BACKGROUND Elective caesarean section is performed mainly under spinal anaesthesia using hyperbaric bupivacaine combined with opioids. Despite rapid onset, good quality anaesthesia, bupivacaine provides a long duration of motor block and is related to maternal hypotension. Current policies appeal for implementation of enhanced recovery procedures after caesarean section. Hyperbaric prilocaine is an intermediate-acting local anaesthetic known for its efficacy in ambulatory surgery. Evidence on the clinical relevance of intrathecal prilocaine use for caesarean section is currently lacking.OBJECTIVES We aimed to investigate whether hyperbaric prilocaine would offer a shorter motor block and recovery than bupivacaine, when comparing equipotent doses. We also assessed the characteristics of sensory block, maternal haemodynamics and side effects for both mother and newborn.DESIGN Prospective, randomised, double-blind, controlled, two-centre, clinical trial.SETTING One university teaching hospital and one general teaching hospital in Brussels, Belgium.PATIENTS American Society of Anesthesiologists' physical status 2 parturients (n ¼ 40) undergoing caesarean section under spinal anaesthesia.INTERVENTIONS Patients were randomly assigned to receive spinal anaesthesia using hyperbaric prilocaine 50 mg or hyperbaric bupivacaine 10 mg, both given with sufentanil 2.5 mg and morphine 100 mg. An epidural catheter was introduced as a backup in case of failure.MAIN OUTCOMES The primary outcome was the motor block regression (modified Bromage scale 1 to 6). Secondary outcomes included sensory block characteristics, first unassisted ambulation, maternal side effects, newborns' parameters and overall satisfaction.RESULTS Median [IQR] motor block was significantly shorter in the hyperbaric prilocaine group (110 [104 to 150] min versus 175 [135 to 189] min, P ¼ 0.001). First unassisted ambulation was achieved earlier after prilocaine (204.5 [177 to 246.5] min versus 314 [209.25 to 400] min, P ¼ 0.007), and the incidence of maternal hypotension was significantly higher with bupivacaine (P ¼ 0.033). No supplementary epidural analgesia was needed.CONCLUSION Prilocaine provides shorter motor block, faster recovery and better haemodynamic stability than bupivacaine while offering equivalent surgical anaesthesia.