Central Line

Episode Number: 140

Episode Title: Subspecialty: Society for Obstetric Anesthesia and Perinatology

Recorded: August 2024

(SOUNDBITE OF MUSIC)

VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. BROOKE TRAINER:

Welcome back. I'm Brooke Trainor, your host for today's episode. And this is Central Line. Today we're going to continue our dive into subspecialty societies with the society for Obstetric Anesthesia and Perinatology, or SOAP, with Drs. Tracey Vogel and Heather Nixon. They're here with me to discuss intraoperative pain during cesarean delivery, and I'm looking forward to hearing what they both have to say. So let's jump in. Welcome to the show.

DRS. HEATHER NIXON AND TRACEY VOGEL:

Thank you for having us. Thank you so much.

DR. TRAINER:

Yeah, I'm going to start with Doctor Nixon. If you could tell us a little bit more, give us a quick introduction and just tell us about your role within soap.

DR. NIXON:

Sure. I'm Dr. Heather Nixon. I am the current president of SOAP. Vice president last year, and I'm at a board of director member for about eight years now in various roles. So I've been involved in various aspects of soap. And then recently this topic has come up. And so we've been very much involved in trying to put input into how we can help educate people about this problem.

DR. TRAINER:

And Dr. Vogel?

DR. VOGEL:

So I am Tracey Vogel, and I'm located in Pittsburgh, Pennsylvania, and my background is as a fellowship trained obstetric anesthesiologist. But I shifted my direction about 12 years ago when I started working exclusively with pregnant patients, postpartum patients, and halfway through this time doing just exclusively OB. I trained as a sexual assault counselor, and it gave me a different perspective on some of the trends I was seeing in obstetrics regarding especially how survivors of trauma, how they appear, how they behave. And that led me to a grant later on, and then ultimately to create and direct a perinatal trauma informed care clinic here in western Pennsylvania.

So I have been a SOAP member for a long time. I've always really enjoyed and felt very privileged to be working with this special group of patients, for sure, and my roles within it has varied from being part of committees to then ultimately offering workshops and doing lectures on the big stage at the annual meetings. But my favorite role right now is as the director of the Special Interest Group for Maternal Mental Health and Birth Trauma.

DR. TRAINER:

This is a very distinguished group of anesthesiologists that we're talking with today, and I think that today's topic is going to be very important and exploring the intricacies of maternal health and well-being. And I think that this is a hot topic. And so I'd like to get started today and exploring intraoperative pain during cesarean delivery. So today let's start with Dr. Nixon on why this matters to our listeners. And give us a little bit more background on why this is an important topic.

DR. NIXON:

Absolutely. So it's a great question. Why does this matter and why do we need to talk about it? Intraoperative pain during cesarean delivery is really a widespread problem in the United States and abroad, and it's not limited to any particular institution or part of the country.

In other areas of medicine, we're finally starting to learn that women's pain is less likely to be attributed to pain when they report that they have pain, it's more likely to be labeled as anxiety. And there's a systemic bias that women's pain, when evaluated by any type of provider, is not as severe as when men are evaluated. So what does this mean? It means overall, women are less likely to receive comparable pain therapies compared to their male counterparts. Now let's add birth to this, where providers may be focused on the fetal outcomes and the maternal physical health. And we see this just magnify. So there's some intrinsic beliefs that exist about pain and what it means as an end to the matters of birth. So this is kind of a means to an end. And many believe that pain during labor or pain during delivery is normal, expected and even unavoidable. So there's a real disconnect between patient experience and provider expectations in the birth realm.

We did not ask about this for many years. We focused on things like, you know, post-operative neurological complications, postural puncture headaches, and they're really important as metrics of good anesthesia. But we didn't know that our patients were having severe long term psychological consequences from their birth experience. We thought we were doing great. And so that's why I think it's so important to talk about it, because we didn't even know this was a problem for many years. When I trained during my fellowship, this was not something we talked about. We got them off the table and we all patted ourselves on the back and we felt like we had a good experience with it. And what we're finding out is that maybe we're missing things. And so we need to really examine that.

DR. TRAINER:

Yeah. And it's so true about the the long term recovery and essentially the trust that our patients have in this health care system. So do you mind just expanding a little bit more on how widespread this pain problem is and what the scope of the problem is?

