Author: Jordan Francke, MD, MPH
IARS and SOCCA 2026 Annual Meeting coverage
Neuraxial anesthesia remains the preferred technique for cesarean delivery because it generally produces better maternal and neonatal outcomes than general anesthesia. However, spinal, epidural, and combined spinal-epidural techniques do not always provide complete comfort. Intraoperative pain can cause significant psychological trauma and remains an important source of patient dissatisfaction and anesthesia-related litigation.
James O’Carroll, MBBS, FRCA, discussed the difficulty of determining how often pain occurs during cesarean delivery. Reported rates vary according to the anesthetic technique, urgency of surgery, incision type, patient characteristics, language, and how investigators define and measure pain.
The administration of supplemental intravenous analgesics is sometimes used as an indicator of inadequate neuraxial anesthesia, but this may not accurately reflect the patient’s experience. In one study of 399 English-speaking patients, 11.5% reported pain, while 15% received intravenous analgesics.
A meta-analysis involving more than 11,000 patients across 34 studies found that approximately 17% experienced pain during cesarean delivery. The more recent prospective, multicenter MID-CD study reported an incidence of approximately 7.6%.
Across studies, spinal anesthesia appears to produce the lowest rate of intraoperative pain compared with combined spinal-epidural techniques or epidural top-ups.
Ruthi Landau, MD, emphasized that conventional pain scales may oversimplify the patient’s experience. During cesarean delivery, patients may feel touch, pulling, pressure, stretching, or movement. Although clinicians may consider these sensations normal, they can still be distressing or painful to the patient.
Clinicians should avoid dismissive questions or statements such as:
- “Is it pain, or is it just pressure?”
- “Feeling pressure is normal.”
Telling patients that a sensation is normal does not make it comfortable. Instead, Dr. Landau recommended asking:
- “Are you comfortable?”
- “If not, would you like medication to make you more comfortable?”
The language clinicians use can also influence patients’ perceptions. One randomized trial found that patients reported greater postoperative pain when clinicians used words such as “pain” and “surgical trauma” rather than more reassuring terms such as “healing” and “recovery.”
Pervez Sultan, MBChB, FRCA, described an institutional program in which cesarean deliveries requiring general anesthesia or supplemental intravenous analgesics are reviewed regularly for educational and quality-improvement purposes.
These cases can be incorporated into:
- Resident education
- Simulation training
- Quality-improvement meetings
- Problem-based learning
- Postoperative patient follow-up
Patients who experience intraoperative pain may also benefit from psychological support. Follow-up provides an opportunity to acknowledge the experience, explain what occurred, and identify patients who may develop persistent anxiety, traumatic memories, or symptoms of post-traumatic stress.
Key Takeaways
Pain during cesarean delivery is not rare. Depending on the study and methodology, approximately 7% to 17% of patients may experience intraoperative pain despite neuraxial anesthesia.
Spinal anesthesia generally appears to provide more reliable surgical anesthesia than epidural top-ups or combined spinal-epidural techniques, although no method completely eliminates the risk.
Clinicians should assess the patient’s comfort throughout surgery and respond promptly when the patient reports discomfort. Pressure, pulling, or movement should not be dismissed merely because those sensations are expected.
The possibility of intraoperative pain and the available treatment options should be included in the preoperative consent discussion.
Any pain, patient concerns, medications administered, conversion to general anesthesia, and the clinical response should be clearly documented in the anesthetic record.
After a distressing experience, clinicians should provide an explanation, apologize when appropriate, and offer psychological follow-up. An apology is not necessarily an admission of negligence and may help restore trust.
Thank you to IARS and SOCCA for allowing us to summarize this important coverage from the 2026 Annual Meeting.