European Journal of Cardiovascular Medicine

Caesarean section is one of the most commonly performed surgical procedures worldwide, and the demand for effective postoperative analgesia remains a major concern for both patients and clinicians. Effective pain relief after caesarean delivery not only provides comfort but also facilitates early ambulation, enhances maternal–neonatal bonding, and reduces postoperative morbidity [1,2].

Post-caesarean pain is primarily somatic in origin, arising from the abdominal wall incision and visceral manipulation. Multimodal analgesic regimens combining systemic opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and regional blocks have been advocated to provide effective analgesia while minimizing drug-related side effects [3,4]. However, opioid-based analgesia may lead to sedation, nausea, vomiting, respiratory depression, and delayed recovery [5].

The Transversus Abdominis Plane (TAP) block is a regional anaesthetic technique that provides analgesia to the parietal peritoneum and the skin of the anterior abdominal wall by depositing local anaesthetic between the internal oblique and transversus abdominis muscles [6]. The block effectively covers the sensory nerves from T6 to L1, thereby reducing postoperative pain after lower abdominal surgeries, including caesarean section [7,8].

The introduction of ultrasound guidance has significantly improved the accuracy and safety of TAP block administration. It allows real-time visualization of muscle layers, needle placement, and local anaesthetic spread, resulting in enhanced efficacy and reduced complications [9].

Bupivacaine and Ropivacaine are long-acting amide local anaesthetics commonly used in regional anaesthesia. Bupivacaine provides prolonged sensory blockade but has a higher potential for cardiotoxicity and neurotoxicity, particularly when used in larger doses [10]. Ropivacaine, a newer S-enantiomer of propivacaine, offers similar efficacy with a better safety profile, less cardiotoxicity, and greater sensory–motor differentiation, making it suitable for obstetric regional blocks [11,12].

Several studies have demonstrated the efficacy of TAP block for postoperative analgesia following caesarean delivery, but the optimal local anaesthetic for prolonged analgesia with minimal side effects remains an area of active investigation [13,14]. Comparing Ropivacaine versus Bupivacaine in bilateral TAP block can provide valuable insights into the most effective and safest drug for managing postoperative pain in caesarean patients.

Therefore, this study was undertaken to evaluate and compare the efficacy of bilateral TAP block using Ropivacaine and Bupivacaine for postoperative analgesia following caesarean section, with respect to duration and quality of analgesia, rescue analgesic requirement, hemodynamic stability, and side-effect profile.

Study Design and Setting
This study was a prospective randomised controlled trial conducted in the Department of Anaesthesiology at NKP Salve Institute of Medical Sciences and Research Centre, Nagpur (NKPSIMS & RC) and the study period extended from November 2016 to November 2017.

Study Population
A total of 80 parturients scheduled for elective lower segment caesarean section (LSCS) under spinal anaesthesia were included in the study. Participants were randomly divided into two equal groups of 40 patients each.

Inclusion Criteria

• ASA (American Society of Anesthesiologists) physical status I and II.
• Singleton term pregnancy undergoing elective LSCS under spinal anaesthesia.
• Patients aged between 18 to 35 years.
• Patients are willing to give written informed consent.

Exclusion Criteria

• Refusal to participate in the study.
• Known allergy or hypersensitivity to amide local anaesthetics.
• Infection at the site of block placement.
• Coagulopathy or bleeding disorders.
• Severe preeclampsia/eclampsia.
• History of chronic pain or opioid dependence.

Ethical Considerations
Prior approval was obtained from the Institutional Ethics Committee of NKPSIMS & RC, Nagpur. Written informed consent was taken from all participants after explaining the nature and purpose of the study in their own language.

Randomisation and Grouping
Patients were randomly allocated into two groups using a computer-generated randomisation list:

• Group R (Ropivacaine group): Received bilateral TAP block with 20 mL of 0.375% Ropivacaine on each side.
• Group B (Bupivacaine group): Received bilateral TAP block with 20 mL of 0.25% Bupivacaine on each side.