DR. NIXON:

Sure. Um, so this has kind of become my passion project at my own institution and nationally. And how did that happen? Well, I first started researching this topic because I was asked to do a talk at the Soap meeting in 2023, and I thought I was going to focus on things like drugs, techniques. I was looking at what are the best practices, what are the doses we should be using? And I really didn't have any idea of the floodgates that were going to await me when I started really looking into this topic. So I started looking online and I found more and more disturbing patient accounts regarding under-treated pain during cesarean delivery. And these ranged from what we might consider or call like an unmedicated major abdominal surgery where patients described pain as tearing, searing, I felt everything so pain that was ignored or undertreated. Patients described not being believed or having no control. And I thought to myself, well, this this can't be real. This has got to be hyperbole. These must have been emergency cases where it was a mistake or they started before the patient was asleep. But then it became a little personal for me.

So at the same time frame that I was preparing for this talk, we had an event at my home institution where a patient was undertreated and had severe intraoperative cesarean delivery pain. This patient has given me absolute permission to talk about this publicly. She wants to me to educate others and that alone is horrific in itself. But the real eye opener was it happened to a person who worked on labor and delivery. She was one of my colleagues, and I thought to myself, if this can happen on my unit to a person I know, this could be happening elsewhere.

And so I started to talk to people and wow, it was a report that we were hearing more and more and more often. So I continued my search, and I found a couple of articles that I think really provided some important information that anesthesia providers who practice on the labor and delivery floor should know. In 2022 Patella et al. Published what I consider to be one of the most compelling articles in this area for any anesthesiologist. It was a study examining intraoperative pain in patients who had spinal anesthesia. So the study looked at the incidence of intraoperative pain and the need for supplementation. So that was the primary outcome. The patients received what would be considered to be the normal dose or Ed 95 of bupivacaine in their spinal anesthesia. And they still needed supplementation. There was no data at all because it was retrospective about the effectiveness of the supplementation, and they found that this happened in about 15% of patients. So that's one-five percent of patients in this category where a simple spinal was not enough. If we consider patients with epidural anesthesia meaning top offs from labor, there is historically a higher rate of block inadequacy in those patients. So we probably see a larger number in that group as well. So I thought to myself, imagine anywhere else where an anesthesiologist practices where 15 to 20% of your patients experience intraoperative pain, none of us would have jobs. Yet this is the truth. We're like 1 in 10 to 1 in 5 women undergoing cesarean delivery. So at the time, I also looked and I saw that there were some other articles that were coming out internationally from France and the UK that were practice bulletins and advisory guides, saying this is a problem and we need to fix it. And I thought to myself, oh, this is a much bigger issue than I anticipated.

DR. TRAINER:

And this is even eye opening for me. And I knew that this was an issue. But I think this is really eye opening for all anesthesiologists out there. I mean, there must be long term psychological effects on these patients that are experiencing this kind of pain and coming back, you know, for even other deliveries. I mean, Dr. Vogel, can you enlighten us on your experience on some of these long-term consequences?

DR. VOGEL:

Yes. And there are there are several. And I just want to comment on what Dr. Nixon was talking about. I was seeing this in my clinic more and more frequently, and this was happening in parallel to, I think, what Dr. Nixon was reading about and seeing. And I think the two of us had the opportunity to meet up at that meeting in 2023, and we realized that we need to approach this from a variety of different angles in the hopes of making change.

But when we think about consequences, there are, of course, the long term. And I'll touch on those in a moment. But thinking even just the short-term consequences--what's happening in the immediate time frame after this event happens? And we have to think about the patients and their families. I mean, they're in this heightened state of psychological shock in those moments. They are losing trust in us. They lose trust in our systems. A lot of times they're losing this sense of what happened. What's the meaning in this? They don't understand why. How could this have happened? And when we talk about acute stress responses, you can see any variety of them. And acute stress responses fall in the same categories as chronic PTSD or post-traumatic stress symptoms. We have things like hyper arousal where the patients could be anxious, they could have panic. They could have paranoia. We have avoidance behaviors. They might not want to even look at you for the moment after this. They don't want to speak to providers, and some of them don't even want to look at their babies after this. And then we have to think about an immediate time frame. If they had inadequate anesthesia during the procedure. many, if not all of them have significant acute, severe post-operative pain. And I just want to point out that if patients have pre-existing anxiety, depression, other mental health issues prior to that event, they might already have altered pain thresholds. And if they then have additional acute pain and it's not adequately treated, even the post-op period, I worry about increased risk for chronic pain afterwards for these individuals. So and all of this is in addition to maybe some of the physiologic responses they might have in the moment, such as increased heart rate, blood pressure, respiratory rate that might come with panic. So that's just the acute phase.

