A cesarean section, or C-section, is one of the most common surgeries in the United States. In 2023, 32.3 percent of live births were cesarean deliveries, while 67.7 percent were vaginal deliveries, according to the National Center for Health Statistics.

Pain during cesarean delivery under neuraxial anesthesia (regional anesthesia including spinal and epidural anesthesia) is a recognized clinical challenge and one that has received growing national attention. Recent media coverage, including the second season of The Retrievals podcast and a feature in The New York Times, has highlighted cases in which patients experienced intraoperative pain and felt their concerns were not adequately addressed. The Retrievals podcast series on C-sections is an intimate investigation into what it takes to solve one of medicine’s most persistent problems: Listening to birthing patients and adequately treating their pain.

The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, examined its data from 308 closed malpractice claims involving C-sections from 2010 to 2024. Six cases alleged maternal pain during the surgery. Consider the following scenario.

Case example

The G1P0 patient with a full-term gestation was admitted in active labor with pain 10/10. An epidural was placed with good pain relief. The patient was ultimately scheduled for a non-emergent C-section for failure to progress. The anesthesia clinician re-dosed the epidural with lidocaine and bupivacaine for surgery. When the incision was made, the patient yelled, stating she could feel it. The obstetrician stopped, and the patient was given intravenous ketamine. The obstetrician continued with the C-section. The patient began actively hallucinating and continued to feel pain. The baby and placenta were delivered, and the patient was given general anesthesia and intubated.

Postpartum, the patient had difficulty bonding with her baby due to the traumatic events related to the delivery. She suffered from depression and anxiety about future pregnancy and childbirth.

While individual stories are compelling, as clinicians, the focus must remain on clinical excellence, patient safety, and systems that support effective anesthesia care. In this article, we share emerging data, national guidance, and actionable strategies that anesthesiology teams can adopt to mitigate issues and improve outcomes.

Understanding the scope

A prospective study by Kinsella (2008) evaluating over 5,000 cesarean deliveries found that up to 24 percent of patients reported inadequate anesthesia, particularly when conversion occurred from an epidural placed for labor analgesia. While many cases are minor and managed effectively, even rare instances of unaddressed pain can have clinical and reputational implications. Pain-free surgery was not guaranteed: Spinal anesthesia failed in about 6 percent of cases, while women whose epidurals were topped up during labor also reported pain nearly a quarter of the time. For decades, patients who spoke up were often dismissed, told their pain was “normal” or that nothing more could be done.

In parallel, the CDC released its report “Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees” for 2017 to 2021, studying deaths that occur any time from established pregnancy through the first year postpartum. The data revealed that mental health conditions, including PTSD, suicide, and substance abuse disorder, have become the leading cause of pregnancy-related death in the U.S. Though cesarean pain is not listed as a direct contributor, the findings underscore the importance of optimizing patient experience and minimizing distress when possible. It is well established that a patient’s perceived birth experience influences their likelihood of developing childbirth-related PTSD.

Prevention strategies and resources

Most anesthesia clinicians already practice with vigilance and empathy, but there are multiple organizations that can assist with practice improvement. The Society for Obstetric Anesthesia and Perinatology (SOAP) provides a forum for discussion of problems unique to the peripartum period. The SOAP website has a provider section with resources, including learning modules, videos, and information for patients to answer questions about managing pain before, during, and after delivery.

North American Partners in Anesthesia provides an Obstetric Resource Center with educational videos about anesthesia during labor and delivery and C-section procedures. The center provides information for patients on what to expect before, during, and after labor and delivery. Given the high visibility of recent cases, institutions and practitioners can benefit from structured protocols and early interventions to reduce the likelihood of intraoperative pain and ensure a coordinated response if it does occur.

