Authors: O’Carroll J et al.
Anesthesiology 144(4):784–795, April 2026
Summary:
This large prospective multicenter cohort study provides one of the most definitive assessments to date of intraoperative pain during cesarean delivery under neuraxial anesthesia. Across 15 centers in the United States and Canada, nearly 3,700 patients were surveyed on postoperative day 1, capturing patient-reported pain and satisfaction.
The study found an overall pain incidence of 7.6%, meaning roughly 1 in 13 patients experienced pain during their cesarean delivery. Pain severity was clinically meaningful, with a median score of 6 out of 10. Importantly, the incidence varied significantly depending on anesthetic technique. Spinal anesthesia had the lowest rates of pain (as low as 3.7% in elective cases), while epidural top-up had the highest rates (up to 13.2%), with combined spinal–epidural techniques falling in between.
Pain was more common in non-elective cesarean deliveries, reflecting the urgency and potentially less optimal conditions under which anesthesia is administered. Despite this, the consistency of higher pain rates with epidural top-up across both elective and non-elective settings raises concerns about the reliability of this technique for surgical anesthesia.
Although only about 10% of patients who experienced pain reported dissatisfaction with their care, the findings highlight that intraoperative pain remains a real and measurable issue. The use of postoperative recall to assess pain emphasizes the importance of the patient’s lasting perception of the experience, which may influence satisfaction and future healthcare decisions.
Overall, this study confirms that intraoperative pain during cesarean delivery is not rare and varies meaningfully by technique, underscoring the need for improved strategies in prevention, recognition, and management.
Key Points:
- Approximately 7.6% (1 in 13) of patients report pain during cesarean delivery with neuraxial anesthesia
- Spinal anesthesia has the lowest pain rates; epidural top-up has the highest
- Pain is more common in non-elective cesarean deliveries
- Median pain score among affected patients is moderate to severe (6/10)
- A subset of patients report dissatisfaction with pain management
What You Should Know:
This puts real numbers behind what we’ve all seen. Epidural top-ups are clearly less reliable, and that matters. If 1 in 13 patients is feeling pain, that’s not a rare complication—that’s a system issue. Technique selection and early recognition need to improve.
We would like to thank Anesthesiology for allowing us to summarize and share this article.