Now when we talk about long term consequences, there has been a plethora of data out there in the psychiatric psychological literature for years. They've known about this for a long time. We're just beginning to understand it and to come up with our own research and data. But here are just some examples of some of the long-term consequences, and it's probably not a complete list. Dissociation can happen when individuals are in extreme pain, and that is one of their known coping mechanisms. So what happens is they have this sense of disconnection to their bodies. Now that coping mechanism may have helped them survive previous types of trauma. But when it comes to childbirth, they often don't remember the birth of their child, and that can often lead to significant mental health issues, including depression, because they have to grieve the loss of that experience. As I mentioned before, some people might have hyperarousal, they might be anxious, they might have anger or rage or hostility against the providers. They hate us after this. They don't come back often for postpartum care, and that we know that's a really important time for us to assess physical and psychological complications. Many don't come back for antenatal care in a future pregnancy, and often, sadly, we judge them when that happens and we say, oh, they didn't come in. And why is that? Did they not care or did they not want prenatal care? But it was because of their traumatic experience. These are sometimes the patients that write a grievance to the hospital or seek legal intervention as a consequence as well. There are maternal fetal issues that develop after a traumatic birth like this. And that can include decreased rates of successful breastfeeding, decrease bonding with the neonate that can snowball into negative parenting styles that can lead to attachment disorders in the offspring, that can then snowball into increased risk for behavioral and psychiatric disorders in the offspring. So when you think about it, this one event could have an impact on future generations to come.

And I've mentioned depression and trauma. PTSD can be a result, but we have other mental health issues that result from trauma, like this. Postartum psychosis, even suicidal ideation can occur with birth trauma. I talked about altered pain states, the need to really think about what we're doing because they could develop chronic pain. Some individuals avoid the operating room for future pregnancies for any type of future necessary surgeries that they might need. They don't come back. I've had patients who have delivered vaginally at home after a cesarean section because of their fear. Another one that we don't often think about is the fact that the birth trauma anniversary also falls on the anniversary of the birth, which is the birthday. And there is this lifelong negative association created with that birth. And that's just morbidity.

The other one is maternal mortality. We know that the number one cause of maternal mortality in our country right now is mental health and trauma related conditions. So it is really essential that all of us practicing obstetric care understand the significant consequences. And I just want to add, it's not just the patients that are impacted, it's their spouses. It's their partners, and the providers often are also traumatized by some of these procedures as well. Or these events.

DR. TRAINER:

Thank you. This topic is personal to me, and a lot of ways. I had an experience with a really close friend of mine calling me after a very traumatic experience of her own where she had a very dense nerve block, couldn't move her legs, but she was still feeling excruciating pain and was telling the anesthesiologist that she's still having a lot, a lot of pain, and ended up that she actually did have to have an emergency C-section. And that pain was like that indicator. But she felt like no one listened to her because she suffered like that for hours and hours. And I just feel like that's a personal, close experience. And she called very angry and very upset, you know, knowing I'm an anesthesiologist. Why do your fellow anesthesiologist not listen? You know. And I just wonder, are there misunderstandings and misperceptions that anesthesiologists should better understand? And what can you convey to help them better understand this? And I'll pass this question to Dr. Vogel, actually.

DR. VOGEL:

