Anesthesia Patient Safety Podcast

#279 From Birthrooms To Boardrooms: Preventing Trauma And Elevating Maternal Anesthesia Care

• Anesthesia Patient Safety Foundation • Episode 279

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Power, control, and communication shape every birth—and too often, they decide whether care feels safe or traumatic. We dig into practical ways to prevent harm in obstetric anesthesia by centering trauma-informed care, reducing stigma around substance use disorder, and giving real choice during cesarean delivery.

We start by distinguishing complications from trauma and laying out the six pillars that make care safer: safety, transparency, peer support, collaboration, empowerment, and cultural humility. From there, we map prevention across three levels—primary disruption of trauma through clear communication and environment, secondary recognition and mitigation of events, and tertiary support for patients with PTSD. You’ll hear concrete steps for SUD in pregnancy, including continuing methadone or buprenorphine, optimizing regional anesthesia, avoiding medication switches, and using person-first language that builds trust rather than barriers.

We also spotlight the Elevate project, which advances patient-centered anesthesia choices for cesarean delivery through stakeholder engagement, research, and an in-person summit focused on equity and shared decision-making. The aim is simple and vital: align what clinicians must do with what patients most value, from how we speak at the drape to who is present in the room. Finally, we share life-saving resources from the AFE Foundation—education, an international registry, and a stabilization checklist—to turn rare crises into moments of coordinated, effective response.

If these ideas resonate, share this episode with a colleague, subscribe on your favorite platform, and leave a review with one change you plan to make on your next shift. Your feedback helps more clinicians find these tools and deliver safer, more humane maternal anesthesia care.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/279-from-birthrooms-to-boardrooms-preventing-trauma-and-elevating-maternal-anesthesia-care/

© 2025, The Anesthesia Patient Safety Foundation

SPEAKER_00:

Traumatic experiences and complications are not the same. One can experience significant complications, but they might say, I felt supported. I felt safe. Yeah, it wasn't fun, but I don't have mental health complications. And the flip is also true that you don't need physical complications to have a trauma.

SPEAKER_01:

