Anesthesia Patient Safety Podcast

#284 Safer C-Section Pain Control with Ruth Landau, MD

• Anesthesia Patient Safety Foundation • Episode 284

Share episode

The fastest way to improve post-cesarean recovery is to start before the first incision—by setting expectations, testing the block, and validating what patients feel. We sit down with Dr. Ruth Landau, Virginia Apgar Professor and Chief of Obstetric Anesthesia at Columbia University, to map a safer path from the OR to the nursery: neuraxial-first analgesia, scheduled non-opioids, and small, truly PRN opioid prescriptions at discharge. She explains how intrapartum cesareans carry higher risk for discomfort and why simple shifts—active epidural management, timely redosing, and clear, compassionate communication—reduce pain, opioid exposure, and the chance of a traumatic birth experience.

We break down practical steps that clinicians can apply today. Learn the difference between systemic and neuraxial opioids for breastfeeding safety, when to use ultrasound-guided TAP or QL blocks after general anesthesia, and how micro-boluses of IV dexmedetomidine can blunt visceral sensations, anxiety, and shivering. Dr. Landau also shares the latest from ASA statements and SOAP guidance, including dose-dependent monitoring strategies that make neuraxial opioids feasible even in resource-constrained settings.

The conversation moves beyond pharmacology to focus on outcomes that matter to families: fewer leftovers at home, less persistent opioid use, and birth memories grounded in trust instead of fear. We talk debriefs, trauma-informed care, and patient-reported experience measures, plus new research on sensation profiles and intrathecal adjuvants like dexmedetomidine and clonidine. If you’re building an opioid-sparing cesarean pathway—or refining the one you have—this is a clear, evidence-informed playbook.

If this resonates with you, follow the show, share it with your OB and nursing teams, and leave a review with one change you plan to make next shift. Your feedback helps more clinicians find these strategies and keeps more parents safe and comfortable.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/284-safer-c-section-pain-control-with-ruth-landau-md/

© 2025, The Anesthesia Patient Safety Foundation

SPEAKER_01:

We need to understand, and we know that that if we move them in an urgent manner from a labor room into the operating room, hitting every wall and every door on our way to the operating room, and then you know, doing everything so rushed that our anesthetic has barely had the time to kick in, it's going to be not only a painful experience, but a traumatic one. So we have a tremendous responsibility and a tremendous opportunity to make a difference.

SPEAKER_00:

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 have a very special show for you today. Dr. Ruth Landau joined me for a great conversation all about keeping patients safe and comfortable throughout the peripartum period, and especially when it comes to pain management during and after cesarean delivery. Dr. Landau is the Virginia Apgar Professor of Anesthesiology and Director of the Division of Abstetric Anesthesia at Columbia University. She also serves as the editor-in-chief of the International Journal of Obstetric Anesthesia. Dr. Landau is truly an expert in the field, and her dedication to research, clinical care, education, leadership, and mentoring really shines through in our discussion. So stay tuned. Before we dive further into the episode today, we'd like to recognize Eagle, a major corporate supporter of APSF. Eagle has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, Eagle. We wouldn't be able to do all that we do without you. And now my conversation with Dr. Ruth Landau. Can you introduce yourself and tell us a little bit about your anesthesia training career and your current role? And then we'd love to know how you became interested in obstetric anesthesia as the focus for your practice.

SPEAKER_01:

Wonderful. So I'm Ruthie Landau. I was born in Switzerland and I traveled a little bit as a child. My parents traveled because my father was a diplomat for the United Nations. But I did my high school and medical training and anesthesia residency training at the University of Geneva in Switzerland. And in Europe, we actually do not have fellowships, or definitely didn't have them back in those days. And my goal was to become an anesthesiologist and take it from there. So when I finished my training and I found myself and attending in the operating room, I think after one week, I felt this is terrible. I need some focus, I need something. And I happened to see an ad in anesthesiology for fellowships in New York. I had no idea what a fellowship was, but it sounded very cool. So I applied. And when I applied, they told me, sure, but which subspecialty of anesthesia do you want to do the fellowship in? And I was like, oh, I've always liked OB anesthesia. So I applied for that one. And I came for an interview in New York and I met the team at Columbia. And you know, it was the beginning of everything. I felt for the first time that that was exactly what I wanted to do. So I came for the fellowship at Columbia in New York. I did a two-year fellowship. I was extremely fortunate to have wonderful mentors and did some research that was back in the days quite unique. I don't want to say cutting edge, but it was cutting edge. And so that launched my, I would say, my academic career and anchored me into a field that I thought was just perfect for me. So the field of research, it's important because it was genetics and how genetic variability may impact our, you know, our vulnerability, susceptibility to diseases, but more specifically, how our genetic makeup may make us more or less responsive to medication. And that was very much something that appealed to me in the sense that we're all different, we respond to medication differently. And even though I'm a big fan, those who know me and work with me know that I love guidelines, I love standardized things. At the same time, I love the variation around a theme. And so this sort of put it together. You know, at the time we called it personalized medicine, then we called it precision medicine, we can call it tailored, customized uh approach to patients' care. But that's how it all started. And it was actually through, you know, genomics, genetics, and that was over 25 years ago. So my current role, because that was your question, I'm the division chief at Stetric Anesthesia at Columbia. I hold, I'm very proud of that title, the Virginia Abgirl Professorship. Um, so this is my hospital and academic title, but something else that I've recently um started to do, I am now, for the last 18 months, the editor-in-chief of the International Journal of Obstetric Anesthesia, which I'm particularly excited to do because I I always love the, you know, reviewing, editing, and now publishing. And I feel like there's a tremendous opportunity to shape what gets, you know, published, the way things are framed, the way things are contextualized. And so that's what I do in addition to being the division chief of obstetric anesthesia at Columbia.