Well, it's a great question. What are the barriers that prevent us from addressing pain or even, if you back up and say, what is keeping us from truly listening to our patients? Right. Isn't that the essential question here is why why are we having a difficulty listening and believing what the patients are telling us? I think when we think about what's happening in the operating room, I kind of break it down into fear. Certain fears are barriers. And then also there are misconceptions. Like in general, when I think about, okay, what are the fears? What keeps someone from offering an appropriate anesthetic for someone. When we have the equipment, we have the knowledge. These are specialists. We all know what to do. Where is the disconnect? Um, but, you know, I think some of these fears are legitimate. There's often a fear of physical complications, especially with airways. And we have been trained and we know that the the airway of a pregnant patient who's been in labor is going to be maybe more challenging than others, but we've also developed better tools. But there is that fear still of of worrying about the airway. Um, I think that it is fear of judgment, too, that happens in this interplay in the operating room. Are we afraid of being seen as a failure? I failed instead of the block has failed. What are we worried about with this judgment? Are we afraid that if we give too much medication, we'll take away the patient's memory of the event? We take away her experience. Are we afraid of being judged against certain metrics? We have metrics now for centers of excellence and hospital established goals that are looking at the rates of general anesthesia, and I see those as a disincentive to being able to give an adequate anesthetic somehow. Um, maybe there's the fear of what's going to happen to neonates or the mom with these drugs. Right. So so we have fears.

And then I like to think of some of these things as misconceptions, too, that women somehow don't know what they're feeling, like. They can't tell you whether it's pressure or pain. I think if someone is screaming, that's a pretty good indication that it's not pressure, right? They're not just having pain, they're suffering. I think there's a misconception that somehow this is less serious. Having pain is less serious than like awareness under general anesthesia perhaps. Maybe that the word maternal physical health is is the only thing that matters. And psychological health doesn't like how Dr. Nixon said earlier. We walked out of there with a pat on the back like we did it. They're physically alive. They made it.nAnd we just don't even consider that psychological health. Um, there's a misconception that all blocks work. Yeah. That, uh, as long as we saw CSF, it must be working. Or that the patient was comfortable with their epidural in labor. It must be working. So there are these biases that come into play to fixation confirmation bias.

I've got a couple others that are coming to mind too. That normalization of the circumstance to like this happens all the time. Therefore somehow it's appropriate or acceptable. Or the timing of things. Well, there's only ten minutes left, so we don't need to to do anything about that. Even though time is is very different to someone who's in that space being traumatized. And then one recent thing that came up that I wanted to mention is we have this conception that we must use epidurals that are in use in labor for cesarean delivery. And I just throw that out as a question. Do we need to? Should we? Is that the right thing.

So so those are a lot of like what I think of as, as barriers is keeping us from doing this. I wonder if Dr. Nixon has some others that she wants to add in there too.

DR. NIXON:

Yeah. I would love to reiterate a couple of things. So when I when I think about anesthesiologists, I think about a group of people who are hard working. They care about their patients. They treat pain aggressively. I mean, we're not afraid of pain medications, unlike many other doctors. So how could we be so off in some of these cases? Well, it's not malignancy, okay. We're not sitting there going, you must suffer. But it's a lot of fear surrounding the care of praetorians for years, textbooks have told us, as Tracey said, about the pregnant airway, it's difficult. Their full stomachs, they desaturate quickly. General anesthesia is bad for the baby. So we've been taught. We've been socialized to think that we shouldn't do this and that pregnant patients are the big, bad wolf of general anesthesia. And let's face it, as provider, the trauma of hurting or losing an airway in a pregnant woman with their baby, that's crushing. Even thinking about that, you know, brings tears to my eyes of like, what that would be like. But this dogma developed to try to perform like neuraxial under any circumstances, to use it. And sometimes we allow patients to be, quote unquote, a little uncomfortable to allow what we call a safe birth.

In addition, we often want patients to have a good experience, right? Maybe they're motivated to be awake for the birth of their child, and so they will often be quiet and suffer through for the good of their baby. They don't always, it's not always explained to them that their baby will be fine, that they are not a failure as a mother, and there's tremendous mom guilt around birth and especially having a C-section. A lot of women already feel like failures just from being in the operating room versus having a vaginal birth, that they're not a failure for treating their own pain, and their child is not going to suffer behind it.