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel, and I'm your host. Thank you for joining us for another show. We hope that you are enjoying our latest series on the 2025 APSF SOLTI Conference all about transforming maternal care. What are you doing in your institution to reduce maternal morbidity and mortality? For ideas about innovations and collaborations, we hope that you will check out the first three episodes in our series, and we are happy that you are here today for part four. If you weren't able to attend the Stolteen Conference this year, then we hope that you will enjoy this podcast series, and you can also check out the recordings from the conference on our YouTube channel. Check out the show notes for more information. Before we dive further into the episode today, we'd like to recognize Medtronic, a major corporate supporter of APSF. Medtronic has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, Medtronic. We wouldn't be able to do all that we do without you. Now it's time to get back into the conference. Thank you to our industry sponsors for supporting the 2025 APSF Stolting Conference, BD, Medtronic, Solventum, and IntelGard. First up, we have a session on trauma-informed care by Tracy Vogel, an obstetric anesthesiologist and director of the perinatal trauma-informed care clinic in Pittsburgh, Pennsylvania. Tracy introduces the idea of trauma-informed care as a universal precaution, and these practices can help prevent re-traumatization and traumatization. So, what is trauma? According to Judith Herman's work, psychological trauma is an affliction of the powerless. It involves a sense of powerlessness, helplessness, and terror combined with the removal of the sense of control, connection, and meaning. Tracy reminds us that trauma is in the eyes of the beholder. Our role as clinicians is not to triage someone else's emotional experiences based on how we think they should feel about it. When we do this, patients may not have a chance to express any negative emotions that they may be feeling. An example of this may be a patient's experience with an emergency C-section. They may feel positive and negative emotions related to the experience, happy about a healthy baby and mom, but also struggling with the loss of control during the surgery. It is also important to remember that complications and traumatic experiences are not the same thing. You do not need a physical or identifiable complication to happen. Perhaps we can think about trauma as defined by the three E's. It is from an event experienced by the individual and has negative effects. How can we provide trauma-informed care? Tracy describes six pillars, including safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, voice and choice, and cultural, historical, and gender issues. Trauma-informed care replaces the question, what's wrong with you? To the question, what happened to you? And the follow-up action, here's what I'm going to do to you, transform to what can we do together to achieve mutual goals based on each person's individual context. This requires a shift from thinking about patients as problematic to symptomatic. Trauma-informed care incorporates the following considerations. Realizes the impact of trauma and understands the paths for recovery. Recognizes signs and symptoms of trauma in patients, families, staff, and others. Can we give the appropriate care in these situations? Responds fully integrating knowledge about trauma into policies, procedures, and practice. This involves knowledge acquisition. For example, we have learned that restraining women for C-section is harmful psychologically and usually not indicated in most circumstances. This may lead us to create a protocol to ensure that this doesn't happen. Actively seeks to resist re-traumatization. Keep in mind that respectful maternity care plus shared decision making plus patient-centered care all overlaps with trauma-informed care and allows for the understanding of trauma and resilience and the impact of trauma on the clinician. Let's go through a few more definitions of types of care. Trauma aware is the process of learning what is trauma and increasing your knowledge base. Trauma sensitive is when you see something from someone else's perspective. Trauma-informed involves building policies and protocols. Healing-centered care involves a multidisciplinary approach and proactive adaptability. Are we doing the right thing and how can we improve? And finally, trauma disrupting care, which recognizes trauma events in real time and uses a framework for intervention and disruption. This process involves self-reflection. So why do we need this for safe obstetric anesthesia care? We have been talking about this a lot in the series. There are many types of traumatic events that may occur during the peripartum period, including OB-related hemorrhage, emergency, or severe maternal illness, anesthesia related, including inadequate anesthesia, needle trauma or complication, and fetal or neonatal events, such as intrapartum emergency events or separation of mother and child. These traumatic events have real consequences for our patients, including the following: disassociation with no memory of the childbirth experience, hyperarousal with agitation and anger with caregivers, psychological harm impairing the maternal fetal bond, increased risk for maternal mental health consequences involving depression and suicide. Negative alteration in pain perceptions leading to chronic pain states, lifelong negative association, negative impact on future reproduction, and avoidance of the operating room. Anesthesia professionals may be impacted as well, leading to an increased risk of job dissatisfaction and burnout. So, what can anesthesia professionals do? For primary prevention, we need to prevent birth trauma from ever occurring. Remember that this is trauma disrupting care. For secondary prevention, we need to identify when a traumatic event happened and then try to prevent the development of post-traumatic stress symptoms. And for tertiary prevention, we need to take steps to minimize symptom severity once PTSD has been diagnosed. These are important ways to work to help keep patients safe during obstetric anesthesia care. Our next speaker is Brinda Camdar, an associate professor of anesthesiology, to talk about substance use disorder during pregnancy. Did you know that the prevalence of maternal opioid use doubled between 2010 and 2017? And there are increased risks for worse outcomes and challenges with pain control. There are also worse fetal outcomes, including intrauterine growth restriction and stillbirth. In addition, neonatal abstinence syndrome occurs in 60 to 80% of babies who are exposed to opioids in utero. Treatment options include methadone, bufenorphine, and naltrexone. We hope that you will check out the 2010 New England Journal of Medicine article, Neonatal Abstinence Syndrome after methadone or bufenorphine exposure. See the show notes for the citation. For patients on these medications, here are some treatment pearls. If on methadone, continue this medication throughout the pregnancy. If on bufenorphine, continue this medication throughout pregnancy. Patients may have good pain control, especially with regional anesthesia techniques, even at doses greater than 16 milligrams per day. Do not switch medications. And patients may require an increased dose of maintenance therapy in the third trimester to prevent withdrawal symptoms. Keep in mind that there is still a stigma about substance use disorder in prenatal care. Healthcare discrimination is very common due to old beliefs that addiction is a moral failing rather than a true diagnosis. This is a vicious cycle of stigmatizing behaviors such as bias and discrimination and stereotyping patients, leading to dismissing symptoms, and premature tapering of maintenance medications with the resultant patient reaction of loss of trust in the healthcare system, avoidance of health care out of fear of being labeled, or fear of family separation, which leads to missed prenatal care, continued or escalated substance abuse, poor maternal and neonatal outcomes, and long-term disengagement. So