Introduction
Caesarean section (CS) is a prevalent surgical procedure globally, accounting for 15–20% of births, with higher rates in some developing countries. While it reduces maternal and neonatal mortality, postoperative pain presents significant challenges, often hindering recovery and bonding. Effective pain relief is crucial for improving mobility, comfort, and reducing risks of complications like thrombosis and postpartum depression. Spinal anesthesia is preferred for its quick effect and minimal impact on the infant, but lasts only 2-4 hours, necessitating further analgesia. Systemic opioids are commonly administered via IV-PCA for tailored pain management, though they can lead to side effects that impair early movement and breastfeeding [1][4].
Regional techniques in multimodal analgesia aim to reduce opioid use while ensuring effective pain relief. The TAP block, introduced by Rafi in 2001, targets the area between the internal oblique and transversus abdominis muscles to alleviate pain following lower abdominal surgeries like cesarean deliveries. Utilizing ultrasound guidance since 2007, this method enhances the accuracy and safety of local anesthetic administration. The bilateral TAP block effectively blocks T6–L1 thoracolumbar nerves, reducing pain from surgical incisions primarily caused by somatic components, while also addressing visceral pain through the use of additional systemic or neuraxial analgesics for comprehensive pain management [5-8].
The early postoperative period after a cesarean delivery is crucial for recovery, as effective analgesia facilitates deep breathing, ambulation, and gastrointestinal recovery. Inadequate pain control can lead to complications such as shallow breathing, thrombosis, and chronic pain syndromes in new mothers. Non-opioid analgesics enhance recovery through enhanced recovery after surgery (ERAS) protocols. TAP block emerges as a promising multimodal pain relief option, particularly in settings lacking advanced analgesia methods. Despite research, optimal postoperative pain management remains debated; IV-PCA is common but has drawbacks. TAP block may offer similar benefits with fewer systemic effects, necessitating further research on analgesic efficacy, duration, maternal satisfaction, and side effects [9-11].
This study compares Transversus Abdominis Plane Block (TAP) to Intravenous Patient-Controlled Analgesia (IV-PCA) following spinal anesthesia in women undergoing cesarean sections. It aims to assess postoperative pain intensity using standardized metrics and total analgesic consumption in the first 24 hours. Secondary objectives include evaluating maternal satisfaction, time to initial analgesic request, adverse effects, and recovery indicators like early ambulation. The comparison seeks to determine if TAP is a better, safer, and easier method for pain management, aiming to enhance recovery and reduce opioid reliance post-surgery.
This study aims to compare the analgesic efficacy of TAP block and Intravenous Patient Controlled Analgesia (IV-PCA) following spinal anesthesia in patients undergoing elective cesarean sections. Outcomes evaluated include postoperative pain scores, total opioid consumption, duration of analgesia, patient satisfaction, and adverse effects for each technique, with the goal of identifying the more effective and safe analgesic modality.
Methods
The study was a prospective, randomized comparative study conducted in the Department of Anesthesiology, SRN Hospital, MLN Medical College, Prayagraj, over a period of one year. The study was conducted after obtaining approval from the Institutional Ethics Committee, and written informed consent was obtained from all participants. Pregnant women aged 18–40 years, with BMI 25–30 kg/m², ASA physical status I or II, singleton term pregnancy, and scheduled for elective lower-segment cesarean section under spinal anesthesia were included. Patients with drug allergy, BMI >35 kg/m², coagulopathy, infection at the block site, chronic pain, emergency cesarean delivery, or refusal to participate were excluded.
Fifty eligible participants were randomized into two equal groups of 25 using a computer-generated randomization number with allocation concealment. Group I received spinal anesthesia with 2.2 mL of 0.5% hyperbaric bupivacaine and 25 µg fentanyl, followed by an ultrasound-guided bilateral TAP block after surgery. Group II received the same spinal anesthesia but had a patient-controlled analgesia (PCA) system instead. The TAP block was performed by identifying the anatomical plane between the internal oblique and transversus abdominis muscles under ultrasound guidance, followed by administration of the study local anesthetic according to the predefined protocol. Group II received identical spinal anesthesia followed by intravenous patient-controlled analgesia (PCA) using nalbuphine.
Postoperative pain was assessed using the Visual Analog Scale at predefined intervals. Time to first analgesic request, cumulative opioid consumption over 24 hours, patient satisfaction using a Likert scale, and adverse effects were recorded. Continuous and categorical variables were analyzed using appropriate statistical tests in IBM SPSS Statistics version 24, with p<0.05 considered statistically significant. Sample size was determined a priori based on the primary outcome of postoperative opioid consumption.