SPEAKER_00:

That's great. It was so nice hearing your story about how you got into obstetric anesthesia. Have you been at Colombia the whole time since you started there? Or was it a coming home to Colombia after a little bit?

SPEAKER_01:

I always said that I'm not good at cutting umbilical cords, which is true. I came to Colombia for the fellowship and I stayed for two years, but then I went back to Switzerland and I was the division chief at the University of Geneva. But because I'm not good at cutting umbilical cords, and mostly because I still had some research, ongoing research, I was fortunate to be able to be a visiting professor for six or seven years at Columbia. I used to come and go um usually twice a year, usually around the times of meeting. So I was able to come in spring for SOAP and then in the fall for ASA. And I was clinical and research at Columbia and in Switzerland. Uh great chairs that let me do a little bit, you know, out of the box. It's not usual that you can have two roles and two titles and go back and forth, but I did that between 2000 and 2007. And then I got recruited to go to the University of Washington in Seattle. So I went to the West Coast for six years, where I was the division chief there and did some uh research there. And then I came back to New York, which was the for the first time I was full, you know, full faculty because I hadn't been before. So I've been full faculty at Columbia since 2014. Oh, okay. I'm full faculty in New York and I hold the title of the division chief since 2018.

SPEAKER_00:

Nice. Well, since this is the Anesthesia Patient Safety podcast, we'd also like to start the conversation off about patient safety. So, what got you interested in patient safety in your practice?

SPEAKER_01:

So, extremely fortunate that my chair in Geneva, Switzerland, Professor François Clerc, was a pioneer in patient safety in France. He actually is from Paris and was recruited to serve as the chair of the department in Switzerland just when I was transitioning from resident to attending in Switzerland. And I know that he was the first, I was the first resident that he promoted to the role of faculty. And he championed patient safety in France, I can say in Europe, and definitely in our hospital in Geneva. And we talked about safety all day, which was something very new. And I remember very well one of the first things that happened, and I'm saying it a little bit facetiously, was that we started to have the colored labels to, you know, label the syringes of medication, because before that we would just scribble, you know, on a piece of tape on this or directly on the syringe with a Sharpie. So that I remember thinking, okay, that it does seem like it's much safer, but I thought it was funny to imagine that this in itself could make a difference. But of course it did. So drug errors, you know, all this. We were pioneers, I would say, in Europe back in those days. And we also had the culture of safety and the culture of crew resource management before it was called this way, and to air as human, all these things were implemented in our hospital much sooner than anywhere else that I can think of in Europe. And I thought it was amazing that we could talk about human errors and how you know it shouldn't be stigmatized, but it's, you know, that every opportunity is a learning opportunity for individuals, for a system. And this was implemented very early on. So I can I can remember of patient safety being really something that was cultural to our institution and key and central because this was our chair's focus.

SPEAKER_00:

Oh, that's so cool. And it's so nice to see it from the ground up, and then to help build your career on that as well, because those principles were just part of your training and and everyday life as an early anesthesiologist, too.

SPEAKER_01:

Absolutely. It was part of the, I would say the value, you know, the the philosophy of the department. And it was a change. It was a big change. We didn't talk about these things before, and then suddenly it became central to everything we did.

SPEAKER_00:

Can you tell us about your research and your work on pain management during cesarean delivery? So now we're going to get into the meat of the show here. And then also, we'd love to know a little bit more about traditional pain management during and after cesarean delivery and how this has evolved a little bit over the years.

SPEAKER_01:

