Authors: O’Carroll JE et al.
Anesthesiology, November 2025. DOI: 10.1097/ALN.0000000000005868
Summary
This international, prospective cohort study aimed to determine the true incidence of patient-reported pain during cesarean delivery performed under neuraxial anesthesia. Previous estimates were limited by retrospective or single-center study designs; therefore, the investigators conducted an 8-week prospective study across 15 centers in the United States and Canada.
A total of 3,693 patients were included. All underwent neuraxial anesthesia for cesarean delivery and were surveyed on postpartum day 1 regarding intraoperative pain, pain scores (0–10), and satisfaction with management. The overall incidence of pain during cesarean delivery was 7.6% (95% CI 6.8–8.5), with 282 patients reporting pain.
Pain incidence varied significantly by anesthetic technique. For elective cesarean deliveries, incidence was lowest with spinal anesthesia (3.7%) and highest with epidural top-up anesthesia (12.2%). Combined spinal-epidural (CSE) had an intermediate incidence at 9.2%. In nonelective cesarean deliveries, pain was more common: 5.7% with spinal, 7.1% with CSE, 8.0% with dural puncture epidural, and 13.2% with epidural top-up.
Among patients who experienced pain, the median numeric rating score was 6 (IQR 4–8), and 10.3% expressed dissatisfaction with how their pain was managed by the anesthesia team. The findings indicate that while neuraxial anesthesia is highly effective overall, a nontrivial proportion of patients still experience significant intraoperative pain — with considerable variation depending on the specific neuraxial technique used.
Key Points
• Prospective, multicenter data show a 7.6% overall incidence of pain during cesarean delivery under neuraxial anesthesia.
• Spinal anesthesia had the lowest pain incidence; epidural top-up had the highest, in both elective and nonelective settings.
• Patients who experienced pain reported a median pain score of 6/10.
• Most patients remained satisfied, but 10% of those with pain were dissatisfied with intraoperative pain management.
• Further work is needed to determine causes of breakthrough pain and develop strategies to reduce its incidence.
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