So I think there's an evolution of the type of thinking was to kind of normalize this pain, as Tracey said. We were certainly uncomfortable with it, and we always want our patients to be happy, but we allowed it and we even created constructs, we created a language. So you heard Tracy say the word pressure. I cannot say loudly enough. I cannot scream it from the rooftop. It does not matter if it's sharp or pressure, if your patient has a ten out of ten pain. All it tells you is a provider clinically, of whether it is somatic or visceral pain, but it does not tell you that you shouldn't treat that pain. So we would never describe a vice on someone's finger as just pressure. But the same type of pain in OB during a major abdominal surgery is written off. So we don't always empower patients to say, this hurts. I want something done. And they describe a loss of control. Many of them get real quiet. When my patients get quiet, I get very nervous that I'm missing something. So we need to empower those patients and say you should not be feeling severe pain. So I always say, if you feel more than a three out of ten, please let me know, right? Because I might be able to do something about it. We might be at a point where we can offer something through IV, or there might be something that's just a comfort measure that I can provide that actually makes that go away. But I think that we just were so scared of hurting patients that we just said, this is okay. And as Tracy said, a lot of times, well, it's almost over. I mean, you would never torture someone and be like, well, it's almost over. But we do it in an operating room during birth and it's really mind boggling. And I will say, I'm ashamed. For years I probably did this because I was kind of this was the working, you know, order of things. And I think we got taught that that pressure is okay somehow, yet it can be incredibly painful and traumatic to patients.

DR. TRAINER:

So how can we make a change to better serve these patients? I mean, what can we as anesthesiologists do? And I know you've touched on part of these, but hasn't the ASA issued new recommendations recently? Do you mind sharing what those are and offer any advice for anesthesiologists on how to implement them? Doctor Nixon?

DR. NIXON:

Sure. We definitely need to do things differently. We need to think about it from top to bottom differently. And there was an ASA statement on intraoperative pain that was kind of on the heels of the UK recommendations. So both of those papers together in conjunction, give some really good advice of things you should do.

So we need to recognize as a specialty that we're not hitting the outcomes we really desire, that maternal health and physical health are both paramount, and we don't always recognize that patient discomfort or experience that we have biases that we have to confront. We have a, you know, a dogma that we really need to kind of shed and we need to do things differently. So I think this all starts, if you like, look at the recommendations, this all starts by really empowering patients. Right. Having that preoperative conversation to number one, and Tracey touched on this, to understand have they had a traumatic experience before. Are there things we're encountering in the operating room that are going to be bombs for them, right. Or things that they're worried about going in because we don't want to exacerbate those, right. We want to we want to reassure them. We want to give them options prior to going in the operating room. I've heard several cases where patients got in the operating room and then refused to have C-sections, even under emergent circumstances, because there was a previous trauma. So we need to really understand, are our patients coming in with that already, and then what can they expect in the operating room? Right. I can expect that my patients are going to be comfortable if I have a good working neuraxial. It's working the way that it's supposed to and that maybe they feel some pressure when we're delivering the child, but they really shouldn't feel like five out of ten pain or above beyond that. And that if they do have that, that they are empowered to tell me so that we can do something and I have to give them those options beforehand, I can give you this, I can give you this. But what you're trying to do is empower your patients to have some control, right? Maybe some of them are motivated. I've had patients who like, are like, yeah, it's a six out of ten, but I want to stay awake. And I'm like, okay, you tell me if you change that. And they're very happy afterwards and they're not traumatized. And I've had patients who were four at a ten and were, you know, afterwards were really upset and really like just never wanted to go back to the operating room again. And so we can't always predict exactly how patients are going to react based on pain scores. But I think they're important to have that shared language and to give them the options of like, hey, remember, I can offer you this if you don't want it, that's fine. If you do, you know, you do.

