The purpose of this systematic review and network meta-analysis was to determine the
analgesic effectiveness of peripheral nerve blocks (PNBs), including each anatomical approach, with or without intrathecal
morphine (ITMP) in cesarean delivery (CD). All relevant randomized controlled trials comparing the
analgesic effectiveness of PNBs with or without ITMP after CD until July 2021. The two co-primary outcomes were designated as (1)
pain at rest 6 h after surgery and (2) postoperative cumulative 24-h
morphine equivalent consumption. Secondary outcomes were the time to first
analgesic request,
pain at rest 24 h, and dynamic
pain 6 and 24 h after surgery. Seventy-six studies (6278 women) were analyzed. The combined ilioinguinal nerve and anterior transversus abdominis plane (II-aTAP) block in conjunction with ITMP had the highest SUCRA (surface under the cumulative ranking curve) values for postoperative rest
pain at 6 h (88.4%) and 24-h
morphine consumption (99.4%). Additionally, ITMP, ilioinguinal-iliohypogastric
nerve block in conjunction with ITMP, lateral TAP block, and
wound infiltration (WI) or continuous infusion (WC) below the fascia also showed a significant reduction in two co-primary outcomes. Only the II-aTAP block had a statistically significant additional
analgesic effect compared to ITMP alone on rest
pain at 6 h after surgery (-7.60 (-12.49, -2.70)). In conclusion, combined II-aTAP block in conjunction with ITMP is the most effective post-cesarean
analgesic strategy with lower rest
pain at 6 h and cumulative 24-h
morphine consumption. Using the six described
analgesic strategies for
postoperative pain management after CD is considered reasonable. Lateral TAP block, WI, and WC below the fascia may be useful alternatives in patients with a history of sensitivity or severe adverse effects to
opioids or when the CD is conducted under
general anesthesia.