In the present study we evaluated whether the sitting position during initiation of small-dose combined spinal-epidural anesthesia (CSE) would induce less hypotension as compared with the lateral position. Sixty women undergoing elective cesarean delivery were randomly assigned to receive a spinal injection consisting of 6.6 mg hyperbaric bupivacaine with sufentanil 3.3 microg in either the lateral or the sitting position. After securing the epidural catheter, patients were turned to a 15 degrees left lateral supine position. Ephedrine 5 mg IV was administered prophylactically and subsequently in case of nausea/vomiting and/or hypotension, defined as a systolic blood pressure less than 95 mm Hg or a 25% decrease from baseline values. Although the incidence of ephedrine supplementation was not different, females in the sitting group required less ephedrine (P = 0.012) and there were fewer problems with identifying the epidural space (P = 0.01). However, more patients in this group required epidural supplementation (35% versus 3%; P = 0.007). In the lateral group, blocks extended more cephalad than with the sitting position (P = 0.014). Apgar scores did not differ, but umbilical artery pH values were significantly higher in patients of the sitting group (7.31 +/- 0.04 versus 7.26 +/- 0.03; P = 0.02). We conclude that performing a CSE technique for cesarean delivery in the sitting position was technically easier and induced less severe hypotension.