#315 Pain During Cesarean Delivery

Pain during cesarean delivery is not “just pressure,” and it is not rare. We dig into why inadequate pain control during C-section remains underrecognized even as patient-reported data suggest it may be one of the most common anesthetic complications in obstetric anesthesia, with consequences that can reach far beyond the operating room including PTSD, postpartum depression, disrupted bonding, and lasting distress about birth.

We walk through what the research has measured so far (conversion to general anesthesia, neuraxial replacement, and intravenous rescue medications) and what those markers can miss when the team does not recognize pain in real time. Patient stories, including lessons highlighted in The Retrievals podcast, make the safety gap impossible to ignore and help explain how bias, hierarchy, and cultural norms can quietly normalize suffering. We also unpack how language choices, especially the casual overuse of “pressure,” can minimize pain and derail clear assessment.

From there, we get practical. We talk about shared decision making, objective ways to identify intraoperative pain, and how teams can escalate care: pause when possible, optimize neuraxial anesthesia, use evidence-based adjuncts, and move to general anesthesia when regional anesthesia is not sufficient. We also cover why systems matter, from reliable block testing to OR readiness for safe obstetric general anesthesia and postoperative follow-up when pain occurs.

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For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/315-pain-during-cesarean-delivery/

© 2026, The Anesthesia Patient Safety Foundation

Transcript

Pain During C-Section Is Harm

Alli 0:00

We are discussing a threat to patient safety from inadequate pain management during cesarean delivery today. Anesthesia professionals strive for effective pain management during these procedures, and solutions to this anesthesia patient safety problem include standardized protocols, clear patient provider communication, and the proactive use of general anesthesia when regional anesthesia is just not cutting it. Hello and welcome back to the Anesthesia Patient Safety Podcast. I'm your host, Allie Bechtel. This is a topic that we've talked about during our series on the 2025 APSF Stolting Conference. We also had an interview with an obstetric anesthesia expert in December of 2025. We hope that you will add episodes number 280, Speak Up to Save Lives, and number 284, Safer C-section Pain Control with Ruth Landau. We are continuing the conversation today. This is an important conversation since pain during cesarean delivery may be underrecognized and undertreated, leading to negative impacts on maternal health. The authors highlight that past research has evaluated optimal neuraxial techniques, ideal medication combinations, risk factors for failed spinal anesthesia, and risks for failed labor epidural conversion to surgical anesthesia. What we have missed is that inadequately treated pain during C-section is a patient safety issue that can have significant consequences, including post-traumatic stress disorder, postpartum depression, poor infant bonding, poor breastfeeding, intimate partner relational dissatisfaction, and negative feelings about birth for new mothers. The first step forward involves listening to patients, learning from their experiences, and supporting clinician conversations. Stay tuned as we highlight the scope of the problem and more practical solutions.

Sponsor And Featured APSF Article

Alli 2:02

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. Our featured article is Pain During Caesarean Delivery: Improving Patient Safety by Bringing the Patients and Anesthesia Professionals into the Conversation by Heather Nixon and colleagues. This is an APSF newsletter article that was published online February 1st, 2026. To follow along with us, head over to apsf.org and click on the newsletter heading. The first one down is newsletter articles. Then you can scroll down until you get to our featured article. And I will include a link in the show notes as well.

Scope And Patient-Reported Incidence

Alli 2:58

Let's get started with the scope of the problem, keeping in mind that this is not a new problem. Studies have evaluated inadequate surgical anesthesia for cesarean delivery, and the incidences of failed spinal, epidural, or neuraxial anesthesia vary widely depending on the definitions used by researchers. In these studies, failed neuraxial anesthesia has been captured by measuring surrogate markers of pain, including the rate of intraoperative conversion to general anesthesia, or the need for neuraxial replacement, or even the need for intravenous pain medications, with rates ranging from 1 to 24%. Higher failure rates were seen with conversion of labor epidural anesthesia catheters compared to spinal anesthesia or combined spinal epidural anesthesia. So far, we haven't figured out how to study pain during cesarean delivery when it is not recognized by the anesthesia professional in the room or when it's undertreated. What if we ask patients? There is a 2025 systematic review and meta-analysis published in anesthesiology that found 34 publications that included patient-reported pain. The overall pooled incidence of pain was 17%, with 14% for spinal anesthesia and labor epidural catheter conversion of 33%. This means that this is likely the most common anesthetic complication for patients undergoing cesarean delivery, experiencing pain during cesarean delivery.