Something I often say and something we talk about is like, I'm your partner, you drive this ship, you are in control. When you say stop, we will stop, right? When you say you're okay, I will believe you. And then we need to adequately test our blocks. So we do sensory tests on the skin. But sometimes what we're really missing is more visceral discomfort. So it's that deeper discomfort. Right. And so even though we test through the skin when we enter the abdomen, we need to really understand that if somebody touches the uterus and the patient has pressure, that's not adequate anymore. Right? Our sensory block to the skin, our somatic block was adequate. But when the uterus is touched, if the patient wants to vomit, throw up and is screaming that it hurts, that's not adequate. It does not matter what your, you know, your skin prick test shows. We need to use the appropriate doses of medications. We need to use adjuncts. I personally, and this is not in the ASA guidelines, but I personally, our institutions started using clonidine as an adjunct at our spinals and epidurals in the last six months, and my patients pain scores went dramatically down, in addition to fentanyl and pivocaine in there, or even lidocaine for their epidurals. Our institution takes pain force every 15 minutes. So every 15 minutes I'm like, hey, I'm gonna be annoying, but I don't want to miss something because providers are not good at evaluating pain by watching patients. Some patients have kind of a more stoic personality. They're not the complainers. They think they're going to hurt their baby right? When they get in pain, they just shut down. They have a difficult time expressing that or advocating for themselves, and they're in a very disempowered and vulnerable position. So we need to kind of ask them, where are you at right now? I can't read your face. I don't know if this is anxiety, pain, whatever it is, tell me, right. And so we don't want to treat that with midazolam and some anti-anxiety drugs. We want to treat pain with pain drugs. And there's multiple studies showing that we're bad at assessing that globally as providers, we're bad at it. So we have to stop thinking good at it. We have to stop surgery if necessary and if possible. Right. So if a patient is having extreme pain, we should not continue. And they should not just soldier on. And then we have to convert to general anesthesia when it's necessary, right? We can't be afraid of that. As Tracey mentioned, we we have advanced airway equipment. We have the ability to safely take care of patients. And we need to not do it, you know, in a rogue fashion or cavalierly. But we need to do it when it's appropriate. And then after the procedure, we need to check with patients. We need to make sure that they're okay and get them the right resources. If they did experience, you know, what they would consider to be a traumatic experience.

So these are all things that are coming up that are just they're not really taught in residency, right? You focus on the spinal. You focus on laying the patient down, treating the blood pressure. These are the things that actually make a difference to the patient's real experience. Um, and I think it's something that we really need to focus on in our medical education and in the way we kind of approach patients.

DR. TRAINER:

So I do have more questions for you both, but we need to take a quick patient safety break. So please stay right here with me.

(SOUNDBITE OF MUSIC)

DR. JEFF GREENE:

Hi. This is Doctor Jeff Green with the ASA patient safety editorial board the bed to bed transfer that occurs at the start and end of nearly every surgical procedure is an often under-recognized hazard that can cause patient harm. Patient falls and the accidental removal of tubes, lines, or drains can lead to injury. Checklists and protocols are available for optimal lateral transfer and supine to prone transfer, but steps can be omitted in the busy or using a simple, standardized verbal memory tool where questions are posed to the team can help ensure safe patient transfers. For example, on the count of one, the team has asked that lines, drains and tubes are able to move with the patient on the count of two. The team has asked that both beds are locked. Verbalizing safety concerns during transfer helps the entire team work as one to identify issues before they cause problems that threaten patient safety.

VOICE OVER:

For more patient safety content, visit asahq.org/patient safety.

DR. TRAINER:

We're back with Drs. Tracey Vogel and Heather Nixon talking about the subspecialty of obstetric anesthesia. So I love to hear that your approach is to ask more questions. Ask the patient, I think you said every 15 minutes. I think, you know, even being on the other side of it, as a mom, one of the things you don't want to do is bother the anesthesiologist. I think patients sometimes feel like they bother us, or maybe they feel like we're overworked or we're tired and they just don't want to annoy us or bother us. But by asking it, it gives them that opportunity to really say how they feel and be honest about where they are in that spectrum of control of pain. And you mentioned about all the different doses and different medications and things like that. So my thought is a lot of those things can result into or turn into difficulties and complications. And then how do you sort of navigate that when those difficulties or complications come up and, you know, should we be providing more, even follow up care for these patients to, to make sure that we're we're covering those? So, Dr. Vogel, I'll hand this question over to you.

DR. VOGEL:

Sure. First, I just want to applaud Dr. Nixon and her approach. I just would love to clone all of that and be able to take that everywhere. Um, because I love it. And that's what patients need. And I hear their narratives, 11 narratives a week in my trauma clinic. And if they had that kind of care, I would hopefully put myself out of business. Let me just say that.

Um, but to to address that question, like, what do we do when something bad happens? Or how do we approach follow up on these patients? It's not as easy as you think, because there's a challenge in how to, first of all, identify who has had that traumatic experience. Like Dr. Nixon said, not everyone who has some pain ends up with a traumatic experience. Those patients who felt supported, felt like they were listened to, had some sense of control, felt safe, they may have been able to manage their pain and leave there with maybe not a positive experience, but not necessarily a traumatic one that's going to increase their risk for postpartum mental health issues, for example. And then there are going to be those individuals who appeared to have the appropriate medical interventions to address pain. They might have become quiet and withdrawn, but they're the ones, ultimately that may have felt abandoned or betrayed by their providers, those that they were supposed to trust, angry that they were placed in that situation in the first place. I've had patients tell me they could hear people talking about what they were going to do on the weekend, sidebar discussions during their most painful experience, and that just added another layer of trauma. So we can't always tell, but we don't have a good standardized screening tool at this point. But as of right now, I think if we can start to identify when we have to use additional medications, when a patient states they are in excruciating pain, especially when you have to put someone under a general anesthetic as the best course of action. We should be following, following up with them closely. And I just have a couple of very important points here.

