Background: Spinal and epidural anesthesia are the dominant neuraxial techniques for caesarean delivery, but their comparative effects on maternal and neonatal outcomes remain uncertain. This systematic review aimed to compare the safety and effectiveness of spinal versus epidural anesthesia for caesarean section, focusing on hemodynamic, fetal, and neonatal endpoints.​

Methods: Electronic databases (PubMed/MEDLINE, Scopus, Web of Science Core Collection) and trial registries were searched from 1 January 2000 to 30 June 2025, with an update to 30 November 2025. Randomised controlled trials and high‑quality comparative cohort studies of pregnant individuals ≥18 years undergoing elective or emergency caesarean section were eligible if they directly compared spinal with epidural anesthesia and reported prespecified maternal or neonatal outcomes. Risk of bias was assessed using RoB 2 for RCTs and ROBINS‑I for non‑randomised studies, and evidence certainty appraised with GRADE.​ Ten studies met inclusion criteria (two Cochrane reviews and eight primary comparative studies; total N = 3,877).

Results: Across trials, spinal anesthesia consistently achieved faster onset and shorter time to surgical readiness than epidural techniques. However, spinal was associated with substantially higher rates of maternal hypotension and vasopressor use, and more intraoperative bradycardia and nausea, while epidural provided greater hemodynamic stability.​ Neonatal 1‑ and 5‑minute Apgar scores were generally higher, or at least not inferior, with spinal compared with epidural, and some studies reported marginally higher umbilical artery pH with spinal, whereas a network meta‑analysis suggested epidural may optimise umbilical venous pH. Both techniques yielded low rates of serious neonatal morbidity, with no consistent differences in NICU admission or acidosis. Postoperative analgesia duration tended to be longer with spinal, but epidural permitted extended analgesia when catheters were used.​

Conclusion: Both spinal and epidural anesthesia provide effective neuraxial options for caesarean delivery. Spinal may be preferred when rapid onset and superior early neonatal scores are prioritised, whereas epidural may be favoured in women at high risk of hemodynamic instability or when prolonged titratable block is desired. Further adequately powered trials are needed to clarify long‑term maternal and neonatal outcomes and cost‑effectiveness.​