So obviously, as an obstetric anesthesiologist, I mean, managing pain and analgesia is the essence of what we do, you know, whether it's for labor, whether it's for cesarean deliveries. And I must say that the way pain is managed in Europe compared to the United States, you probably know, is very different. I was surprised to see the heavy reliance on systemic opioids. One, because I'd never seen that. In Switzerland, women didn't expect to be given opioids, and it was not prescribed. So I was surprised to see how much opioids were prescribed, and not only that opioids were prescribed, but they were prescribed instead of the non-opioids. So pain management after any surgery, but in particular after cesarean delivery because of breastfeeding and you know uh breast milk transfer of opioids, pain management in general was really based on the fact that we should be combining multimodal non-opioid analgesia, and that's you know, from 25 years ago. So it was surprising. And with all that, at the same time, we know, I mean, I noticed, and then through our different projects, noticed that they were not getting the non-opioids, they were getting opioids and they were in pain. So my first impression was that that the reliance on the opioids without giving the non-opioids didn't result in better pain management. In fact, it resulted in poorer pain management. And then compounded over all of this started the whole you know opioid epidemic. So not only were patients not getting better analgesia, but we were potentially the source of the first exposure to opioids during the you know delivery hospitalization, where patients were given opioids, then prescribed tremendous amounts of opioids, and then you know, the lingering of it, the persistent use, and then potentially uh chronic use and opioid use disorder. So it was a realization over years of something that was happening in terms of the initial management, that not only wasn't it great, but then it had long-term consequences. So that's a series of many studies that resulted in the realization that opioids are prescribed after surgery in a manner that, first of all, I think it's difficult for anesthesiologist. It was difficult back in the days to even imagine it because we weren't, as you know, we're not the ones prescribing these opioids when patients leave the hospital. And I I can tell you that I noticed it's 10 years ago. It's exactly 10 years ago because we started looking at for you know, in the cesarean delivery uh space, it's what are the obstetricians prescribing? And more importantly, when the prescription is actually made was a big realization that we have a problem that is quite awful, but actually quite fixable. So for me, you know, I didn't know when the prescription is made. And I realized that patients who have a scheduled cesarean delivery, the prescription is actually made on admission, which I I didn't know. And it's not, it was definitely not based on the pain trajectory or how much opioid the patients had taken during the two, three days of their hospitalization. It was just prescribed, and you know, it's on a prescription. And the other thing that was missing was the explanation. So patients were not told what to do with this prescription and whether it, you know, they went home with a little orange uh, you know, vial that contained a certain number of tablets. Are they supposed to take everything? How are they supposed to take that? So for me, as you know, an outsider, you know, coming back to the US, but also not the one prescribing it. And I don't think that my colleagues knew that either. So we started those studies where we looked at what is prescribed, when is it prescribed, how much patients go home with. And that was one of the papers that showed that the larger the prescription, like the supersizing it, patients actually took more, just I presume because they had it at home, and why not? Or maybe they didn't know that they're not supposed to take it unless they are in pain, and that there was no explanation surrounding that. So that's when the concept of shared decision making, how many tablets do you want to go home with, and then individualized opioid prescriptions. And we did some of these studies as well, and it really shifted how you know everybody, you know, from the patients to the prescribers to anesthesia, to some extent, the anesthesia may be less involved in that part of the equation. But obviously, if we're going to retroengineer or retrofit, so the the less patients take or took opioids after their cesarean delivery or any surgery for that matter, the less they should be prescribed. But this needs to be accompanied by some explanation. And for that reason, you can't do that prescription on the day of admission. You have to do that prescription when they're about to leave the hospital, which might be a little bit less convenient, but is definitely the right thing to do. So it was a whole, you know, a whole pathway into realizing what needs to be done. And this was after many years of trying to identify the response to pain and try to individualize what we give as anesthesiologists based on genomics, and then realizing that maybe that's, I mean, it is important, and maybe there is a signal and maybe there is a little bit of a genetic effect, but that ultimately it doesn't matter what our genes do for us if what happens is zero explanation, and patients are just giving a large dose of systemic opioids in the hospital because they're not getting the non-opioids, and then they're sent home with a prescription. So, to summarize everything, it was baby steps putting them all together, but it was stopping the reliance on systemic opioids and favoring neuraxial opioids because that's much safer. It's more effective, much safer, doesn't cross the breast milk, is better for mom and baby, then not prescribe the opioids as a standard, but just PRN and have the non-opioids be standard around the clock with a good explanation that, by the way, takes only two to three minutes to the patients and the nurses and everyone. And then when patients go home to not just do a generic uh cookie-cutter prescription, but really tailor to what every single specific patient uh what their pain trajectory is, what they want, and explain. And then the last piece of it in the spirit of um patient safety is what to do with leftovers, because that was another piece that was absolutely missing. So I'm talking about, you know, an evolution over 10 or 15 years of building a story of systemic opioid reduction and coming to what actually happens in Switzerland. No one gets opioids, systemic opioids after a c-section. And I often started my presentations by saying, I had a c-section and I did not take any opioids. Zero. It wasn't offered, I didn't want it, I didn't need it, I think I'm doing fine. I I think it's really a cultural shift, it's a paradigm shift, it's educating every single person along the road, but it's definitely doable. And I think we've we've made, you know, a big a lot of progress. Back in those days, the prescription of opioids, it was 40 to 60 tablets of oxycodone, five milligram. Now I think most institutions, it's between zero and ten, maybe fifteen. So huge progress.

SPEAKER_00:

And a lot of work to get there. It's very interesting to hear the international perspective too. And I think that's one of the interesting parts of the Anesthesia Patient Safety Foundation because we are able to get that international exposure. We hear about how practices are done in other areas of the world and can kind of use the knowledge gained throughout the world to help make anesthesia safer and keep patients comfortable at the same time. One of the APSF patient safety priorities is opioid-related harm with a focus on prevention and mitigation of opioid-related harm for surgical patients. And so this is something that's kind of come up when we were talking about pain management during cesarean sections. So I think we already know the answer to this question, but should we be using opioid-sparing protocols for cesarean delivery and postoperative pain management? And what do you see as the most important considerations when it comes to pain management during the cesarean delivery and then in the postoperative phase? And how can anesthesia professionals help prevent and mitigate opioid-related harm for patients undergoing cesarean delivery?

SPEAKER_01:

Such good questions, and so many of them like this.

SPEAKER_00:

You can just take your favorite.

