Optimizing Intrathecal Opioid Strategies for Cesarean Section: A Comprehensive Narrative Review of Pharmacology, Clinical Outcomes, and Safety.

Intrathecal opioids (ITOs), such as morphine, fentanyl, and sufentanil, are widely used as adjuvants in spinal anesthesia for cesarean sections to enhance postoperative analgesia and reduce systemic opioid exposure. Optimizing their selection and dosing is critical to balancing effective analgesia with maternal and fetal safety. This article aims to critically analyze the use of intrathecal opioids in spinal anesthesia for cesarean sections, focusing on their mechanisms of action, clinical benefits, associated risks, and role within Enhanced Recovery After Surgery (ERAS) protocols. A comprehensive narrative review was conducted using PubMed, Scopus, and Google Scholar to identify relevant literature published between January 2010 and March 30, 2025. Morphine provides prolonged postoperative analgesia but is associated with higher rates of pruritus and delayed respiratory depression. Fentanyl and sufentanil offer faster onset but shorter analgesic duration. Combining intrathecal opioids with local anesthetics improves hemodynamic stability and reduces overall opioid requirements. While adverse effects are common, they are dose-dependent and manageable with appropriate monitoring. The tailored selection of intrathecal opioids, guided by pharmacological profiles and patient-specific factors, enhances analgesia and patient-specific safety in cesarean delivery. Refining dosing strategies and integrating multimodal analgesia protocols are essential to minimize adverse effects and optimize maternal and neonatal outcomes.