Results
A total of 50 patients participated in the study, with 25 patients in each of the two groups. Group 1 received spinal anesthesia with 2.2 ml of 0.5% bupivacaine plus 25 mcg fentanyl, followed by a TAP block post-surgery. Group 2 received the same anesthesia but was administered intravenous patient-controlled analgesia (PCA) after surgery. The mean age of participants in Group 1 was 29.44 ± 5.28 years, while in Group 2 it was 29.48 ± 5.88 years, with no significant age difference (t = -0.03, p = 0.980). Mean BMI was 26.28 ± 1.10 kg/m² in Group 1 and 26.24 ± 0.88 kg/m² in Group 2, also showing no significant difference (t = 0.14, p = 0.888). The mean gestational age was 38.48 ± 1.53 weeks in Group 1 and 38.40 ± 1.12 weeks in Group 2, again with no significant difference (t = 0.21, p = 0.834) (Table 1).
| Group 1 (n=25) | Group 2 (n=25) | t | p-value | |||
| Mean | ±SD | Mean | ±SD | |||
| Age (years) | 29.44 | 5.28 | 29.48 | 5.88 | -0.03 | 0.980 |
| BMI (kg/m2) | 26.28 | 1.10 | 26.24 | 0.88 | 0.14 | 0.888 |
| GA weeks | 38.48 | 1.53 | 38.40 | 1.12 | 0.21 | 0.834 |
The study compares the mean duration of surgery and VAS pain scores between two patient groups. The mean duration was similar: 99.79 ± 15.00 minutes for Group 1 and 99.00 ± 8.42 minutes for Group 2 (t = 0.23, p = 0.820). VAS pain scores at rest were significantly lower in Group 1 at all postoperative times: 1 hour (2.82 vs. 4.93), 2 hours (2.52 vs. 4.65), 4 hours (2.42 vs. 4.38), 6 hours (2.37 vs. 4.22), 12 hours (2.72 vs. 3.98), and 24 hours (2.96 vs. 3.59), with p < 0.001. Similarly, VAS pain scores on movement were also lower in Group 1 at all intervals: 1 hour (3.64 vs. 6.67), 2 hours (3.56 vs. 6.29), 4 hours (3.68 vs. 6.20), 6 hours (3.61 vs. 5.58), 12 hours (3.97 vs. 5.44), and 24 hours (4.14 vs. 4.93), also with p < 0.001 (Table 2).
| Group 1 (n=25) | Group 2 (n=25) | t | p-value | |||
| Mean | ±SD | Mean | ±SD | |||
| Duration (min) | 99.79 | 15.00 | 99.00 | 8.42 | 0.23 | 0.820 |
| VAS at Rest | ||||||
| 1h | 2.82 | 0.44 | 4.93 | 0.02 | -24.10 | <0.001 |
| 2h | 2.52 | 0.45 | 4.65 | 0.02 | -23.81 | <0.001 |
| 4h | 2.42 | 0.45 | 4.38 | 0.11 | -21.07 | <0.001 |
| 6h | 2.37 | 0.42 | 4.22 | 0.04 | -21.79 | <0.001 |
| 12h | 2.72 | 0.30 | 3.98 | 0.20 | -17.39 | <0.001 |
| 24h | 2.96 | 0.13 | 3.59 | 0.10 | -19.23 | <0.001 |
| VAS at move | ||||||
| 1h | 3.64 | 0.73 | 6.67 | 0.21 | -19.93 | <0.001 |
| 2h | 3.56 | 0.55 | 6.29 | 0.20 | -23.25 | <0.001 |
| 4h | 3.68 | 0.54 | 6.20 | 0.40 | -18.80 | <0.001 |
| 6h | 3.61 | 0.47 | 5.58 | 0.37 | -16.45 | <0.001 |
| 12h | 3.97 | 0.36 | 5.44 | 0.02 | -20.43 | <0.001 |
| 24h | 4.14 | 0.17 | 4.93 | 0.02 | -23.02 | <0.001 |
The study compares the mean time to first rescue analgesia and mean fentanyl consumption between two patient groups. In Group 1, the mean time to first rescue analgesia was 4.42 ± 2.13 hours, significantly longer than the 3.25 ± 0.32 hours observed in Group 2, with a statistical difference indicated by t = 2.72 and p = 0.009. Additionally, the mean fentanyl consumption in Group 1 was 19.20 ± 96.00 mcg, which was significantly lower than the 407.20 ± 79.87 mcg in Group 2. This difference was also statistically highly significant, as evidenced by t = -15.53 and p < 0.001 (Table 3).
