 2ml volume + 0.5 saline (Total volume 3ml) and At the end of surgery patient received bilateral TAP block with 20 ml volume of 0.25% bupivacaine on each side .
The study results showed:
Patients’ characteristics (age and sex) were insignificantly different between both groups. Postoperative heart rate, respiratory rate, SpO2 and mean arterial blood pressure were insignificantly different at all time measurements between both groups.
VAS was insignificantly different at all time measurements between both groups except at 2, 3 and 4 hours were higher in group B than group M. (P <0.001).
Intraoperative Bromage score was insignificantly different at all time measurements between both groups. Postoperative Bromage score was insignificantly different at all time measurements between both groups except at 2, 4 and 6 hours were higher in group B than group M. (P <0.001).
Time of rescue analgesia ranged from 8 to 10 with a mean value of 8.73 ± 0.64 h in group M and ranged from 4 to 5 with a mean value of 4.40 ± 0.5 h in group B. Time of rescue analgesia was significantly prolonged in group M than group B (P <0.001).
Total paracetamol dose ranged from 1 to 2 with a mean value of 1.97 ± 0.18 gm in group M and ranged from 2 to 4 with a mean value of 3.77 ± 0.57 gm in group B. Total paracetamol dose was significantly lower in group M than group B (P <0.001).
Total morphine dose ranged from 2 to 4 with a mean value of 3.93 ± 0.37 mg in group M and ranged from 6 to 8 with a mean value of 7.73 ± 0.69 mg in group B. Total morphine dose was significantly lower in group M than group B (P <0.001).
Pruritis occurred in 10 (33%) patients in group M and didn’t occur in group B. PONV occurred in 12 (40%) patients in group M and in 6 (20%) patients in group B. Pruritis and PONV were significantly higher in group M than group B (P <0.001 and 0.045 respectively).
Summary and Conclusion
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Conclusion
TAP block is a good alternative technique to intrathecal morphine in reducing post-caesarean section pain, with less PONV and pruritis compared with ITM.
Recommendations
1- A TAP block is a good alternative technique to intrathecal morphine in reducing post-caesarean section pain, with less PONV and pruritis compared with ITM.
2- Additional studies including a large number of patients are required for generalization of these results.
3- Further studies assessment of adding bupivacaine in different concentrations by ultrasound-guided TAP block.
4- Further studies using sedative and additive in different doses in combination with bupivacaine in ultrasound-guided TAP block.
5- Combination of both techniques to reduce required doses of each group, to minimize side effect of both.