SPEAKER_01:

I like them all. So listen, we all know that pain is a continuum. So we know that a patient that comes into her pregnancy with chronic pain is going to have pain during pregnancy, won't miraculously go away, and she'll come into her delivery probably with more pain and fear of pain, and maybe she won't be opioid naive, so she'll be opioid tolerant. So I won't talk about these patients who already come with a history of chronic pain because this is a this is a different story, and it's not the time to opioid shame them, as people say. It's not the time to say, oh, you're an opioids, you're having a baby. It's okay. So those patients who are on opioids, we need to keep them on the opioids they're on, neither increase, neither decrease the dose, and then do all the rest as much as possible in a non-systemic manner to get them through uh delivery, whether to, you know, vaginal delivery or cesarean delivery, um, and maintain what they're on. So I'll put this aside. So for those who are opioid naive, I think the most important thing that we never talked about enough is setting expectations. The women, and by the way, we talk about cesarean delivery as if it's one bucket of everyone the same. It's not. Some women know they're going to have a scheduled section, they expect surgery. They might have not wanted it, but they know it's going to happen. We have more time to discuss it, we have more time to prepare them, and it's different. Then there are those who don't have a priori an indication for a C-section, but during labor, things don't go as expected. Either labor doesn't progress, baby doesn't do well, they don't do well, they need an intrapartum cesarean delivery. These are the women for whom it's going to be the most difficult for a variety of reasons. We think that the pain of a cesarean delivery that occurs intrapartum is higher. Maybe because the uterus, after all the contractions, there's some hypersensitization already. Maybe it's because within epidural we can't get the same level of noraxyl blockade. Maybe it is because they so didn't want that C-section or didn't expect it, they're not prepared. There's not, or maybe it's because we don't have the time to prepare them. We don't have the time. So the multitude of reasons for which it's going to be more difficult. And also the recovery is more likely to be difficult because they might have been in labor for 36 hours, they might have some a bit of, you know, some infection, something else, and it's going to be difficult. So they might bleed more, and the anemia in itself is also going to make their recovery more difficult. So when we talk about cesarean delivery, the first thing I want to say, not all cesarean deliveries are the same. So our role as an anesthesiologist is precisely that. We should know that what we're going to do, our type of anesthetic, has a direct impact on the level of comfort that women are going to have. The second thing is that we need to understand, and we know that, that if we move them in an urgent manner from a labor room into the operating room, hitting every wall and every door on our way to the operating room, and then, you know, doing everything so rushed that our anesthetic has barely had the time to kick in, it's going to be not only a painful experience, but a traumatic one. So we have a tremendous responsibility and a tremendous opportunity to make a difference. Obviously, we can't anticipate the stat C section, but we can have some preparation. We can tell women that we're there, that we're going to help them. So I look at it this way. If we have an intrapartum caesarean delivery, we do have some few minutes, and it doesn't take a long time to say you're going to feel some sensations. And the sensations that you're going to feel that we expect you to feel, I'll tell you which ones they are. The three of them. We know that now. We have research that shows that again and again, and it comes from qualitative research. It doesn't come from the RCTs, it comes from qualitative research. It is touch, pressure, and movement, and some discomfort that comes from the pulling and tugging. I don't particularly use these words because pulling and tugging is a different sort of difficult to understand. But to say you will feel sensations, and it doesn't matter what we call them, and it doesn't matter how much we score them. If for a patient a sensation is uncomfortable, I always tell them, let me know. I can give you medication. And if they have an epidural in place, I'll tell them I can give you medication in the epidural. And if they don't have an epidural, I tell them I can give you medication in the IV. And if they do have an epidural, I tell them you can have medication in the epidural or the IV. But you have to tell me if you are uncomfortable. And I'll never ask them, is it pressure or is it pain? Because again, for some women, pressure is uncomfortable. And for other women, other women, pain might not be uncomfortable. And what matters is not what it's called. It doesn't matter if it's called cheeseburger or hot dog. What matters is, is it uncomfortable? And the next question should be, would you like me to give you something? And this is where we have failed over the last 10 years or 15 or 20 years, is that we never really asked women if they wanted something. Now we're discovering that we're very bad at knowing, first of all, what patients are experiencing. There have been several studies, including one from Colombia. And we're also equally bad at guessing or making the assumption of whether for that sensation women want to be given something. So we can't make that decision. I ask them, You look uncomfortable. Would you like me to give you something? And in my mind, I'm thinking she'll say yes, and sometimes she says no. I think she'll say no, and they say yes. And it doesn't matter. It's not me, it's them. And then the different options, um, although these days we're all using more and more dexmeditomidine because we know that it covers a lot of visceral sensations, it covers pain. Um, it's um also a little bit anxiolytic, it's also great for shivering, which a lot of women experience and say is very uncomfortable. So I usually tell them we have medication that will help with different things. Tell me if you want something. So I think this is the first step in the operating room. Now, if they're not in pain in the operating room, it is already one element that is very predictive of what's going to happen after. In other words, if our anesthetic worked great, they're less likely to have immediate pain in the PACU. Um, or the flip is if they had pain in the operating room, it's quite obvious they'll be uncomfortable in the PACU. They might end up receiving more medication, which might end up being opioids, they might take more opioids, and they're more likely to have persistent opioid use. So it is imperative that we offer the best anaesthetic, that we set expectations, that we reassure patients, that we talk to them, that we tell them that we have medication available. Now, if all this fails, sometimes we have epidoles that don't work, sometimes we have spams that don't work. And it's obvious that giving more medication might not be sufficient. And if they're not comfortable, we will end up doing a general anesthetic. And it's not a disaster. People think that obstetric anesthesiologists don't want to do a general anesthetic because we're afraid of the pregnant airway, as we call it. We're not afraid of the pregnant airway. We just think that sometimes the general anesthetic doesn't fix the issue. And if you're doing a general anesthetic without actually treating the pain, they'll wake up in pain. So it doesn't solve the problem, it just resolves the critical moment in the operating room. But a lot of women, if we haven't really offered them options or discussed options or given them analgesic once they are under general anesthetic, or done a tap lock so that they wake up without pain, it's not going to be a great recovery. So I think a tremendous responsibility intraoperatively, and this will shape the post-op period and definitely, you know, persistent pain and potentially opioid-related heart.