Anaesthetic Technique
All patients were preloaded with 500 mL of Ringer’s lactate before administration of spinal anaesthesia. Spinal anaesthesia was given at L3–L4 or L4–L5 interspace using 2 mL (10 mg) of 0.5% hyperbaric Bupivacaine with a 25G Quincke needle under aseptic precautions.

After completion of surgery and before reversal of anaesthesia, a bilateral Transversus Abdominis Plane (TAP) block was administered under ultrasound guidance using a high-frequency linear probe (6–13 MHz). A 22G blunt-tipped needle was inserted in-plane, and after confirmation of correct placement between the internal oblique and transversus abdominis muscles, the study drug was injected on each side.

Assessment Parameters

1. Pain Assessment:
• Pain was assessed using the Visual Analogue Scale (VAS) (0 = no pain, 10 = worst pain) at 0, 2, 4, 6, 8, 12, 18, and 24 hours postoperatively.
2. Duration of Analgesia:
• Time from administration of TAP block to first request for rescue analgesia.
3. Rescue Analgesia:
• Injection Diclofenac 75 mg IM was given as a rescue analgesic when VAS ≥ 4.
4. Total Analgesic Consumption:
• The total dose of rescue analgesic required in the first 24 hours was recorded.
5. Hemodynamic Parameters:
• Heart rate, systolic and diastolic blood pressure, and oxygen saturation were monitored at regular intervals.
6. Adverse Effects:
• Any complications such as nausea, vomiting, local anaesthetic toxicity, or infection at the injection site were noted.

Statistical Analysis
Data were entered and analysed using SPSS software version 20.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD), and categorical variables as percentages.

• Comparison between the two groups was done using the Student’s t-test for continuous data and the Chi-square test for categorical data.
• A p-value of < 0.05 was considered statistically significant.

A total of 80 parturients were analysed — 40 in Group R (Ropivacaine) and 40 in Group B (Bupivacaine).
Both groups were comparable in baseline characteristics, ensuring the validity of the comparison.

Table 1. Demographic Profile of Study Participants

No significant difference in baseline demographics between the groups.

Table 2. Intraoperative Characteristics

Table 3. Mean Visual Analogue Scale (VAS) Scores at Rest

Table 4. Mean VAS Scores During Movement (Coughing)

VAS scores during movement were significantly lower in the Ropivacaine group after 4 hours.

Table 5. Duration and Quality of Analgesia

Table 6. Total Analgesic Consumption (Diclofenac 75 mg IM)

Patients in the Ropivacaine group required fewer rescue doses and had lower total analgesic consumption.

Table 7. Patient Satisfaction Scores (5-point Likert Scale)

A higher proportion of patients reported “very satisfied” in the Ropivacaine group.

Table 8. Hemodynamic Parameters (Average of Readings)

Both groups maintained stable hemodynamics throughout; no significant variations were noted.

Table 9. Adverse Effects

Both drugs were well tolerated, with minimal and comparable adverse effects.

Effective postoperative pain management following caesarean delivery is essential to enhance maternal comfort, promote early ambulation, and facilitate breastfeeding and bonding with the newborn. Neuraxial opioids such as intrathecal morphine have been widely used but are associated with side effects including nausea, vomiting, pruritus, and respiratory depression [1]. Hence, peripheral nerve blocks like the Transversus Abdominis Plane (TAP) block have gained attention as a component of multimodal analgesia to minimise opioid requirements and related complications [2,3].

The present randomised controlled study was conducted to compare the efficacy and safety of bilateral TAP block using 0.375% Ropivacaine versus 0.25% Bupivacaine for postoperative analgesia in patients undergoing caesarean section under spinal anaesthesia.

Comparison of Demographic and Surgical Parameters

The demographic characteristics (age, weight, height, and BMI) and surgical durations were comparable between the two groups, ensuring uniformity and eliminating potential confounding factors. This is consistent with the methodology followed by McDonnell et al. (2008) [4] and Kiran et al. (2011) [5], where baseline characteristics were similar between treatment arms to allow a fair comparison of analgesic efficacy.

