Background: Dexmedetomidine can help extend the pain-relieving effects of local anesthetics and reduce the need for opioids during spinal anesthesia in women having planned cesarean sections. In order to determine which combination of dexmedetomidine and hyperbaric prilocaine (2% or 0.5%) is more successful in delivering dependable spinal anesthesia and adequate postsurgery pain management for pregnant women having an elective caesarean section, this study attempted to compare both of them. Methods: In a prospective, randomized, double-blind clinical trial, we assessed the efficacy of hyperbaric prilocaine (50 mg in 2.5 mL) versus bupivacaine (12.5 mg in 2.5 mL), both combined with 5 µg dexmedetomidine, for spinal anesthesia in 74 participants undergoing elective cesarean section. The primary outcome was postoperative pain intensity, assessed using the Visual Analog Scale (VAS). Secondary outcomes included the onset and duration of sensory and motor blockade, time to rescue analgesia, patient satisfaction, and the incidence of adverse events. Results: Postoperative VAS scores were comparable between groups except at 4 and 8 hours post-procedure, where the prilocaine group demonstrated significantly higher VAS scores (P < 0.001). Significant variations were observed in the regression of motor and sensory block, independent ambulation, first rescue analgesia time, and total analgesia within the first 24 hours, as the bupivacaine group had longer durations and lower analgesic doses in all these parameters (P < 0.05). The bupivacaine group experienced a significantly higher incidence of hypotension, nausea, and vomiting. Paradoxically, despite these adverse events, patient satisfaction scores were significantly higher (P=0.04) in the bupivacaine group compared to the prilocaine group. Conclusions: Hyperbaric prilocaine (2%) with dexmedetomidine was as effective and safe as hyperbaric bupivacaine (0.5%) with dexmedetomidine in achieving spinal anesthesia for elective cesarean sections, offering adequate postoperative analgesia and early ambulation. Prilocaine may offer a quicker profile with fewer side effects.