Traumatized individuals do not always have the ability to concentrate and hear and remember what you're telling them. If you're talking to them in the PACU. But I do feel that it is important to validate their experience. If they're at a point where they can talk to you. You might not be able to talk to them right away. They might need to recover in a space that's calm and quiet with a warm blanket, their people next to them. But if you have an opportunity to talk to them, remember we're not justifying or rationalizing why something happened. We don't want to be saying to them, well, the spinal, the spinal worked initially. Everything looked good. That's not helpful. Instead, support their emotional experience and know that they may not remember you talking to them. So please document it. I review a lot of charts with patients, and that sense of abandonment is often mitigated when I can review the chart with them and say, a provider did speak with you in the recovery room, they documented it here, and perhaps you have gaps in your memory because of trauma, and they understand that. It makes them feel that this wasn't done on purpose, which is something I never thought about before listening to these trauma stories. So it's important to document. It's also important to think about following up at different time points. We might need to talk to them in the PACU. On postoperative day two right before discharge, and then again a week later just to check in on mental health. And then the other really important thing is to think about what resources you might have at your hospital in terms of mental health support. Who can they talk to? Let them know you're not just validating, but we are going to offer you a space to talk about your narrative, and we want to keep you safe. We want to make sure that you have the right resources to heal going forward. Right. That's important to them and whatever that looks like in your hospital. If you have a robust peripartum mental health team, get them the referral. If you have social workers who act in that capacity at your hospital, get a social worker involved. Do not lose track of these individuals. They're going to need some ongoing support for a bit.

DR. TRAINER:

I think what’s key in what you're saying here is that as much as it's important to follow up with their physical health, it's just as much important, if not more, to follow up with their psychological health. And, you know, making sure we have and implement a structured follow up process for both of these things is super important, you know, the first few weeks after that delivery in helping them to feel more safe and cared for, you know, that psychological wellbeing. And so, you know, in those patients that you do unveil or discover that they had a traumatic experience or some difficulty with intraoperative pain and the control of it, what is your approach and how should we handle subsequent deliveries for these patients?

DR. VOGEL:

Dr. Nixon kind of alluded to some of the things she already does with these patients with a subsequent pregnancy. But I do see a fair number of these patients in my clinic. And I think it's important to think about a structure when they come in. And when you think about trauma informed work or thinking about like trauma awareness, sensitivity, trauma informed care, or just recognizing that they had that bad experience and something else needs to be done. There are some some pillars that can be a structure for anesthesia providers. And we want to think about safety, physical and psychological in this upcoming delivery experience. How can we establish trust? Do they need peer support? Do they need to talk to someone with lived experience, for example, to find out what are some options? Um, collaboration and mutuality. So what can we do together with them to get them to to a decision that they're comfortable with? Um, empowerment. You've heard that word quite a bit already in this podcast, but giving them a voice and choice in what's going to come and then understanding them in their cultural context, whether that's trauma background, gender background, ethnic, whatever that is.

So thinking about a subsequent plan in consideration of those pillars, the first thing I do is listen to them, give them a space to tell their narrative what has happened in the past.

That's number one. Validate their experience too, right? We don't want to diminish it. We want to acknowledge it. And then digging in to ask them, well, what are your biggest fears? What what makes you feel safe? How can we establish safety for you? I often keep the significant others with them, even during placement of any neuraxial, if they even want neuraxial. I think it's important that we all think about choice -- general anesthetic for a subsequent pregnancy or not, or no general anesthesia. And I'm not sure we're all offering that choice to our patients.

