Intraoperative remimazolam-nalbuphine infusion reduces visceral traction response during cesarean delivery: a randomised trial

Abstract Background Visceral traction response (VTR) occurs in over 40% of cesarean delivery under spinal anesthesia. This study evaluated the efficacy and safety of intraoperative remimazolam combined with nalbuphine for attenuating VTR. Methods In this prospective, randomised, double-blind, placebo-controlled trial, 72 parturients undergoing elective cesarean delivery under spinal anesthesia received either remimazolam (0.05 mg/kg) with nalbuphine (0.1 mg/kg) (R + N group, n = 36) or normal saline (Placebo group, n = 36) after umbilical cord clamping. The primary outcome was positive traction response incidence. Results The R + N group demonstrated significantly lower positive traction response incidence (5.6% vs. 41.7%, p < 0.001) and reduced VTR scores during abdominal exploration and suturing. The incidence of nausea (22.2% vs 58.3%, p = 0.002) and chest tightness (8.3% vs 36.1%, p = 0.005) was significantly lower in the R + N group. Maternal satisfaction was higher (9.56 ± 0.88 vs. 7.11 ± 1.47, p < 0.001). No significant hemodynamic differences or serious adverse events occurred. Conclusions Remimazolam combined with nalbuphine significantly reduces VTR during cesarean delivery, providing effective sedation and analgesia while maintaining hemodynamic stability, representing a safe adjunct to neuraxial anesthesia. Trial registration Chinese Clinical Trial Registry ChiCTR2500108913, registered 9 September 2025.