what can we do? Our words can create barriers to treatment and recovery, or they can convey support. Instead of stigmatizing language, we can use safer words. Here are some examples. Instead of pregnant drug addict, we can say pregnant woman with substance use disorder. Instead of the label IV drug use, we can say a person who injects substances. And instead of addicted baby, we can say a baby born to a mother with opioid use disorder. Another important step is to see the person behind the pain. This involves the following. Connect before you assess. Find one point of genuine connection. Invite them to tell their story. You could say, I'd like to understand your journey. Can you share how fentanyl first became part of your life? Move from measuring to understanding, starting with the mindset that the patient's report is real and worthy of attention. Impact over intensity. Use a functional pain score and discuss with your patient. You could say, can you walk me through what you can and can't do because of the pain? And finally, participate in shared decision making by giving options and empowering patients. Thank you so much to Brenda for sharing these important considerations for caring for patients with substance use disorder. Our next speaker is Grace Lim, an obstetric anesthesiologist and chief of OB in Women's Anesthesiology at the University of Pittsburgh to talk about the Elevate project, advancing patient-centered anesthesia choices during cesarean delivery. This project focuses on how we show up at the patient's bedside with trauma-informed care combined with substance use disorder management. Not only at the bedside, but also at the system level, involving patient-centered care with research projects. Grace highlights the problem of pain during cesarean delivery, keeping in mind that this is an area where patients may not have had a chance to engage in shared decision making. Remember, pain is only one outcome. Patients may have different priorities, including how they are spoken to, what they heard said about them, or the way information was communicated to them. The focus is to empower patients through informed anesthesia choices for C-section delivery to help bridge the gaps between the maternal experience, patient safety, and equitable care access. The Elevate team tackled this problem from different angles, including stakeholder queries, interviews, and an in-person summit. The summit was held in January 2025 and covered shared decision making in cesarean anesthesia, addressing health disparities in maternal care, and policy making and reimagining reimbursement models. We hope that you will check out their website, elevateproject.org. You can find the link in the show notes. Here is the introduction to the project on their website. The big goals for Elevate is to use collaborative research, stakeholder engagement, and innovative strategies to address knowledge gaps, improve clinical practices, and work together so that all birthing individuals receive respectful, informed, and high-quality anesthesia care aligned with their preferences and needs. Grace reminds us that patients and clinicians are not always on the same page when it comes to obstetric anesthesia goals. For example, during a C-section, anesthesia professionals' goals may include timely administration of anesthetic, appropriate monitoring, oxygen delivery. But for the patient, they may have different goals. This is likely an opportunity to partner with patients better. We can ask ourselves: how can I do the things that I need to do, but also meet the patient's needs? Can we get creative about the people in the delivery room to help the patient have a good outcome? For more information, head over to the Elevate website. You can find the link in the show notes. And if this is something that interests you, you can even join the project by signing up on their website. The Elevate project is expanding and looking for collaborators, clinicians, patients, researchers, and stakeholders to join upcoming studies and funded initiatives. We have time to cover one more talk today. Miranda Classen is the executive director of the Amniotic Fluid Embolism, or AFE Foundation, which she founded in 2008 after surviving an AFE during childbirth. The mission for the AFE Foundation is to support research and families as well as clinicians and anesthesia professionals providing care for patients with AFE. The foundation offers education with AFE courses, a simulation toolkit, and tools for effective communication. Research support includes the AFE registry, which is an international registry of more than 250 cases of AFE, as well as a biorepository with specimen studies that are underway. There is still so much that we do not know about amniotic fluid cases. The goal is to transform AFE into something that is predictable, preventable, and treatable. For more information, we hope that you will check out their resources over at AFESupport.org. One of the resources is a hotline that you can call to reach an HIPAA compliant hotline to quickly connect healthcare providers with the AFE Foundation to offer crisis support for the patient, family, or healthcare team, guidance on how to collect AFE specimens for the AFE biorepository, and expertise to aid with the treatment and management of an AFE patient. There is also an AFE stabilization checklist to help during emergent management of a patient with an AFE. This is an uncommon event, and having a checklist is a great way to make sure that you provide the necessary care during the emergency. Let's go through the checklist now. The first box is breathing, and recognition is important here. Patients may present with acute shortness of breath, increasing respiratory rate, and new oxygen requirement. The response includes activate the rapid response team, bring in the crash cart, frequent vital sign monitoring, listen for breath sounds, administer oxygen, and prepare for intubation. The next box is blood pressure, and patients may develop unexplained acute hypotension or cardiac arrest. In the setting of declining blood pressure, it's time to activate the rapid response team, monitor vital signs closely, and perform uterine displacement. For cardiac arrest, call the obstetric code team, including PEDs or neonatal response teams. Note the time and begin chest compressions with manual left uterine displacement. Begin CPR and follow the ACLS algorithm. Deliver within five minutes of pulselessness if greater than 20 weeks gestation or fundus at the level of the umbolycus. The final box is bleeding, which may present with declining blood pressure and maternal tachycardia or pulse pressure less than 30 millimeters of mercury. The response involves notifying the rapid response team, including the anesthesiologist, and activating the massive transfusion protocol. Transfusion with packed red blood cells, FFP, platelets, and cryo precipitate as needed, as well as tranxamic acid administration and ordering labs when appropriate. If possible, before transfusion, draw 5 mLs in a red and purple top tube and set aside for AFE specimen research. For more information, you can call the hotline when able. Check out the show notes for more details about the AFE Foundation, the hotline, the checklist, and more resources. If you have any questions or comments from today's show, please email us at podcast atapf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apf.org for detailed information and check out the show notes for links to all the topics we discussed today. Thank you so much for tuning in. And if you found this episode valuable, please share it with your colleagues, friends, or anyone you know who is interested in improving anesthesia patient safety and improving anesthesia patient care. Your support helps us reach more listeners and spread awareness about the importance of safety in anesthesia. We're excited to share that the podcast is available on Spotify and YouTube and wherever you get your podcasts, so it's easier than ever to listen and share. If you're on Spotify, make sure that you click the bell icon to subscribe so that you don't miss an episode. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.