Abstract Study objective The aim of the study was to compare conventional landmark method with ultrasound-guided spinal anesthesia in cesarean delivery cases where spinous processes and interspinous spaces were not prominent on physical examination. Design Randomized controlled clinical trial. Setting Operating rooms of university hospital of Erzurum, Turkey. Patients Sixty-four 18- to 45-year-old American Society of Anesthesiologists I-II patients scheduled for cesarean delivery under spinal anesthesia having hardly palpated anatomic landmarks on vertebral column. Interventions Palpation difficulty of vertebral column landmarks was scored as 0, 1, 2, or 3 from easy to difficult for all patients in sitting position. The patients with score 2 or 3 were randomly allocated into 2 groups as group C (conventional, n = 32) and group U (ultrasound, n = 32) in which ultrasound guidance was used. Measurements The number of skin punctures, the number of needle steering, the number of puncture tried vertebral levels, and procedure time were all recorded. Main results The number of skin punctures was significantly lower in group U ( P < .001). Successful subarachnoid puncture on first attempt was also significantly higher in group U ( P < .01). The duration of procedure in the patients with score 2 was determined to be significantly longer in the ultrasound-guided group ( P < .001). Conclusions Ultrasound guidance is an effective and safe method to reduce the number of puncture attempts, improve the success rate of subarachnoid access on the first attempt, and reduce the need to puncture multiple levels, although it prolongs procedure time in patients with score 2 according to our scoring system designed for this current study.