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Bilateral Ultrasound-Guided Transversus Abdominis Plane Block Combined with Ilioinguinal-Iliohypogastric Nerve Block for Cesarean Delivery Anesthesia

Mei, Wei MD*; Jin, Chuangang MD*; Feng, Lin MD; Zhang, Yi MD*; Luo, Ailin MD*; Zhang, Chuanhan MD*; Tian, Yuke MD*

doi: 10.1213/ANE.0b013e31821891e2
Obstetric Anesthesiology: Case Report

The ultrasound-guided transversus abdominis plane block and ilioinguinal-iliohypogastric nerve block have been shown to provide pain relief after abdominal surgery. A combination of the 2 blocks may provide acceptable surgical anesthesia for cesarean delivery. We describe 4 women who had contraindications to neuraxial anesthesia, who underwent cesarean delivery with ultrasound-guided bilateral transversus abdominis plane block combined with ilioinguinal-iliohypogastric nerve block using 40 mL 0.5% ropivacaine. Breakthrough pain during the delivery of the fetus was treated with small doses of IV ketamine and propofol. We suggest that this technique may be an alternative to local anesthesia for cesarean delivery in clinical practice.

Published ahead of print April 5, 2011

From the Departments of *Anesthesiology, and Obstetrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.

Funding: Intramural departmental sources.

The authors declare no conflicts of interest.

Address correspondence and reprint requests to Yuke Tian, MD, Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave. 1095#, 430030 Wuhan, China. Address e-mail to

Accepted February 23, 2011

Published ahead of print April 5, 2011

Local infiltration anesthesia is an alternative method for cesarean delivery in situations when safe induction of neuraxial and general anesthesia are contraindicated or not available. A combination of bilateral ilioinguinal-iliohypogastric (IIIH) nerve block and infiltration anesthesia was reported to provide acceptable surgical anesthesia for cesarean delivery in a patient with severe peripartum cardiomyopathy.1 Bilateral ultrasound (US)-guided transversus abdominis plane (TAP) and IIIH nerve blocks have been successfully used for pain relief after cesarean delivery.2,3 However, inconsistent blockade of the IIIH nerve was common after TAP block.4 Therefore, a combination of TAP block and IIIH nerve block may produce more extensive sensory blockade than either alone and may provide sufficient surgical anesthesia for cesarean delivery. We report 4 cases of bilateral US-guided single-shot TAP block and IIIH nerve block for cesarean delivery. The reporting of these cases was approved by the IRB and all patients gave written informed consent for the report.

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Case 1

A 28-year-old woman (gravida 1, para 0) with congenital kyphoscoliosis and asymptomatic congenital patent ductus arteriosus was admitted to a local hospital for elective cesarean delivery at 39 weeks' gestation. She was 150 cm tall and weighed 50 kg (body mass index [BMI]: 22.2 kg/m2). The anesthesiologist at the local hospital was unable to perform epidural anesthesia and the patient was transferred to our hospital. The epidural space could not be identified on US. Because signs of active labor were evident with the presence of cephalopelvic disproportion caused by severe congenital kyphoscoliosis, cesarean delivery was planned. The patient and her family refused general anesthesia.

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Case 2

A 28-year-old woman (gravida 2, para 0) with a history of ankylosing spondylitis was admitted to our hospital at 39 weeks' gestation. She was 159 cm tall and weighed 74 kg (BMI: 29.3 kg/m2). A past radiograph showed fusion of the spine from the cervical to the lumbar regions, and an ossified ligamentum flavum. Preoperative airway examination showed adequate mouth opening with normal dentition, Mallampati grade IV, and restricted neck mobility. Because of an anticipated difficult airway and back anatomy, elective cesarean delivery was performed under US-guided TAP block and IIIH nerve block.

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Case 3

A 38-year-old woman (gravida 3, para 1) with eclampsia and seizures was admitted to our hospital at 37 weeks' gestation. She was 158 cm tall and weighed 92 kg (BMI: 31.4 kg/m2). Her arterial blood pressure was 158/92 mm Hg, heart rate 98 bpm, and blood tests were within normal limits. Computed tomography indicated fresh subarachnoid hemorrhage in the frontal and temporalis regions of the right cerebral hemisphere. There were no radiological signs of cerebral edema and increased intracranial pressure. The patient refused general anesthesia; therefore, the decision to perform cesarean delivery under regional anesthesia was made.

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Case 4

A 31-year-old woman (gravida 3, para 0) with a HELLP syndrome (hemolysis, elevated liver enzyme levels, and low platelet count) was admitted to our hospital at 35 weeks' gestation. She weighed 74 kg and was 170 cm tall (BMI: 25.6 kg/m2). Blood tests revealed a platelet count of 62 × 109/L; normal prothrombin and activated partial thromboplastin time; and elevated liver transaminase and bilirubin levels. The patient preferred local to general anesthesia.