Retrievals Podcast And System Drivers

Alli 4:33

Have you listened to the Retrievals podcast? If not, you definitely need to add it to your cue. In 2025, the New York Times and Serial Productions released season two by Susan Burton, which focused on the problem of pain during cesarean delivery and the consequences told through the lens of two patient stories. The podcast also included conversations with anesthesia professionals about why this happens and their experiences providing anesthesia care for patients undergoing C-section with neuraxial anesthesia. The stories told on this podcast highlight why pain during cesarean delivery has become an accepted outcome and the contributions from bias, culture, fear, and poor communication to this important patient safety issue. We're going to take a closer look at each of these factors.

Bias And OR Culture

Alli 5:24

First up, the impact of bias. Studies have revealed that women's pain is more likely to be attributed to anxiety or emotional distress and less likely to be treated than men's pain. This gender bias may lead to under-treated pain for women. This occurs in the operating room during cesarean delivery as well. Two studies investigated pain during cesarean delivery and found that anesthesia and obstetric professionals were not able to reliably recognize pain by observation, attributed pain to anxiety, and relied on anxiolytics, and as a result, patients did not receive pain medications to treat their pain. Another bias involves our confidence in noraxial blocks to provide adequate pain relief. Here is a quote from episode two of the Retrievals podcast. Susanna says, I was lying on my back looking up into the face of someone who is convinced that the block would be working. He was the expert, the person with authority. For litigation claims related to pain during cesarean delivery, 33% of claims stated that the anesthesia professional did not acknowledge or believe their pain, failed to accept that the block wasn't working, or failed to offer general anesthesia. Next, let's look at the contribution from culture. If we put on our patient safety hats, we know that patient safety depends on collaboration and teamwork to optimize patient outcomes. But if we step inside the operating room, we can still see the hierarchical systems with the anesthesia professional responsible for the anesthetic management and the rest of the team deferring to their expertise in this area. There is an opportunity for improvement here if everyone in the room feels empowered to respectfully speak up and express concerns. The culture in the obstetric operating room also plays a role when it comes to shared expectations and language, like the use of the word pressure. We often tell the Praeturian that they may feel some pressure during the delivery. But the misuse and overuse of this word may lead to inadvertently renaming a painful sensation as something more innocuous and strengthening the culture of accepting patient pain.

Fear, Framing, And Communication Failures

Alli 7:40

Another limitation here is the fear of complications related to general anesthesia during cesarean delivery. These feared and serious complications include maternal aspiration, failed airway with hypoxic injury, awareness under general anesthesia, increased postpartum hemorrhage, worse fetal outcomes, and worse postoperative pain control. We need to keep in mind that these are also rare complications in current practice, while pain during cesarean is much more common and has significant consequences when left untreated. Finally, communication plays an important role in all of this. For patients experiencing pain during cesarean delivery, how anesthesia professionals communicate during delivery and postpartum can have a big impact. Let's look at the example of Susanna from the Retrievals podcast. Susanna describes the first missed communication when the anesthesia professional was testing for the spinal block and she was unsure how to answer and then felt pressure to give the correct answer. During the delivery, Susanna felt embarrassed that she needed to ask to stop the surgery, and she believed that she was experiencing more pain than was expected of her. While she was in pain, she remembers that the anesthesia professional offered her a general anesthetic, but the communication missed the mark again because the discussion was not framed in a way that presented general anesthesia as an appropriate option and that she was, quote, expected to cope. Postoperatively, Susanna tried to express her emotional distress from her experience in the operating room, but her clinician dismissed her concerns by highlighting that she was healthy and she had a healthy baby, and, quote, that's all that really matters. For Susanna, a big takeaway is that words matter and how we frame patient choices and validate experiences plays a big role in how patients are supported and may impact shared decision making. And speaking of shared decision making, this serves as an ethical framework that recognizes a patient's personal priorities and values and should impact their care. Our communication cannot focus on only the fetal outcome. We need to avoid incorrect assumptions about our patients' choices, that they would want to be awake for their cesarean delivery, that they would refuse supplemental medication that may impact their child or affect their memory, or would choose to prioritize their fetus over their own emotional well-being. Communication, when combined with even a subtle bias, does not support honest exchange of information, expression of personal autonomy, or real shared decision making. So, what can we