| Group 1 (n=25) | Group 2 (n=25) | t | p-value | |||
| Mean | ±SD | Mean | ±SD | |||
| Rescue Time (hr) | 4.42 | 2.13 | 3.25 | 0.32 | 2.72 | 0.009 |
| Fentanyl mcg | 19.20 | 96.00 | 407.20 | 79.87 | -15.53 | <0.001 |
The study compares the side effects experienced by patients in Group A and Group B. Nausea was reported at 0.00% in Group A compared to 84.00% in Group B, showcasing a highly significant statistical difference (Chi-square = 36.21, p < 0.001). Vomiting occurred in 8.00% of Group A patients and 40.00% of Group B patients, revealing a statistically significant difference as well (Chi-square = 7.02, p = 0.008). While Group A showed no instances of sedation, 8.00% of Group B patients reported sedation, although this difference was not statistically significant (Chi-square = 2.08, p = 0.149). Lastly, pruritis was absent in Group A, whereas 28.00% of patients in Group B experienced pruritis, indicating a statistically significant difference (Chi-square = 8.14, p = 0.004) (Table 4).
| Group A (n=25) | Group B (n=25) | Chi-square | p-value | ||||
| n | % | n | % | ||||
| Nausea | Yes | 0 | 0.00 | 21 | 84.00 | 36.21 | <0.001 |
| No | 25 | 100.00 | 4 | 16.00 | |||
| Vomiting | Yes | 2 | 8.00 | 10 | 40.00 | 7.02 | 0.008 |
| No | 23 | 92.00 | 15 | 60.00 | |||
| Sedation | Yes | 0 | 0.00 | 2 | 8.00 | 2.08 | 0.149 |
| No | 25 | 100.00 | 23 | 92.00 | |||
| Pruritis | Yes | 0 | 0.00 | 7 | 28.00 | 8.14 | 0.004 |
| No | 25 | 100.00 | 18 | 72.00 | |||
| Respiratory Depression | Yes | 0 | 0.00 | 0 | 0.00 | — | 1.000 |
| No | 25 | 100.00 | 25 | 100.00 |
Discussion
In our study, we assessed the postoperative analgesic efficacy of a TAP block versus intravenous patient-controlled analgesia (PCA) in 50 women undergoing cesarean sections under spinal anesthesia. Results indicated that the TAP block group experienced superior pain control, exhibited lower pain scores at rest and during movement, had a longer time to first rescue analgesia, required less fentanyl, and reported fewer opioid-related side effects such as nausea and vomiting. Both groups had similar demographic and clinical characteristics, enhancing the reliability of the comparison. The findings suggest that TAP block is a safe and effective analgesic technique following cesarean sections, potentially decreasing the need for systemic opioids, aligning with previous research, although some studies noted better visceral pain control with PCA.
The study found comparable baseline demographic characteristics between the two groups, with no significant differences in mean age (29.44 ± 5.28 years in Group 1 vs. 29.48 ± 5.88 years in Group 2, p = 0.980) or mean BMI (26.28 ± 1.10 kg/m² vs. 26.24 ± 0.88 kg/m², p = 0.888). This balance suggests that postoperative differences are unlikely due to demographic imbalances. The findings align with previous studies by Buluc et al. (2019) and Salman et al. (2024), which also reported no significant differences in age and BMI between groups. Overall, the results indicate that comparison groups in postoperative analgesia studies are typically well matched at baseline [12,13].
In our study, surgery durations were similar: 99.79 ± 15.00 minutes for Group 1 and 99.00 ± 8.42 minutes for Group 2, showing no significant difference (p = 0.820). This parity allows for more reliable attribution of postoperative pain scores and opioid consumption differences to the TAP block versus PCA, rather than surgery length. Comparatively, Salman et al. (2024) and Lalchand et al. (2024) also reported no significant differences in surgery durations across various groups. In contrast, Buluc et al. (2019) found longer surgery durations in the TAP group, yet still observed improved pain control with TAP blocks. Our matched operative times further affirm the TAP block's advantages in postoperative outcomes [12-14].
The study found that postoperative pain at rest was significantly lower in the transversus abdominis plane (TAP) block group compared to the intravenous patient-controlled analgesia (PCA) group at all time intervals measured. Specifically, at 1 hour, the mean Visual Analog Scale (VAS) score was 2.82 in Group 1 (TAP) and 4.93 in Group 2 (PCA), with similar results observed at subsequent intervals: 2 hours (2.52 vs. 4.65), 4 hours (2.42 vs. 4.38), 6 hours (2.37 vs. 4.22), 12 hours (2.72 vs. 3.98), and 24 hours (2.96 vs. 3.59), all showing highly significant differences (p < 0.001). The TAP block not only provided better somatic pain relief but also improved patient outcomes such as comfort and early recovery. These findings align with previous studies, including Salman et al. (2024) and McDonnell et al. (2007), which highlighted lower pain scores in the TAP group. However, some studies reported lower pain scores with PCA, particularly regarding visceral pain. Thus, while TAP blocks appear more effective for alleviating resting pain, variations in study results may stem from differences in pain types and analgesia protocols used [7,11-13].