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TAP and IIIH Nerve Blocks

Cesarean delivery was performed in the 4 patients under bilateral TAP block and IIIH nerve block. The patients were fasted >8 hours. Ranitidine 50 mg and metoclopramide 10 mg were administered IV 2 hours before the procedure for aspiration prophylaxis. Thirty minutes before anesthesia, 0.1 g sodium phenobarbital and 0.5 mg atropine were administered via an IM injection according to our standard. Upon arrival in the obstetric operating room, standard monitors were applied, IV access was established, and oxygen was administered by facemask. The block site was cleaned with antiseptic solution and draped with sterile towels. US-guided posterior TAP block was achieved using the method described by Hebbard et al.5 using a linear array US 8- to 13-MHz probe (12-L-RS, Logiq e; General Electric Healthcare, Pewaukee, WI) and a 120-mm, 22-gauge Stimuplex needle (B. Braun, Melsungen, Germany). The probe was positioned in the midaxillary line in the axial plane halfway between the iliac crest and the costal margin. The TAP was visualized, the needle was introduced anteriorly in the plane of the US beam, and the needle tip was guided posterior to the midaxillary line. The US-guided IIIH nerve block was performed according to the method described by Gofeld and Christakis6: the US probe was placed on the line connecting the anterior superior iliac spine (ASIS) with the umbilicus; and the IIIH nerve was visualized between the internal oblique and transverse muscles 1 to 3 cm from the ASIS. The block was performed using an “in-plane” technique under direct visualization of the needle tip, which was placed lateral to the nerve structures within the TAP. If the nerve could not be identified clearly, the local anesthetic was injected close to the deep circumflex iliac artery. Ten milliliters ropivacaine was injected for the TAP and IIIH nerve blocks on each side, respectively. Sensory block to ice was assessed 15 minutes after injection by mapping the area of diminished sensation in a parasagittal plane 5 cm lateral to the midline and in a parasagittal plane passing through the ASIS, with repeated application of cold stimuli at 1-cm intervals along this cephalocaudal plane (Table 1).

The cesarean delivery was performed through a Pfannenstiel incision in 2 patients and through a midline vertical incision in 2 patients. Additional local infiltration with 1% lidocaine 10 mL was injected by the surgeon for patient 3 (midline vertical incision) because of incomplete T12 sensory bock. The patients reported little or no pain during the dissection of skin, muscle, and peritoneal layers. At the time of delivery of the fetus, ketamine and propofol were administered IV if the patient complained of pain. No opioids or nonsteroidal antiinflammatory drugs were administered. Surgical procedures for all 4 patients were successful, and no patients required blood transfusion. Details of the procedures are found in Table 2. Apgar scores were recorded at 1 and 5 minutes.

After the operation, rectal diclofenac was administered for postoperative analgesia. At 24 hours, patients were asked to assess their average pain experienced over the 24-hour period using the numeric rating scale (0–10; 0 = no pain, 10 = worst pain imaginable). No complications attributed to the US-guided TAP block and IIIH nerve block were observed in any of the patients. None of the patients developed aspiration, shivering, nausea, vomiting, or required administration of antiemetic drugs postoperatively. Long-term outcomes such as chronic postoperative pain were not assessed.

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We chose to induce regional anesthesia for our 4 patients because neuraxial anesthesia was contraindicated and our patients preferred not to have general anesthesia. In developing countries, including China, local infiltration anesthesia is generally used for the above-mentioned cases.7 In other countries, local anesthesia is also used in emergencies when neuraxial and general anesthesia are not available or cannot be induced for safety reasons. Because US-guided TAP block2 or bilateral US-guided IIIH nerve block3 have been used successfully for analgesia after cesarean delivery, we elected to try to use these blocks for surgical anesthesia.

Previous studies and reports have only demonstrated the utility of TAP and IIIH nerve blocks as analgesic blocks and not for surgical anesthesia. To our knowledge, the combination of bilateral TAP block and IIIH nerve block for cesarean delivery has not been reported. In our 4 patients, a combination of TAP and IIIH block provided acceptable surgical anesthesia for cesarean delivery using either Pfannenstiel or midline vertical incisions. We used a single 120-mm needle for both TAP and IIIH block for economic reasons. Because the IIIH nerves are superficial, a 120-mm needle is very long for a superficial block and others would suggest the use of a shorter needle.

Typical local infiltration for cesarean delivery requires 6 steps and approximately 100 mL of local anesthetic solution.8 Adequate local infiltration frequently requires a large dose of anesthetic, and may exceed recommended doses. Infiltration techniques requiring high volumes of local anesthetic are therefore limited by the necessity of using low-concentration local anesthetic solutions, which may limit the effective block duration. Compared with a local infiltration technique, the TAP and IIIH blocks allow the administration of more conventional local anesthetic concentrations by enabling a reduction in total volume. The use of US to guide the nerve blocks may also decrease the necessary anesthetic volume, and may reduce risk of accidental intravascular injection and visceral injury. Finally, a combination of TAP and IIIH blocks may provide more extensive abdominal wall block than local infiltration alone, enabling not only vertical but also low transverse incision.