SPEAKER_00:

Wow, that was excellent. Just for a detail that may help some people out in practice, but if you are gonna give dexenoetominine during the cesarean as a polis or in the recovery room, how do you dose that?

SPEAKER_01:

So that's a good question. So it's pretty recent practice. And first of all, I want to refer people to the ASA statement that came out. Excellent statements. The first one was published in 2023 in October. Just even just describing the phenomenon of pain during cesarean delivery, because it was absolutely not recognized before. And I'm sure you heard everybody say, oh, it's not pain, it's just pressure, and pressure is normal. So even just recognizing and validating that for some women, sensations are uncomfortable. And that's why I said it doesn't matter how we call them, but this discomfort needs to be acknowledged and needs to be validated and needs to be not just say, okay, sure, but you know, you need to do something. So in the second ASA statement, which was published exactly one year later in October 2024, um, Dexmeditomedine is mentioned as an adjuvant. You can give it IB, you can give it neuraxily. I will mention that it is not uh FDA proof, so it's an off-label use, but there are more and more publications, and I want to refer. I know you have the ability to refer to publications, so there are a few 2025 publications that talk about intravenous dexmedatomidine. One of them is a focused review in the International Journal of Obstetric Anesthesia, the other one is a scoping review on the use of intrathecal dexmedatomidine, and there are two recently published retrospective studies on the use of intrathecal dexmedatomidine. But I'll tell the, I'll tell you the dose. So it was first described as being extremely helpful in preventing andor managing shivering. There was a first study done a few years ago, published by our colleagues from Beth Israel in Boston. Initially, they gave 30 micrograms and saw it was efficient, but it was accompanied by quite a bit of sedation. So they repeated the study with lower doses of 10 micrograms intravenously. And this actually really helps prevent or treat the shivering, also for pain, might need to be repeated. So the way we do it, we repeat by boluses of 10 micrograms. And sometimes on a longer procedure, if the case goes longer, patients need a little bit of sedation, we might start an infusion. But that's definitely not routine. I would say 10 micrograms intravenously has become our routine, particularly if they are intrapartum and they arrive in the operating room, they're usually already shivering from you know labor itself. Um, a lot of patients will tell us, oh, I shivered so much last time. This feels so much better now. Thank you for you know treating it. Now, for the intrathecal doses, I must tell you that we don't have well conducted studies that tell us what the dose should be when it is given with multimodal neuraxial medication. In other words, the studies that studied intrathecal dexmeditomidine used it instead of fentanyl and doramorph or preservative-free morphine. They often came from not from the United States, so it was in clinical environments where the anesthesiologists either didn't have access to opioids or were trying to replace the opioid. So the doses are probably a little bit higher than what needs to be given. But we have now some experience with different centers in the US that use it. And I think the dose that most would be using is five micrograms intrathecally, four micrograms intrathecally. But again, we need well-conducted randomized control trials. I don't want to say that we know that that's the appropriate dose, but that's what we've been using.

SPEAKER_00:

Oh no, that's very helpful. And I will include the statements and links to those publications that you mentioned in the show notes as well. If we think about the whole peripartum time period, there seems to be an increasing role for anesthesia professionals. So is there something that anesthesia professionals can do to ensure safe and effective pain management throughout that time period? And kind of thinking about this in terms of are there longer-term effects for patients after discharge from the hospital directly related to the anesthetic management?

SPEAKER_01:

