Author: Jordan Francke, MD, MPH
The Daily Dose
Cesarean delivery is one of the most commonly performed operations worldwide. Although neuraxial anesthesia provides better maternal and neonatal outcomes than general anesthesia, it does not always provide complete comfort. Intraoperative pain can produce a traumatic birth experience and may have significant psychological and medicolegal consequences.
At the 2026 IARS and SOCCA Annual Meeting, experts discussed the incidence of pain during cesarean delivery, the limitations of current pain-assessment methods, and strategies for prevention, treatment, documentation, and postoperative support.
How often does pain occur?
James O’Carroll, MBBS, FRCA, explained that determining the true incidence of pain during cesarean delivery is difficult. Reported rates vary according to the neuraxial technique, whether the procedure is elective or emergent, surgical factors, patient characteristics, language, and how investigators define and measure pain.
Supplemental intravenous analgesic administration has sometimes been used as an indirect measure of intraoperative pain. However, this approach may be unreliable. In one prospective study of 399 English-speaking patients, 11.5% reported pain, while 15% received intravenous analgesics.
A pooled analysis involving more than 11,000 patients across 34 studies found that approximately 17% experienced pain during cesarean delivery.
The multicenter MID-CD study, conducted at 15 sites in Canada and the United States, reported an incidence of approximately 7.6%.
Across studies, single-shot spinal anesthesia appears to produce the lowest rate of intraoperative pain compared with combined spinal-epidural techniques or epidural top-ups.
Understanding the patient’s experience
Ruthi Landau, MD, emphasized that pain during cesarean delivery is difficult to reduce to a simple numerical score.
Patients may experience light touch, pressure, pulling, stretching, or movement. Although clinicians commonly explain that pressure is normal, these sensations may still be painful, distressing, or intolerable for an individual patient.
Asking, “Is it pain or just pressure?” may unintentionally minimize the patient’s experience. Repeatedly telling a patient that pressure is normal may also discourage her from reporting discomfort.
Dr. Landau recommended asking two straightforward questions:
- Are you comfortable?
- If not, would you like medication to make you more comfortable?
These questions recognize that the patient’s comfort and desire for treatment are more important than whether the clinician classifies the sensation as pain, pressure, or pulling.
The language used by clinicians may also influence the patient’s experience. One randomized trial found that postoperative pain ratings were higher when clinicians used terms such as “pain” and “surgical trauma” rather than more reassuring language such as “healing” and “recovery.”
Responding to intraoperative pain
When a patient reports discomfort, the anesthesiologist should acknowledge the complaint, evaluate the adequacy of the neuraxial block, communicate with the surgical team, and offer appropriate treatment.
Management may include pausing surgical stimulation when possible, administering supplemental analgesics, extending an epidural block, providing sedation when appropriate, or converting to general anesthesia when pain cannot be controlled adequately.
The goal should not be to persuade the patient that her sensations are normal. The goal is to determine whether she is comfortable and intervene promptly when she is not.
Education and quality improvement
Pervez Sultan, MBChB, FRCA, described a departmental process in which cesarean deliveries requiring general anesthesia or supplemental intravenous analgesics are reviewed weekly for educational purposes.
Real cases can help residents and faculty identify inadequate block assessment, delayed recognition of pain, communication problems, and missed opportunities for treatment.
His institution has also incorporated intraoperative cesarean pain into simulation exercises, quality-improvement meetings, and problem-based learning.
Postoperative follow-up may be particularly important for patients who experienced severe pain or distress. Direct follow-up from the anesthesia team can clarify what occurred, address unanswered questions, and provide psychological support.
Documentation and medicolegal considerations
Pain during cesarean delivery is a frequent cause of anesthesia-related litigation in the United States and the United Kingdom.
In many cases, the anesthesia record contains no documentation that the patient reported pain or that treatment was provided. Accurate documentation should include the patient’s complaint, the timing and character of the discomfort, assessment of the block, communication with the surgeon, medications administered, the patient’s response, and any decision to convert to general anesthesia.
The possibility of intraoperative discomfort should be discussed during informed consent, along with the steps that may be taken if pain occurs.
An apology or acknowledgment of a distressing experience is not necessarily an admission of negligence. A sincere discussion can help preserve or rebuild trust between the patient and the clinical team.
Clinical significance
Pain during cesarean delivery is more common than many clinicians may recognize. Neuraxial anesthesia reduces risk compared with general anesthesia, but it cannot guarantee a completely pain-free procedure.
Anesthesiologists should assess the block carefully, set realistic expectations, listen to the patient without minimizing her symptoms, and treat discomfort promptly.
Departments should review cases involving intraoperative analgesics or conversion to general anesthesia, educate clinicians through simulation and case discussion, document events thoroughly, and provide postoperative psychological support when needed.
The patient’s report should remain central. When a patient says she is uncomfortable, the appropriate response is to listen, evaluate, and offer treatment.
Thank you to The Daily Dose and IARS for allowing us to summarize this important discussion of pain during cesarean delivery.