In the study, the TAP (Transversus Abdominis Plane) block group exhibited significantly lower pain levels during movement throughout the postoperative period compared to the control group. Evidence is presented using Visual Analog Scale (VAS) scores at various postoperative time intervals: 1 hour (3.64 vs. 6.67), 2 hours (3.56 vs. 6.29), 4 hours (3.68 vs. 6.20), 6 hours (3.61 vs. 5.58), 12 hours (3.97 vs. 5.44), and 24 hours (4.14 vs. 4.93), with all differences deemed highly significant (p < 0.001). This reduction in pain is particularly crucial for mothers who need to mobilize to care for their newborns post-cesarean section. The results align with works by Innamorato et al. (2023) and Baeriswyl et al. (2015), which also highlight the effectiveness of TAP blocks in reducing movement-related pain. However, while Kumar Reddy et al. (2026) noted no significant difference between TAP and ESP blocks, the importance of TAP blocks becomes evident when compared to systemic opioid techniques, like PCA. Overall, the study reinforces the efficacy of TAP blocks in managing dynamic postoperative pain following cesarean deliveries [11,16-18].
In this study, patients receiving a Transversus Abdominis Plane (TAP) block experienced a significantly longer mean time to rescue analgesia compared to those in the Patient-Controlled Analgesia (PCA) group. Specifically, Group 1 (TAP block) had a mean rescue analgesia time of 4.42 ± 2.13 hours, whereas Group 2 (PCA) had a time of 3.25 ± 0.32 hours (p = 0.009). This extended pain-free interval is seen as a meaningful advantage, reflecting enhanced quality of initial postoperative analgesia and reducing the need for early drug administration. For cesarean patients, this period is particularly beneficial, allowing for stabilization, bonding with the newborn, and initiating breastfeeding with minimal discomfort. Several studies support the conclusion that the TAP block effectively delays the need for rescue analgesia. Prajapati et al. (2021) observed longer mean times to first rescue analgesia in the TAP block group compared to controls (12.25 hours vs. 7.96 hours, p < 0.001). Similarly, Salman et al. (2024) found a significant delay in the time to the first opioid dose (14.85 ± 3.74 hours in TAP vs. 12.21 ± 3.55 hours, p < 0.01). Boules et al. (2020) reported a median analgesia duration of 8 hours for TAP, which is clinically beneficial, while Parikh et al. (2015) confirmed longer times for first rescue analgesic doses with continuous TAP blocks compared to controls. Nafea et al. (2025) reiterated that TAP group patients experienced considerably longer times before requesting analgesics than those in the PCA group. Overall, these findings align with the view that TAP blocks enhance postoperative comfort [12,13,18-21].
A major strength of the study is the significant opioid-sparing effect of the TAP block, as evidenced by an average fentanyl consumption of 19.20 mcg in Group 1 compared to 407.20 mcg in Group 2 (p < 0.001). This reduction underscores the TAP block's capability to decrease systemic opioid needs post-cesarean section, leading to fewer side effects, heightened maternal alertness, earlier mobilization, and improved newborn care. The study reinforces the objective of modern obstetric anesthesia to minimize opioid exposure while ensuring effective pain management.
Our findings align with Salman et al. (2024), showing lower 24-hour opioid consumption in the TAP group (44.44 ± 11.02 mg vs. 62.62 ± 17.88 mg, p < 0.01). McDonnell et al. (2007) noted a reduction from 80.4 ± 19.2 mg to 21.9 ± 8.9 mg with TAP block. Srivastava et al. (2015) reported a nearly 50% drop in PCA tramadol use in women after cesarean sections with TAP. Tammam et al. (2013) found lower morphine requirements in the TAP group (18.1 ± 4.1 mg vs. 57.9 ± 5.3 mg). Baeriswyl et al. (2015) confirmed in a meta-analysis that TAP block decreases opioid consumption at 6 and 24 hours post-surgery. While Ayad et al. (2016) deemed TAP infiltration noninferior to IV PCA for opioid use, the majority of literature, including our findings, supports the opioid-sparing effects of TAP block [12-14,18-20].