So obviously, my answer is that we have a tremendous role. I think, I think what we're discovering more and more, which is no surprise, is that setting expectations is so important. You know, we consent patients talking about the rare events, right? We talk about the epidural hematoma, we talk about the infection, we talk about all these things, you know, the risks that we always mention when we consent patients for neuraxial procedures. I think that when we consent a patient for neuraxial labor analgesia, we do tell them that maybe the epidural will need to be replaced, it might, you know, might get dislodged, might not work well. I think it's very important to use maybe, you know, 30 seconds more to say, and just in case you do go for cesarean delivery, we will communicate around whether we think this epidural is working well enough and maybe it will need to be replaced. Now, I know women probably don't want to hear this because they're not thinking about a cesarean delivery. And now we're telling them that maybe the epidural won't work. That seems terrible. But I think we need to own this. I think we need to talk about it because they are there are opportunities to replace the epidural. And by the way, it's very important to perform what we call now active management of neuraxial labor analgesia or epidural analgesia. In other words, you can't just place an epidural and expect it to be an autopilot because you gave the patient, you know, she has her infusion or the program intermittent bolus, and then she has the button, and then the nurse will call us if the patient is in pain. It should not work this way. We have to, you know, we have to assess whether the catheter is working, not just for labor, but bearing in mind that maybe the patient will need to go to the operating room. I didn't mention it specifically, but the latest studies looking at pain during cesarean delivery really showed that the women the most at risk are those who have an intrapartum caesarean delivery with an epidural that is topped up. So the epidural top-up for cesarean delivery. And there's a paper that was just accepted for publication in anesthesiology three days ago. It's not yet even online, but you can look for it by published by our colleagues from Stanford. It's a soap research network study. 15 centers across the United States contributed data looking at pain during cesarean delivery. And clearly, again and again, it's not the only study that shows that, but this one shows it again that patients who have an epidural topped up for c-section are the most likely to experience discomfort during cesarean delivery. So we need to make sure that the epidural is working. If it's not working for labor, it will not work for C-section miraculously. We have an opportunity if we communicate well with the obstetrician, if we see that the tracing is starting to be not great, if we see that labor is stalling, we have the opportunity to check the epidural to make it work. To also explain to patients that the I want to feel nothing is not possible. They will feel sensations and it will be important to communicate around these sensations. Is it comfortable? Is it uncomfortable? And to remember to dose the epidural. If the C-section is lasting longer, we need to redose the epidural, not to forget to redose the epidural, not to forget to give adjuvants and opioids short acting are important interoperatively for the visceral sensations. Alpha 2 agonists, including dexmedatomidine, will be helpful as well. And talk and reassure with patients. But your question was about what happens after. So I think that patients, first of all, patients with a c-section are likely to come back. So not only do we have the responsibility to ensure that they don't leave the hospital with a traumatic experience, but this patient that went home with a traumatic experience might be the one you'll see again in 18 months or two years later for a repeat C-section. And she is coming terrified into the experience of having another delivery. Maybe she'll try to have, you know, to have a tollak because she's so afraid of a c-section. Maybe she will fail the tollak, and now it's another, you know, another um added um fear, which brings me to the third statement of ASA, which I didn't mention yet. But this is about uh traumatic birth experiences and the psychological impact and how to avoid uh traumatic birth experiences, but also how to apply trauma-informed care for those women who did have a previously traumatic experience. And sometimes they will not express it, but it can be recognizable if you know how to recognize symptoms of PTSD. So the patient that you might have not taken care of, but now comes back, you need to be able to have this conversation with her, and or the patient you took care of, who did unfortunately have a suboptimal experience. It is absolutely essential to offer a debrief, to offer maternal mental health services for the patients to be able to talk about these things and not build, you know, build up the emotions and have full-blown childbirth-related PTSD. So, and we talk about it more and more and we see it more and more. We we know better how to look for it. They're now questionnaires of patient-reported experiences. So, not just the proms of patient-reported outcome measures, but the patient-reported experience measures that some of us are are, you know, applying to try and better identify women at risk and also better learn what the experiences are and who you know, what are the risk factors for those childbirth PTSD.

SPEAKER_00:

Well, that was great. And I think I'll just highlight that the really important takeaways seem to be setting expectations and then active management of labor epidurals to help then if women do need a cesarine delivery at a later time period.

SPEAKER_01:

Also in the operating room, that if the patient is not comfortable, you can't just tell her, oh, it's normal. Patient tells you this is not comfortable, you don't normalize the discomfort. There's always something that we can give. And I think the ASA statement really says it very well in the introduction that it is to help clinicians give medication when it was believed before that before the baby is born, we shouldn't be giving anything because it might frost the decenta and it would be unsafe for the baby. So I think that the the first statement was really there to guide and say you can give medication. The second one was to say what to give and at what doses with cutoffs. I can't go through everything, but it really gives a sense of you can give medication. We can't just tell women you're having a baby, you're going to be uncomfortable, and it's normal. This cannot be the practice in in anymore. It should have never been, but definitely not now.

SPEAKER_00:

Well, and now it's nice to have those statements from the ASA as such a good resource, like you said, to give us permission and then also that knowledge to say, oh, but this is what you can give to, and have those options available.

SPEAKER_01:

And there have been a lot of review articles that have given a little bit more granularity. Pain during cesarean deliveries is a topic that we talk about a lot. And there have been a few excellent review articles that each one of them focuses on different, and you know, how to consent, what to explain, how to explain. I didn't talk about how to test the block. That's another topic. There's not no real consensus of how to do it well, but the real consensus is you need to test the block. Like you can't just assume I gave a spinal, she the blood pressure dropped a little bit. She can move her legs, so probably she won't feel pain. You need to check the block. So there are some guidelines, there's still some work to do to make sure what's the best way to check the block, but this is obvious that it needs to be done.

SPEAKER_00:

We have talked a lot about spinal and epidural anesthesia during cesarean delivery. But I was wondering if you could talk a little bit about how you approach pain management for patients who do require general anesthesia for their cesarean delivery in order to help them with good pain control during the surgery as well as in the recovery phase.

SPEAKER_01:

That's an excellent question. So, first of all, some patients do have an epidural in place, but there was no time to activate, or it was activated, but still, you know, it didn't kick in fast enough, and you convert to a general anaesthetic. I want to remind everyone that if you had an epidural, use the epidural. Don't just say, oh, share the GA, I'm not giving anything through the epidural. Sometimes people forget there's an epidural, use it. There's nothing better than noraxial opioids. Um, and it's you know, no one is confused by the fact that neuraxial opioids are great. What we try to avoid is the systemic opioids. And there's an excellent consensus statement by SOAP that actually describes again and again and gives the references on, you know, the fact that we know that neuraxal opioids provide better pain relief than systemic opioids, something that wasn't known by many, I found out in the US, but it is the case. And that I think there's still some institutions that are reluctant to give noraxyl opioids because they believe that there is no adequate respiratory monitoring in their institutions, but it is very dose-dependent. And we know that even at very low doses, neuraxyl opioids work significantly well. And that um, if you're in an institution where the nurses won't even monitor once every two hours, you can really give a very small dose of 50 micrograms intrathecally or 1.5 milligram epidural, don't require any particular monitoring unless the patient has other issues. Obviously, if they have OSA, they'll require the standard OSA respiratory monitoring. But I really recommend highlighting the soap consensus statement because it's it actually was written to reduce the respiratory monitoring that that was done in institutions. And in fact, it is less tenuous and stringent than the ASA guidelines. In fact, there's no need to monitor once per hour as ASA recommends. So the SOAP guidelines really allow institutions that might feel that they don't have the ability to monitor very often to find the dose that will allow patients to still get some noraxal opioids without having increased burden on the nurses or the patients themselves with a prolonged, you know, step-down unit stay or or monitoring. So I would say again, you asked me about GA and I talk about noraxil because this is what I always do. When I'm asked to talk about GA, I always find a way to talk about noraxil. But let's say the GA without a noraxia. I know that's what you want me to talk about.