Pain Scores (VAS) and Duration of Analgesia

In the present study, the mean duration of analgesia was significantly longer in the Ropivacaine group (11.9 ± 2.3 hours) compared to the Bupivacaine group (8.2 ± 1.9 hours), with p < 0.001. The Visual Analogue Scale (VAS) scores were significantly lower in the Ropivacaine group from the 4th postoperative hour onwards, indicating sustained analgesia.

This finding aligns with Eslamian et al. (2012) [6], who demonstrated prolonged analgesic duration and reduced opioid consumption with 0.375% Ropivacaine in TAP block for caesarean sections. Similarly, Abdallah et al. (2012) [7] in their meta-analysis found that the TAP block significantly decreases postoperative pain intensity and analgesic requirements up to 24 hours.

Ropivacaine provides superior postoperative analgesia due to its longer duration of sensory blockade, less motor block, and lower lipid solubility compared to Bupivacaine [8]. These properties allow preferential blockade of sensory Aδ and C fibres while sparing motor function, making it particularly suitable for obstetric patients.

Rescue Analgesic Requirement

The time to first rescue analgesic was markedly delayed in the Ropivacaine group (12.1 ± 2.1 h) compared to the Bupivacaine group (8.0 ± 1.8 h), and total analgesic consumption within 24 hours was significantly lower in the Ropivacaine group. These results corroborate the findings of Griffiths et al. (2010) [9], who demonstrated that Ropivacaine in TAP block prolonged the pain-free interval and decreased the need for supplemental analgesics after abdominal surgeries.

Reduced analgesic requirement not only decreases side effects of systemic analgesics but also enhances patient satisfaction and early recovery. El-Dawlatly et al. (2009) [10] also reported that TAP block reduces the need for opioids and improves postoperative comfort after caesarean delivery.

Hemodynamic Stability and Adverse Effects

Both groups maintained stable hemodynamic parameters throughout the postoperative period, with no statistically significant differences observed. No patient in either group experienced local anaesthetic systemic toxicity (LAST), nausea, vomiting, or sedation. This demonstrates that both Ropivacaine and Bupivacaine, when administered under ultrasound guidance and within recommended doses, are safe and well-tolerated.

McDonnell et al. (2007) [11] and Petersen et al. (2010) [12] reported similar findings, emphasising that the TAP block is a safe technique with minimal complications when performed under direct sonographic visualisation.

Ropivacaine’s lower potential for cardiotoxicity and neurotoxicity compared to Bupivacaine provides an additional safety advantage, as highlighted by McClellan and Faulds (2000) [8].

Patient Satisfaction

Patient satisfaction scores were higher in the Ropivacaine group (62.5% “very satisfied”) compared to the Bupivacaine group (25%). This reflects the superior quality and duration of analgesia and the reduced need for additional analgesics in the Ropivacaine group. Similar findings were reported by Singh et al. (2017) [13], who found greater satisfaction with Ropivacaine TAP block compared to Bupivacaine.

Clinical Implications

The results of this study confirm that ultrasound-guided bilateral TAP block using Ropivacaine provides effective and prolonged postoperative analgesia following caesarean section. This technique can reduce the dependence on systemic opioids, promote faster recovery, and enhance maternal satisfaction. Given its safety profile, Ropivacaine may be considered the preferred local anaesthetic for TAP block in obstetric analgesia.

Bilateral TAP block using 0.375% Ropivacaine provides more effective and longer-lasting postoperative analgesia than 0.25% Bupivacaine in caesarean section patients under spinal anaesthesia. Ropivacaine significantly reduced pain scores, delayed the need for rescue analgesia, and improved patient satisfaction without additional side effects. It is therefore recommended as the preferred local anaesthetic for the TAP block in post-caesarean analgesia

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