Postoperative Recovery Quality After Cesarean Section: Comparing Erector Spinae and Retrolaminar Blocks Using Turkish Version of the Obstetric Quality-of-Recovery Score in a Turkish Cohort (ObsQoR-11T)

METHODS 1.1. Study Design and Settings

This was a retrospective, single-center observational study conducted to evaluate the effects of ESP and RLB on postoperative pain, opioid consumption, and patient satisfaction in women undergoing cesarean section. The study was carried out at Elazığ Fethi Sekin City Hospital, a tertiary care center in Elazığ, Türkiye. Medical records of eligible patients were reviewed for the analysis. The study protocol was approved by the local institutional ethics committee and conducted in accordance with the principles of the Declaration of Helsinki.

1.2. Participants

The study population consisted of adult women who had undergone elective CS at Elazığ Fethi Sekin City Hospital between [start date] and [end date].

Inclusion criteria

Women aged 18-45 years who underwent elective CS under spinal anesthesia.

Gestational age ≥37 weeks, singleton pregnancy.

Received either ESP or RLB for postoperative analgesia, documented in anesthesia records.

ASA Physical Status II-III.

Completion of ObsQoR-11T questionnaire at 24 hours postoperatively.

Exclusion criteria

Emergency cesarean delivery.

Multiple pregnancy or preterm delivery (<37 weeks).

Severe maternal or obstetric complications (e.g., preeclampsia, placenta previa, placenta accreta spectrum).

BMI ≥40 kg/m².

Significant systemic disease (e.g., severe cardiac, respiratory, renal, or hepatic disease).

Fetal or placental anomalies.

History of chronic pain syndromes, opioid dependence, or long-term analgesic use.

Neurological, psychiatric, or cognitive disorders interfering with pain perception or questionnaire completion.

Missing or incomplete data in the medical records.

1.3. Protocol and Outcome Measures

Anesthesia and Postoperative Analgesia All patients had received a standardized spinal anesthesia protocol. During surgery, patients had been positioned supine with a 15° left tilt and given oxygen at 4 L/min via face mask. Adequate sensory block at the T4-T6 level had been confirmed before the CS procedure began.

Approximately 30 minutes before the end of surgery, intravenous 1 g paracetamol and 50 mg dexketoprofen had been administered as part of multimodal postoperative analgesia. Before recovery, ESP or RLB was performed at the T9 level under ultrasound guidance.

Patients were classified into two groups according to the block technique documented in anesthesia charts:

ESP Group: Bilateral ESP block at T9 with 20 mL of 0.25% bupivacaine per side.

RLB Group: Bilateral RLB at T9 with 20 mL of 0.25% bupivacaine per side.

All blocks had been performed by experienced anesthesiologists trained in ultrasound-guided techniques. Postoperatively, patients were monitored in the recovery unit and transferred to the postpartum ward once stable (Modified Aldrete score ≥9).

Surgical Technique Only patients whose records documented a standardized surgical technique were included. All elective CS operations had been performed using a Pfannenstiel skin incision and a lower-segment transverse uterine incision. Uterine closure had been performed with a single layer of absorbable sutures.

Primary Outcome The primary outcome was postoperative recovery quality, assessed at 24 hours using the ObsQoR-11T score recorded in patient files.

Secondary Outcomes

Demographic and clinical characteristics (age, BMI, ASA status, comorbidities, obstetric history).

Intraoperative data: duration of surgery and anesthesia.

Postoperative analgesic requirements: time to first rescue analgesic, total analgesic consumption within 24 hours.

Pain intensity (VAS at rest and on coughing at 1, 6, 12, and 24 hours).

Adverse events (nausea, vomiting, hypotension, bradycardia, block-related complications).

Patient satisfaction scores as documented in follow-up notes.

1.4. Sample Size

As this was a retrospective study, no prior sample size calculation was performed. All patients who met the inclusion criteria during the study period were included in the analysis.

Inclusion criteria

• Women aged 18-45 years, scheduled for elective cesarean delivery under spinal anesthesia.
• Gestational age ≥37 weeks, singleton pregnancy.
• Undergoing either ESP or RLB for postoperative analgesia.
• ASA Physical Status II-III.
• Ability to understand and complete ObsQoR-11T questionnaire.
• Provided written informed consent prior to participation. Exclusion Criteria
• Emergency cesarean delivery.
• Multiple pregnancy, preterm delivery (<37 weeks),
• Severe maternal or obstetric complications (e.g., preeclampsia, placenta previa, placenta accreta spectrum), regardless of urgency.
• BMI ≥40 kg/m²
• Significant systemic diseases (e.g., severe cardiac, respiratory, renal, or hepatic disease).
• Fetal or placental anomalies.
• History of chronic pain syndromes, opioid dependence, or long-term analgesic use.
• Neurological, psychiatric, or cognitive disorders that may interfere with pain perception or questionnaire completion.
• Patients who declined participation or did not provide informed consent.