Where clinical teams can focus

• Optimize epidural function early: Marginal labor epidurals are a known risk factor for inadequate surgical anesthesia. Frequent top-ups, unilateral coverage, or sacral sparing should prompt consideration of catheter replacement before the decision for cesarean arises. Early counseling can help patients understand this recommendation as a proactive measure, not a complication. When labor epidurals are not providing optimal pain relief, consider early replacement as a preemptive strategy to prevent a poorly functioning epidural during C-section.
• Standardize readiness for intraoperative pain: If a woman says she feels pain during a C-section, it is time to pause, assess, and act. The American Society of Anesthesiologists’ (ASA) “Statement on the Use of Adjuvant Medications and Management of Intraoperative Pain During Cesarean Delivery” provides valuable guidance. Each labor and delivery unit should review local medication availability and ensure familiarity with dosing protocols. Stocking agents such as clonidine, dexmedetomidine, and low-dose ketamine—and training teams on their use—can facilitate timely, effective responses.
• Improve informed consent and communication: Informed consent is more robust when it includes discussion of common and significant possibilities. While practitioners need not dwell on rare outcomes, setting realistic expectations for neuraxial success rates can build trust. Language should be clear and professional, for example, “In some cases, additional medications or adjustments for pain relief may be needed during the procedure.” Acknowledging the potential for pain during C-section in the preoperative consent emphasizes the importance of the patient’s experience to the anesthesia care team, with the goal of encouraging open communication.
• Use structured documentation tools: It is difficult to record a patient’s intrapartum pain scale without first having a unique build-out. Several institutions have implemented EHR prompts to assess intraoperative pain at set intervals during C-section. Sites such as the University of Illinois Chicago have incorporated 15-minute intraoperative pain checks into their workflow, enabling better recognition and documentation. This approach supports both clinical care and quality improvement review.
• Establish criteria for conversion to general anesthesia: While general anesthesia carries its own risks, particularly in the obstetric population, clear internal guidelines can support anesthesia clinicians when escalation to general anesthesia is clinically indicated.
• Support families and focus on mental health: Partners or support people also need to understand what is happening during a C-section. Their reactions can influence a patient’s stress and recovery. Even when the birth is over, it is important to check on the patient’s emotional well-being. Conversations that validate emotions can make the difference between a patient viewing their childbirth as a difficult but rewarding experience versus a traumatic one.

Resources for clinical teams

Led by Grace Lim, MD, MSc, and Mark Neuman, MD, MSc, the Elevating Anesthesia Choices for Caesarean Delivery: A Roadmap to Patient-Centered Research (ELEVATE) project engages stakeholders to create a patient-centered comparative clinical effectiveness research agenda to enhance anesthesia choices during caesarean deliveries. ELEVATE is a unique opportunity to listen and learn from patients and engage in conversation with practitioners about areas where future research can help improve anesthesia choices during a cesarean delivery.

Several professional societies have developed resources that can support anesthesiology teams:

• SOAP Peripartum Pain Management Toolkit for Cesarean Delivery: Includes medication guides, clinical pathways, and team-based communication tools.
• ThePainlessPush.com: (Developed by SOAP) supplies patient-facing materials available for use at institutions with appropriate legal review.
• ASA Practice Guidelines for Obstetric Anesthesia: Outlines pharmacologic strategies and approaches to managing intraoperative pain.
• ASA Statement on Pain During Cesarean Delivery: Provides recommendations and suggested best practices regarding pain during C-sections.

Managing intraoperative pain during cesarean delivery is a multifactorial challenge, spanning patient physiology, neuraxial technique, communication, and systems preparedness. By focusing on proactive management, team training, and clear documentation, anesthesia clinicians can continue to provide high-quality care while minimizing the risk of unanticipated pain or distress in the operating room. As national attention continues to grow, it’s more important than ever that anesthesia teams lead this conversation, not in response to litigation or media scrutiny, but as part of our commitment to clinical excellence and maternal safety.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The opinions expressed here do not necessarily reflect the views of The Doctors Company. We provide a platform for diverse perspectives and health care information, and the opinions expressed are solely those of the author.

Megan Rosenstein, MD, MBA, is with North American Partners in Anesthesia and serves as a board member of the Society for Obstetric Anesthesia and Perinatology.

Founded and led by physicians, The Doctors Company is relentlessly committed to advancing, protecting, and rewarding the practice of good medicine. The Doctors Company helps hospitals and practices of all sizes manage the complexities of today’s healthcare environment—with expert guidance, resources, and coverage—and is the only medical malpractice insurer with an advocacy program covering all 50 states and the federal level. The Doctors Company is part of TDC Group, the nation’s largest physician-owned provider of insurance and risk management solutions. TDC Group serves the full continuum of care.