BACKGROUND: Epidural anesthesia became most popular for a cesarean section, but it is more time consuming and involves a higher incidence of insufficient or superficial blockade, especially of the motor root, despite large doses of local anesthesia. Combined spinal epidural anesthesia has gained an increasing interest as it combines the reliability of the spinal block and the flexibility of an epidural block. A dural puncture using the combined spinal epidural technique making an early sacral blockade might be a solution to disadvantages in epidural anesthesia. We investigated the efficacy of combined spinal epidural anesthesia and epidural anesthesia with prior dural puncture for a cesarean section. METHODS: Sixty pregnant women at full term were divided into three groups. Group I (EPI, n = 20) received epidural anesthesia with 100 mg of 0.5% bupivacaine. Group II (CSE, n = 20) received combined spinal epidural anesthesia with 1.2 1.4 ml of 0.5% hyperbaric bupivacaine intrathecally, followed by sensory block at T10 after by 7 8 ml of 0.5% bupivacaine through the epidural catheter. Group III (DP, n = 20) received epidural anesthesia with prior dural puncture. A dural puncture with a 27 G whitacre needle was done before an infusion of 20 ml of 0.5% bupivacaine through the epidural catheter. The quality and side effects of surgical anesthesia were compared between the three groups. RESULTS: Time to T10 (P< 0.001) and surgical onset time (P< 0.001) were significantly shorter in the CSE group. Maximal sensory block level (P< 0.001) was significantly higher in the CSE group. Muscle relaxation (P< 0.05) and motor block (P< 0.001) were much better in the CSE group. Hypotension occurred in 25% (EPI group), 40% (CSE group) and 20% (DP group) of the patients. While 65% of the EPI group and 50% of the DP group complained of intraoperative pain, only 25% of CSE group did (P< 0.05). CONCLUSIONS: We can conclude that combined spinal epidural anesthesia has great efficacy and less side effects for a cesarean section than epidural anesthesia and epidural anesthesia with prior dural pucture.