In a study comparing two groups, the TAP block group exhibited significantly lower rates of postoperative nausea and vomiting. None in Group 1 experienced nausea, while 84% in Group 2 reported it (p < 0.001). Vomiting occurred in 8% of Group 1 and 40% of Group 2 (p = 0.008). The findings highlight the importance of minimizing postoperative nausea and vomiting to enhance maternal comfort and facilitate early bonding and breastfeeding. The lower incidence in the TAP group is attributed to reduced reliance on systemic fentanyl and opioids.
These findings indicate that the TAP group experienced significantly less postoperative nausea and vomiting compared to other groups. Salman et al. (2024) showed nausea rates of 4% in the TAP group versus 13% in the infiltration group (p < 0.04), and vomiting rates of 1% versus 9% (p < 0.02). Similarly, Sivapurapu et al. (2013) and Nafea et al. (2025) corroborated these results. Abdallah et al. (2012) found that TAP blocks reduce opioid-related side effects during cesarean deliveries, although some meta-analyses, like Baeriswyl et al. (2015), reported no significant differences across all abdominal surgeries. The benefits of TAP blocks in the cesarean section population are particularly evident and clinically relevant [12,13,19-21].
In our study, pruritus was absent in Group 1, while it affected 28% of patients in Group 2, with a significant difference (p = 0.004). Sedation occurred in 8% of Group 2 patients but was not statistically significant (p = 0.149). These findings suggest that TAP block may reduce opioid-related adverse effects, highlighting its practical benefits by lowering the incidence of pruritus and sedation, which can hinder maternal-newborn interaction and breastfeeding.
Our findings align with Salman et al. (2024) regarding the TAP group's absence of pruritus and its overall rarity compared to opioid analgesia. Sivapurapu et al. (2013) noted less sedation at 2 and 4 hours postoperatively in the TAP group, reflecting better alertness with regional analgesia [12,13]. Parikh et al. (2015) confirmed higher sedation levels in the control group versus TAP cathters. Abdallah et al. (2012) highlighted reduced maternal opioid side effects with TAP blocks during cesarean delivery without spinal morphine. Although our study's sedation results were not statistically significant, the trend favored the TAP block. Overall, these findings suggest that TAP blocks provide effective pain relief with a superior side effect profile compared to systemic opioid techniques like PCA [19,20].
Our study demonstrated the superiority of TAP blocks over intravenous PCA in pain scores, rescue analgesia time, fentanyl consumption, and side effects. However, some studies showed differing results; for instance, Salem et al. (2021) found PCA to provide lower pain scores than TAP blocks within the first 24 hours post-cesarean section. Saad et al. (2024) reported lower pain levels in the PCA group at 2 and 4 hours, albeit with increased nausea and vomiting, while TAP was linked to better intestinal motility and longer analgesic duration. Ahmed et al. (2023) concluded both methods were effective, but TAP was less effective for pain relief in their situation [12,13,22].
These differences in pain control may stem from factors like local anesthetic variation, ultrasound guidance technique, and additional analgesics. The TAP block is designed to manage somatic pain from the abdominal wall, being less effective for visceral pain. Despite this, the TAP group demonstrated better outcomes, suggesting that reduced somatic pain and lower opioid use are more significant than the potential advantages of PCA for visceral pain. Limitations of the study included a small sample size, lack of blinding, and a focus on short-term outcomes, which may affect the reliability and generalizability of the findings. The TAP block’s primary focus on somatic pain may create an incomplete understanding of the patient's overall pain and recovery, underscoring the need for larger, multicentric studies to validate these results.
Conclusion
This study concludes that transversus abdominis plane (TAP) block provides superior postoperative analgesia compared with intravenous patient-controlled analgesia (PCA) in patients undergoing cesarean section under spinal anesthesia. TAP block resulted in lower pain scores, prolonged analgesic duration, reduced rescue analgesic requirement, and decreased fentanyl consumption. It also minimized opioid-related adverse effects such as nausea, vomiting, and pruritus, improving maternal comfort and recovery. Therefore, TAP block can be considered an effective, safe, and opioid-sparing component of multimodal postoperative pain management after cesarean delivery.
Declarations
Ethical Approval
The study was approved by the Institutional Ethics Committee of Motilal Nehru Medical College, Prayagraj, and was conducted in the Department of Anesthesiology, Swaroop Rani Nehru (SRN) Hospital, Prayagraj. Written informed consent was obtained from all participants before enrollment.
Patient Consent
Written informed consent was obtained from the patient for the publication of this case report and any accompanying clinical images.
Data Availability Statement:
The data supporting the findings of this study are available from the corresponding author upon reasonable request.
Funding
This case report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of Interest
The authors declare no conflict of interest.
Author Contributions
All authors have contributed equally.