Some people want to say, well, it's safer safer to have regional or Interaxial. But is it? Is it safer psychologically for them? Perhaps not. And we have to balance that. I think if we give them that choice initially when we're talking to them, and hopefully these discussions could happen early in pregnancy, I found that they're more open to having more of a discussion, because I don't think it's a black or white situation. There's a continuum in there. So they might be more apt to say, okay, I can have a general okay, I'm starting to trust this provider. And then I can say, well, how would you feel about a spinal to give you post-operative pain medications and you can still have a general anesthetic and then we can move into, well, how do you feel about anxiolytics to help with panic, always knowing that you have the choice to have a general anesthetic. How do you feel about this way of testing the block? And as Dr. Nixon said, you give them that space, that proper space where they feel comfortable and empowered to tell you how they're feeling. I feel that. I don't feel that. This isn't comfortable for me. We have to establish those spaces as well. And that's how we work towards a more positive birth experience the second time around. And we may have to change our procedure. We might have to do a CSE as opposed to a spinal. Add our adjuncts. I do that routinely. I recommend those routinely. Anything we can do to add to the density of the block. Put in backup plans to the block. How can we address safety, psychological safety, whether it's non-pharmacologic, breathing techniques, music, significant other. Think differently for this individual because that's the only way that we're going to help them to get through this, hopefully in a way that we feel is safe and they feel safe. So that's just one example. But everyone's very unique in their trauma narrative and what they need, but that's one way to approach it.

DR. TRAINER:

Dr. Vogel, I love that. Thank you so much. That that's awesome feedback and advice for our listening audience. And Dr. Nixon as SOAP’s president, I want to give you the last word here and opportunity to fill in anything that we might have overlooked and whatever gaps we have here. But also, if you wouldn't mind, to take a moment to tell our listeners, particularly those who may not be as familiar with your subspecialty, just a little bit more about SOAP and what makes it unique.

DR. NIXON:

Well, thank you for that opportunity. I just one of the things I really want to recognize is Dr. Vogel's absolute expertise in this area. I mean, there are a few of us who really get into the narratives of these patients and really understand them so well. I have, over the years, learned a tremendous amount from her and her experience with patients to kind of help inform my practice and make me a more empathetic provider and really understand the problems you're really facing. So it's amazing that she agreed to be on this podcast with us today, and her career course of being an anesthesiologist and kind of rerouting her career into something she was so passionate about is pretty spectacular, and I applaud her for that.

As far as our specialty, um, well, I'm going to tell you that I am one of the most passionate obstetric anesthesiologists you can find. I think that obstetric anesthesia is the most amazing specialty that we have in anesthesia. You get awake patients in mostly happy--I know we talked about some kind of not happy events today--but in mostly happy circumstances. And I'm thrilled that I get to kind of work with the Society of Obstetric Anesthesia and Perinatology or SOAP. So we are really the premier North American subspecialty society, and we're focused on the field of obstetric anesthesia. We have about 2000 members, mostly national but also international, and many of our members are obstetric anesthesiologists, and they're really the drivers of research and education and quality improvement projects in the area. So I am privileged to have, you know, a friends in high places within SOAP I should say, and that I get to spend time with some of the people who really are making our practice, kind of really defining what we should be doing in the operating rooms. Although most of our members are fellowship trained, our providers practice in both academic and private practice settings, and we welcome anyone who provides care to obstetric patients to join our society and come to our meetings, get involved in our committees, and join various specialty interest groups. So we have a lot of different interest groups. Dr. Vogel was talking about her group in particular. And we also offer many educational opportunities that are geared towards generalists and those who provide care at tertiary centers. So come to our website, come to our meetings, get involved, come talk to us. Come find a board member and we will welcome you in, because we're always looking for more energy and enthusiasm to kind of drive our mission.

(SOUNDBITE OF MUSIC)

DR. TRAINER:

Dr. Vogel, Dr. Nixon, thank you so much for having this conversation with us today. It was very enlightening for me and our listeners, I hope. And spreading the good work that you do for the subspecialty, I've really learned a lot, and I'm sure our listeners did too. And for those of you who want to learn more about soap, please check out their website at soap.org and please come back soon for more Central Line.

VOICE OVER:

Stay ahead of the latest practice and quality advice, with ASA anesthesia standards and guidelines freely available to keep you up to date. Browse now at asahq.org/standardsandguidelines.

Subscribe to Central Line today wherever you get your podcasts, or visit asa.org/podcasts for more.