Practical Fixes And Shared Decisions

Alli 10:24

do? There are some resources available, including statements and guidelines from the American Society of Anesthesiologists and the Obstetric Anesthetist Association to help guide anesthesia professionals for the management of pain during cesarean delivery. There are additional 2025 publications that you can check out as well, including Prevention and Management of Interoperative Pain During Caesarean Section by Orbak Zinger and Ben Yueman, Pain During Caesarean Delivery, Risk Factors Mitigation and Current Approaches by Sharp and Landau, and Noraxial Anesthesia and Pain Management for Caesarean Delivery by Landau and Sultan. I will include these citations in the show notes. This could be an excellent opportunity for an obstetric anesthesia journal club, and we've already done the hard work of picking out the high yield articles for you. Going forward, the authors challenge us to find better ways to listen to our patients so that we can understand how healthcare professional bias and communication failures can lead to patient harm. Maybe it starts with a journal club, but we need to talk about this topic openly, learn from experiences, and prioritize maternal mental health and medical health. While we may not always be able to prevent pain from occurring, we can change what happens next: the recognition, experience, treatment of pain, and communication to improve the childbirth experience for patients. Here are the important takeaways. Clinicians who care for obstetric patients must confront personal and systemic biases that impede the recognition and management of interoperative pain. Tools are needed to foster communication between patients and anesthesia professionals about the high risk of pain during cesarean delivery, the treatments available, and the risks associated with the treatment. Techniques should be in place to reliably test neuraxial blocks prior to beginning surgery. Identify pain during cesarean delivery with objective criteria such as interoperative pain scores and escalate care via shared decision making. When patient pain is identified, the entire delivery team should prioritize treatment by stopping the surgery when possible, optimizing neuraxial anesthesia, utilizing adjuncts, allowing time for treatment, and possibly converting to general anesthesia based on the clinical situation and patient preferences. Systems should be in place to safely perform general anesthesia during cesarean deliveries, including the availability of video laryngoscopes, superglottic airway devices, and trained staff who can assist anesthesiology professionals with intubation. Trained newborn resuscitation teams should be available. Evidence-based protocols to minimize maternal complications like postpartum hemorrhage and awareness under anesthesia should be in place. And patients should be encouraged to speak up about their concerns, questions, fears, and past experiences. Anesthesia professionals should encourage these conversations.

Adjunct Options And Follow-Up Care

Alli 13:28

For obstetric anesthesia professionals providing anesthesia care, the recent ASA statement on the use of adjunct medications and management of interoperative pain during cesarean delivery is a really good resource. Definitely add this to your journal club and check out the link in the show notes. Here are some considerations from the statement. For neuraxioadjuvant medications, additional local anesthetics can be administered through an epidural catheter to provide additional analgesia. Consider the addition of bicarbonate to increase effectiveness as well as epinephrine 5 mics per ml to increase effectiveness and decrease the risk for local anesthetic systemic toxicity. Fentanyl and sofentanyl can be administered through an epidural catheter to improve analgesia. For intravenous adjuvant medications, short-acting opioids such as fentanyl are recommended as first-line agents for pain management during cesarean delivery. Ketamine is considered a second line agent for pain management, but maternal hallucinations can occur. Dexmedatomidine is another secondline agent that can provide analgesia and anxiolysis, but can cause maternal brachycardia and hypotension. Maternal anxiety can be treated with midazlam, dexmedatomidine, or subanesthetic doses of propofol. There are considerations for inhalational adjuvant medications, including inhaled nitrous oxide for maternal analgesia and anxiolysis, but the concentration should not exceed 75%. Volatile anesthetic acids are not recommended without a superglottic airway or endotrecheal tube. Moderate and deep sedation during cesarean delivery are typically avoided, but may be used depending on the shared decision-making with the patient prior to starting sedation and with the lowest effective dose of sedative medications to decrease the risk for patient harm. Keep in mind that sedation is not a substitute for anesthesia in a patient experiencing pain during cesarean delivery. Patients may require conversion from neuraxial to general anesthesia despite these additional supplements, and it is important to follow up with these patients postoperatively and refer for additional support if needed. There is a lot more information in the statement, and we encourage you

Closing, Resources, And Listener Next Steps

Alli 15:46

to check it out. But that's all the time we have for today. If you have any questions or comments from today's show, please email us at podcast atapsf.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. Thanks for joining us for another episode of the Anesthesia Patient Safety Podcast. We hope today's conversation has given you practical insights to help make obstetric anesthesia even safer and more comfortable for every patient. If you enjoyed this episode, please take a moment to like, subscribe, and share the podcast with your colleagues. Your support helps us reach more clinicians who are passionate about improving patient safety. Until next time, stay vigilant and stay informed so that no one shall be harmed by anesthesia care.