SPEAKER_00:

Well, that is it, that was a very good reminder, though, about if you have to do a general, but someone has an epidural in, that there's no reason to just pull that epidural at the end and say, oh, okay, well, we'll take it out. But to use it for pain relief later, too. So excellent reminder.

SPEAKER_01:

So let's say we are in the situation where it's a GA with no neuraxial. Um, so typically you can still give your non-opioid medication. You can give an IV dose of hylenol, you can give an IV dose of NSAIDs. We typically give Ketorolac in the United States. So you can do that before you wake up the patient. And what we would do before we wake up the patient is an abdominal wall block. So that really depends on the institution, if it's a tap block, if it's a QL block, but a block, hopefully with you know, the largest safe, uh, non-toxic amount of local anesthetic, maybe an adjuvant. I mean, there's not no clear evidence that it helps, but we tend to say that it can't harm. So some institutions will add an adjuvant, whether it is clonidine, dexmeditomidine, dexamethasone. I've seen all of those added to the to the block, obviously ultrasound guided. The the interesting question is that quite differently from uh what ASRA recommends, ASRA will always want patients to have consented specifically to the block uh before they go to sleep or before the block is done. I think there is some agreement that for obstetric patients, we sort of have a bundled consent. Most institutions do for anesthesia care. And sometimes those C-sections are so static, you know, we we we tell them we're doing an emergency Cesarean delivery, we're going to put you to sleep. It has happened that we haven't specifically said that we would do a block before, but I know this is very institution-dependent. In most institutions that I can think of, we would do it before we woke up the patient, even if we haven't explicitly mentioned the block. So we do an ultrasound guided block, and then we wake up the patient, and then we see how they do. It has happened on rare occasions where patients are extremely uncomfortable, that we might do an araxial after. I've done sometimes, not often, it's not my routine, but we can do a single-shot spinal after with the doromorph if the patient is extremely uncomfortable to try and reduce um systemic opioid use. And other than that, I will say what I always say, which is a cesarean delivery is a peripheral surgery. There is no evidence that IV opioids work better than oral opioids. So we try, I try not to have patients hooked up to a PCA of whatever opioid it is that the institution is using and particularly diluted, which we know is quite addictive, rapidly addictive. So after the C-section, the block, the non-opioid medication. And if the patient is uncomfortable, then the PRN, PRN oxycodone trying to reduce it. And if a patient doesn't want the systemic opioids and is uncomfortable, that's when I would do an araxial block. There's not much evidence that GABAPentin helps. There's not much evidence that ketamine should be given, and it's not very convenient to give. So I would just say we try like this, and most patients will do okay.

SPEAKER_00:

Oh, that's great. That was really helpful. Now we have talked about a lot of different resources in the literature, but I didn't know if you had any resources that you would recommend specifically when it comes to pain management protocols for cesarean delivery. If, say, there's anesthesia professionals out there who are looking to change up their practice or maybe work in their institution. Are there any specific resources that they could use?

SPEAKER_01:

So there are many. They're not particularly recent, or let's put it this way, they're not from the last two, three years because we've worked on that. It's almost like we're working backwards. We worked on post-op pain before we really tackled intra-op pain. But there are several resources. There's several excellent review articles. Actually, ACOG wrote, which is important because in many institutions it's actually the obstetricians that are writing for post-op uh post-operative pain management. In some institutions, including in in at Columbia, we, anesthesia, write for the post-op orders until discharge. Um, but that was my way of limiting the amount of opioids that is prescribed. So we took over post-op pain management. But I would say ACOG has post-op pain management. I think it's from 2019, maybe something more recent. And they're excellent review articles. I'm happy to give you also an excellent review article published in AJOG, the American Journal of Obstetrics and Gynecology, this year, authored by Ruth Landau and Pervez Selton from Stanford. The reason people ask me, why did you publish an article on anesthesia for si section in an OBGYN journal? Well, it's an interesting story. They reached out, the editor-in-chief of the American Journal, Rep Cetrics and Gynecology reached out asking for a review article for OBGYNs, which I thought was the opportunity to write everything we want them to know about what we do. So it's quite basic for that reason, but I think it's a good refresher for everyone. And we do talk about post-op pain management, including the blocks and their few illustrations.

SPEAKER_00:

But that definitely can be something used by anesthesia professionals. I agree to help bridge that uh communication divide sometimes with the obstetricians and other people in the hospital too, and help get everyone on the same page. Exactly. So, what do you hope to see going forward when it comes to safe maternal anesthesia care as well as safe and effective pain management during and after cesarean delivery?

