When the Newborn Isn’t the Only One Crying: Pain during Cesarean Delivery

Jordan Francke, MD, MPH

Cesarean deliveries (CD) are one of the most commonly performed operations in the world. Neuraxial anesthetic techniques remain the gold standard due to enhanced maternal and neonatal outcomes when compared with general anesthesia, but they are imperfect. For many who practice obstetric anesthesia, it has long been known that pain during CD can occur and leads to traumatizing delivery experiences. This has gained increasing attention in both lay media and scientific literature, from the second season of the Retrievals Podcast and descriptions of personal patient experiences in medical literature to numerous studies in the last few years characterizing the problem and evaluating possible solutions. Brendan Carvalho, MBBCh, FRCA, MDCH, FASA, chief of obstetric anesthesiology at Stanford University, moderated a panel of experts to explore what we know and where questions remain during the session, “Intraoperative Pain During Cesarean Delivery: An Evidence-Based Review of Knowns and Unknowns,” on Friday, May 1 at the 2026 Annual Meeting, presented by IARS and SOCCA.

The first speaker James O’Carroll, MBBS, FRCA, an honorary research fellow and consultant anesthetist at the University College London, illustrated the difficulty researchers face in quantifying the incidence of pain during CD. The incidence varies widely depending upon anesthetic type (e.g., spinal vs. epidural anesthesia), study location, surgical considerations (e.g., emergent vs. elective, incision type), and patient demographics (e.g., preferred language, comorbidities). One reasonable approach to assess presence of pain during CD may be review of supplemental intravenous (IV) analgesics during the surgery. However, Dr. O’Carroll reviewed one prospective observational study, demonstrating that in a review of 399 English-speaking patients, 11.5% of patients reported pain but 15% of all patients received IV analgesics and therefore it may not be a reliable metric. A pooled meta-analysis reviewing more than 11,000 patients across 34 studies had a 17% rate of patients experiencing pain during CD.

Most recently, Dr. O’Carroll published the findings of the MID-CD study a prospective multicenter study across 15 sites in Canada and the US that found approximately 7.6% of patients have had pain during CD. One consistency across most studies is that patients have the least intraoperative pain with spinal techniques compared to combined spinal-epidural or epidural top-up methods. For Dr. O’Carroll, this topic has had increasing relevance as recent NHS data demonstrate, for the first time, more babies are being born in the United Kingdom via CD than via nonoperative vaginal delivery.

The following panelist Ruthi Landau, MD, Virginia Apgar professor of anesthesiology and chief of obstetric anesthesia at Columbia University, has made intraoperative pain during CD a focus of her research for over 20 years, but remarked that the best methods to quantify pain (or when and how often to ask patients about it) still remains elusive. Despite its frequent use, Dr. Landau believes that visual analog scales placing pain experiences on a 1-10 scale are overly simplistic and do not capture the full complexity of a patient’s pain experience. Patients may feel several different sensations during CD, including light touch, pressure, pulling, and movement, and expectations should be set that patients may feel these. However, to some patients even these sensations are uncomfortable. Therefore, Dr. Landau implored the audience to avoid simplifying a patient’s experience to “are you feeling pain or is it just pressure?” and to not reiterate “feeling pressure is normal.” To some patients, pressure is uncomfortable and this merits evaluation. Even the words chosen to ask about patient’s pain may benefit from additional consideration – Dr. Landau showed how one RCT illustrated self-reported postoperative pain scores were more severe when words such as “pain” and “surgical trauma” were used compared to words like “healing” and “recovery.” Dr. Landau recommended that intraoperative pain questions focus on the following: (1) are you comfortable, and (2) if not, would you like medication to make you more comfortable?

The session closed with a presentation by Pervez Sultan, MBChB, FRCA, professor of anesthesiology at Stanford University. Dr. Sultan discussed how, within his faculty group, any CD that receives general anesthesia or intraoperative IV analgesics is reviewed weekly with residents for teaching purposes. He emphasized the education value of learning from real cases, and in some cases, attendings will even follow-up further with patients postoperatively to provide additional psychological support. His group has recently incorporated intraoperative pain into simulations, QI meetings, and problem-based learning with residents. He emphasized that not only is it better for patient care, but may have medicolegal implications as well. One of the most common reasons for anesthesia-related litigation within the UK and US is pain during CD, and many of these patients’ anesthetic records have no report of the patients being in pain or interventions to treat it. Dr. Sultan’s advice: consider including pain as a possibility in consents for CD anesthesia (and interventions that will be taken if it is encountered), document pain during CD and analgesics appropriately, and offer psychological support to those who experience it. He reiterated to the audience that an apology for a negative experience is not an admission of medical malpractice or negligence and helps to build or rebuild trust among patients.