Authors: Landau R et al.
Anesthesiology 144(4):749–751, April 2026
Summary:
This editorial examines the persistent problem of intraoperative pain during cesarean delivery despite the widespread use of neuraxial anesthesia. Drawing on a large prospective multicenter study of nearly 3,700 patients across North America, the authors highlight that approximately 1 in 13 patients report pain during cesarean delivery—confirming that this issue remains clinically significant.
A key finding is the marked difference in pain incidence based on anesthetic technique. Patients receiving spinal anesthesia reported a lower rate of pain (4.4%) compared to those undergoing epidural top-up (13.1%), suggesting that epidural-based techniques may be inherently less reliable for achieving dense surgical anesthesia. This raises concerns about the adequacy of labor epidurals when converted for cesarean delivery, as many may already be partially ineffective prior to surgical dosing.
The study’s focus on patient-reported, remembered pain (assessed on postoperative day 1) is particularly important. Pain that persists in memory carries greater psychological impact and may influence patient satisfaction, future healthcare decisions, and long-term mental health. While this methodology may miss brief or transient intraoperative discomfort, it emphasizes what ultimately matters most—the patient’s lived experience.
The authors challenge a long-standing paradigm in obstetric anesthesia: the reluctance to convert to general anesthesia. While neuraxial techniques are generally preferred for safety reasons, the article argues that ongoing intraoperative pain represents a clear failure of anesthesia care. With modern airway tools reducing risks associated with general anesthesia, clinicians must reconsider whether avoiding general anesthesia should take precedence over preventing patient suffering.
Ultimately, the article calls for greater vigilance, better assessment of block adequacy, and a lower threshold for intervention—including catheter replacement, repeat neuraxial procedures, or conversion to general anesthesia when needed. It also emphasizes the importance of acknowledging and addressing these experiences postoperatively.
Key Points:
- Intraoperative pain during cesarean delivery still occurs in about 1 in 13 patients
- Epidural top-up is associated with significantly higher pain rates than spinal anesthesia
- Many labor epidurals may be suboptimal before conversion to surgical anesthesia
- Remembered pain has important psychological and patient satisfaction implications
- Reluctance to convert to general anesthesia may contribute to ongoing patient suffering
What You Should Know:
This is a failure metric we’ve tolerated too long. If a patient feels pain during a C-section, anesthesia failed—period. With better airway tools and monitoring, the risk-benefit balance is shifting. The real question now is whether we’re prioritizing avoiding general anesthesia over preventing patient harm—and that’s a decision worth rethinking.
We would like to thank Anesthesiology for allowing us to summarize and share this article.