SPEAKER_01:

So I think it's going to be a combination of high touch and high-tech, but I think the high touch is very important. Um, I think it's such a different clinical environment. I mean, for those of us who are obstetric anesthesiologists, we've been saying it forever, but I think that everybody's recognizing now that, you know, women come into the hospital to have a baby, they have expectations of deliveries that might or might not happen for them. And there's so little time to go over it that we really need to reassure them constantly. And it does it's difficult to learn how to do that, and I think that some just have it more innate than others, but I think learning that the experience is so important, not just because you want your patient to have a good one, but that the experience can really become a source of suffering and to your point of opioid use and persistent use. It it think about it, just because we were not able to accompany women through, I don't know, an hour, two hours of surgery in a way that can limit PTSD, we might be causing harm for you know a prolonged period of time, not to say life, you know, for life, is I think where we need to really learn how to listen better, respond better, be very humble, be very nimble, be very sympathetic, very empathetic, which of course is very difficult because it's sometimes at two o'clock in the morning in in very rush situations, but I think that's very important. And the second one is we need to learn how to manage the pharmacological response, and it's not just MIDAS and it's not just an intubation. I think it takes much more than that. And I think we've done a lot already, but I think there's still more to refine, and it will be different for everyone. I don't think that there's any RCT that will tell us which drug at which dose, which brings me back 25 years ago when I thought it was all about genetics. It's not all about genetics. There's some genetics, but it's just that every one of us is different, period. What works for you, Ali, might not work for me, or it might work for both of us, but not for our neighbor. So I think we really need to, as much as I love standards and protocols, I think the protocol needs to allow to understand that certain things will be, you know, pathway A, pathway B, pathway C, and be very, I don't know if I want to say it, but I will intuitive about it. We need to really, you know, get the patient to trust us, us to know and understand what the patients want, what they need, and do our best. And if it wasn't optimal to go and talk to the patients after and try and minimize the harm, the suffering.

SPEAKER_00:

Well, and as you said, anesthesia professionals have an tremendous responsibility and opportunity here. And I think that's something that will continue to play a big role going forward. So, what's next for your research or projects?

SPEAKER_01:

Okay, I'm just about to finish any day of project. We enrolled over a thousand patients in a prospective study that is looking at not just pain, yes, no, because this is mostly what the studies have looked at intraoperatively. We're looking at the sensations and those sensations, which ones patients feel were uncomfortable versus comfortable, um, whether what we gave was sufficient, not sufficient. So it's a survey. We did surveys before, but this one is a is the second version or even the third version of our first survey. We learned from our previous surveys to ask more granular questions. And we enrolled patients that are not just English speaking, but also Spanish speaking, just to learn more about, you know, the language barriers, the cultural differences. So this is the analysis of this study. And then the next study, which I hope, I mean, we'll get through IRB soon, is a randomized controlled trial comparing placebo with intrathecal clonidine and intrathecal dexmedatomidine to try and reduce these visceral sensations and discomfort. And another study that we're also conducting is not specifically looking at pain, but looking at traumatic experiences in patients that are high risk. So we have a designation at Columbia. We call it the CCOB designation, critical care obstetrics, which some patients come with. So someone who's had a liver transplant and is pregnant. Okay, we know that she's high risk of someone who has a cardiac condition and has been, you know, with a cardiac condition all their life. They know that they're high risk and you know they might be concerned because they've been told that, you know, pregnancy is going to be risky for them. We're looking at the experience of delivering with a chronic condition. We're also looking at women who were healthy but had something during delivery, usually postponum hemorrhage, but could be something else, sepsis, pre-eclampsia, and they also become critical care obstetrics, but unexpectedly, and how this impacts the experience. So we're we're running a few questionnaires about the experience of delivery and looking at traumatic experiences. So this is a pilot that we're running right now, and then we'll develop the broader study, trying to better understand what are opportunities that we have to make the experience less traumatic. Looking also at stigmatizing language, looking at implicit bias. So these are the different things that we are interested in.

SPEAKER_00:

Oh, wow. Well, we will definitely have to stay tuned uh to learn more about this. Is there anything that you wanted to share that we have not talked about already on the show today?

SPEAKER_01:

Probably many, but I feel you allowed me to share already. I would say I know everyone comes to work every day wanting the best for their patients. I have no doubt. I just think that there's an extra layer of complexity. Because patients don't know what's going to happen to them. We don't know what's going to happen to them. And maybe that's what I want to say is that we need to be constantly in tune with what's going on in obstetrics. And I'm not saying that it's the only clinical environment, but it's a particularly dynamic environment. And I think that as we're learning to better take care of our patients, I think that anyone should share their experiences. There's a lot to be learned from each other. And I think that the patient experience is not now what's going to be the major focus of our care, clinical care, and also our research, how we, you know, share patients' past and what happened to them and the future. So I would say this is what I would like everyone to think about is that patients don't come to deliver thinking that they'll have surgery. Some of them don't think they'll have surgery, they're there to have a baby. And I want this to be the centerpiece of how we come to work and how we are there to support a family's experience of childbirth.

SPEAKER_00:

Thank you so much to Ruth for joining us on the show today and sharing your expertise. We covered a lot of information. We hope that you will check out the show notes for links and citations to the resources that we talked about on the show today. Before our next podcast drops, you can check out the three ASA statements or the August 2025 expert review article in the American Journal of Obstetrics and Gynecology, Noraxial Anesthesia and Pain Management for Caesarean Delivery. Are there any changes that you need to make in your OB anesthesia practice to help keep your patients safe and comfortable? If you have any questions or comments from today's show, please email us at podcast at apf.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 apsf.org for detailed information and check out the show notes for links to all the topics we discussed today. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.