#316 Safer C-Section Pain Control Revisited, PART 1

If you’ve ever heard “it’s just pressure” during a C-section and felt your gut twist, you’re not alone, and it may be a patient safety issue hiding in plain sight. We sit down with Dr. Ruthi Landau, the Virginia Apgar Professor of Anesthesiology and Director of Obstetric Anesthesiology at Columbia University, to get practical about what patients actually feel during cesarean delivery anesthesia and what we can do when those sensations become uncomfortable.

We talk through why labeling sensations as pressure versus pain misses the point, and why the better clinical question is simple: “Is it uncomfortable?” From there, we unpack a safer communication loop that invites patients to speak up and gives them real choices for relief, whether that means dosing through an epidural, using IV medication, or escalating plans when neuraxial techniques are not working. 

We also dig into opioid-sparing strategies for C-section pain management, including multimodal non-opioid analgesia, the risks of cookie-cutter discharge prescriptions, and how shared decision-making can reduce leftover opioids at home. Finally, Dr. Landau shares current practice insights on dexmedetomidine for shivering, anxiety, and visceral discomfort, along with the evolving evidence base and dosing approaches being used today.

If you care about safer cesarean delivery, obstetric anesthesia best practices, and preventing opioid-related harm, subscribe, share this with a colleague, and leave a review so more clinicians can find the conversation.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/316-safer-c-section-pain-control-revisited-part-1/

© 2026, The Anesthesia Patient Safety Foundation

Transcript

Discomfort Is The Only Label

SPEAKER_00 0:00

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?

Why C-Section Pain Still Matters

Alli 0:47

Hello and welcome back to the Anesthesia Patient Safety Podcast. I'm your host, Ali Bechtel. The APSF recently published a new video featuring Dr. Ruthie Landau on our YouTube channel, all about what to expect for your C-section anesthesia. We hope that you will check it out after this episode. Last week we talked about pain during cesarean delivery and the recent APSF newsletter article on this topic. So we thought it'd be a good time to return to our conversation with Dr. Ruthie Landau, all about safer C-section pain control. This interview show first aired on December 9th, 2025. Dr. Ruthie Landau joined me for a great conversation all about keeping patients safe and comfortable throughout the peripartum period, 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 Obstetric 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. Before we dive further into the episode today, we'd like to recognize PPM, Preferred Physicians Medical, a major corporate supporter of APSF. PPM has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, PPM. We wouldn't be able to do all that we do without you. And now my conversation with Dr. Ruthie Landau.

Dr. Landau’s Path To OB Anesthesia

Alli 2:39

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_00 2:53

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 an 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 and 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 ApGirl 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.

Building A Culture Of Patient Safety

Alli 6:43

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_00 6:57

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 we were 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 is 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.

Alli 9:07

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_00 9:24

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.

Rethinking Opioids After C-Sections

Alli 9:40

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_00 9:58

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 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 the 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.

Alli 18:16

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 section. 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_00 19:38

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

Alli 19:42

You can just take your favorite.

SPEAKER_00 19:45

I like them all.

Set Expectations And Ask Permission

SPEAKER_00 19:46

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 that dose, and then do all the rest as much as possible in an in a non-systemic manner to get them through uh delivery, whether it's a 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 caesarean 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 with an 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 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 dexmedatomidine 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 anesthetic, that we set expectations, that we reassure patients, that we talk to them, that we tell them that we have medication available.

When Regional Fails And What Next

SPEAKER_00 27:11

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 harm.

Dexmedetomidine Dosing In Practice

Alli 28:19

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

SPEAKER_00 28:36

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. There are three excellent statements. The first one was published in 2023 in October. Um, 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 IV, you can give it noraxily. 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 dexmeditomidine, 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 um 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.

Resources, Video, And How To Reach Us

Alli 32:48

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. We have more from an interview show with Dr. Landau that we are going to hear next week on the show. So mark your calendars. We hope that you will check out the show notes for links and citations to all the resources that we talked about on the show today. Before we continue the conversation, you can check out that new APSF video on YouTube and some of the resources that we mentioned on the show today. 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.