Authors conducting previous cadaveric studies reported that the IIIH nerve is readily located in the TAP above the ASIS,9 whereas recent studies have shown that the sites where the IIIH nerve enters the TAP and perforates the internal oblique muscle are subject to significant anatomic variability.1013 Therefore, it is not surprising that local anesthesia does not always spread to the IIIH nerve11 and the L1 dermatome is not blocked 50% of the time after posterior TAP block.4 Without IIIH block, incomplete T12 sensory loss was observed after TAP block with a single shot of 10 mL local anesthetic in our 4 patients. By adding the IIIH block, complete T12 sensory loss was produced in cases 1, 3, and 4, although sensory loss in L1 distribution was not complete. The most common sensory loss in our patients was in the hypogastric region and the medial half of the inguinal ligament, but not in the lateral half of the inguinal ligament and upper medial thigh. Anatomically, the IIIH nerve originates from the T12 and L1 nerves. Near the crest of the ilium, the IH nerve divides between the internal oblique and transversus abdominis muscles into a lateral and an anterior cutaneous branch. Through the approach we used, it was possible that only the anterior cutaneous branch of the IH nerve was blocked. Placement of local anesthetic more laterally or using a higher volume for IIIH blocks may result in a complete L1 blockade.

During skin incision, none of the patients complained of pain and no sympathetic hemodynamic responses were observed. It is important to note that this technique does not provide visceral analgesia, and the patients reported discomfort as the infants were extracted. However, we demonstrated that delivery was possible with low-dose propofol and ketamine supplementation without adverse maternal or fetal outcome. Although the relaxation status of the abdominal wall muscle after TAP and IIIH block was not comparable to that achieved with spinal anesthesia, the operative process was uneventful and the procedure was successful. Spontaneous breathing was preserved in all 4 patients during the operation. None of our patients aspirated gastric contents; however, because systemic sedation was necessary for delivery, aspiration prophylaxis is indicated to decrease the risk of this complication. Hemodynamic variables were stable in our patients, except for transient hypertension observed after IV ketamine administration, as well as transient tachycardia after an IV infusion of 20 IU oxytocin injection after removal of the placenta.14,15 These responses resolved spontaneously without additional intervention.

None of the patients developed complications related to the US-guided IIIH and TAP block. Although the use of US-guided regional anesthesia has not been conclusively demonstrated to improve safety, we believe that the risk of visceral and vascular injury was mitigated by the use of US.

Data from animal studies suggest that 4% of the administered dose of ropivacaine is excreted in the colostrum of mothers.16 Human data demonstrated that plasma concentrations of ropivacaine in the mother and neonate were within safe limits after the epidural administration of a higher dose of ropivacaine than that used in our patients.17 Moreover, patient-controlled epidural analgesia with ropivacaine after cesarean delivery was not associated with excessive milk-plasma concentrations of ropivacaine.18 Further study of neonatal ropivacaine levels using this technique are indicated.

There are significant limitations to this report. The dermatomal spread before initiation of surgery was not checked. Evidence suggests that spread of sensory anesthesia up to 30 minutes can occur.4 Although we found incomplete L1 dermatome spread at 15 minutes after the injections, it is possible that sensory blockade included the L1 dermatome at a later time. This would explain the observation of satisfactory surgical analgesia for low transverse incisions that lie in the L1 dermatome. We arbitrarily chose 10-mL injections for each TAP and IIIH block. The best volume to obtain surgical anesthesia is not known. Higher volumes may be indicated when the target nerve is not visualized by US.

The patient outcomes in our cases indicate that the combination TAP and IIIH block may afford acceptable surgical analgesia in cases of cesarean delivery. For patients in whom neuraxial anesthesia cannot be induced, bilateral TAP block combined with IIIH nerve block may be an alternative. It is possible that this approach is a better option than local infiltration by the surgeon in situations in which no anesthesia provider is present, i.e., in developing countries. However, personnel trained to do these blocks, preferably under US guidance, should be available. We hope that this report will promote further evaluation of the technique in this patient group.

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Name: Wei Mei, MD.

Role: This author helped conduct the study and write the manuscript.

Attestation: This author approved the final manuscript.

Name: Chuangang Jin, MD.

Role: This author helped write the manuscript.

Attestation: This author approved the final manuscript.

Name: Lin Feng, MD.

Role: This author helped conduct the study.

Attestation: This author approved the final manuscript.

Name: Yi Zhang, MD.

Role: This author helped conduct the study.

Attestation: This author approved the final manuscript.

Name: Ailin Luo, MD.

Role: This author helped conduct the study.

Attestation: This author approved the final manuscript.

Name: Chuanhan Zhang, MD.

Role: This author helped conduct the study.

Attestation: This author approved the final manuscript.

Name: Yuke Tian, MD.

Role: This author helped design the study.

Attestation: This author approved the final manuscript.

© 2011 International Anesthesia Research Society