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

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We hope you are enjoying our latest series on the 2025 APSF Stoelting Conference all about transforming maternal care. What are you doing in your institution to reduce maternal morbidity and mortality? For ideas about innovations and collaborations, we hope that you will check out the first three episodes in our series and we are happy that you are here for Part 4 today. If you weren’t able to attend the Stoelting conference this year, then we hope that you will enjoy this podcast  series and you can also check out recording from the conference on YouTube. Check out the show notes for more information.

Before we dive further into the episode today, we’d like to recognize Medtronic, a major corporate supporter of APSF. Medtronic has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Medtronic – we wouldn’t be able to do all that we do without you!”

Now, it’s time to get back into the conference. Thank you to our industry sponsors for supporting the 2025 APSF Stoelting Conference: BD, Medtronic, Solventum, and Intelliguard.

First up, we have a session on Trauma-informed care by Tracey Vogel, an obstetric anaesthesiologist and director of the Perinatal Trauma-informed Care Clinic in Pittsburgh, Pennsylvania. Tracey introduces the idea of trauma-informed care as a universal precaution and these practices can help prevent re-traumatization and traumatization. So, what is trauma? According to Judith Herman’s work, psychological trauma is an affliction of the powerless. It involves a sense of powerlessness, helplessness, and terror combined with the removal of the sense of control, connection, and meaning. Tracey reminds us that trauma is in the eyes of the beholder. Our role as clinicians is not to triage someone’s emotional experiences based on how we think they should feel about it. When we do this, patients may not have a chance to express any negative emotions that they may be feeling. An example of this may be a patient’s experience with an emergency c-section. They may feel positive and negative emotions related to the experience, happy about a healthy baby and mom, but also struggling with the loss of control during the surgery. It is also important to remember that complications and traumatic experiences are not the same thing. You do not need a physical or identifiable complication to happen. Perhaps, we can think about trauma as defined by the 3 E’s. It is from an Event, Experienced by the individual, and has negative Effects.

How can we provide trauma-informed care? Tracey describes 6 pillars including Safety, Trustworthiness and transparency, Peer Support, Collaboration and mutuality, Empowerment voice and choice, and cultural, historical, and gender issues. Trauma-informed care replaces the question, ‘What’s wrong with you’ to the question ‘What happened to you?’ and the follow-up action “Here’s what I am going to do to you’ to ‘What can we do together to achieve mutual goals based on each person’s individual context?’ This requires a shift from thinking about patients as problematic to symptomatic.

Trauma informed care incorporates the following considerations:

• Realizes the impact of trauma and understands paths for recovery
• Recognizes signs and symptoms of trauma in patients, families, staff, and others. Can we give the appropriate care in these situations?
• Responds fully integrating knowledge about trauma into policies, procedures, and practice. This involves knowledge acquisition. For example, we have learned that restraining women for C-section is harmful psychologically and usually not indicated in most circumstances. This may lead us to create a protocol to ensure that this doesn’t happen.
• Actively seeks to resist re-traumatization.

Keep in mind that Respectful Maternity Care + Shared Decision Making + Patient Centred Care all overlaps with trauma informed care and allows for the understanding of Trauma and resilience and the impact of trauma on the clinician.

Let’s go through a few more definitions of types of care.

• Trauma aware is the process of learning what is trauma and increasing your knowledge base
• Trauma sensitive is when you see something from someone else’s perspective
• Trauma informed involves building policies and protocols
• Healing centred involves a multidisciplinary approach and proactive adaptability. Are we doing the right thing and how can we improve?
• And finally, Trauma-disrupting care, which recognizes trauma events in real time and uses a framework for intervention and disruption. This process involves self-reflection.

Why do we need this for safe obstetric anesthesia care? We have been talking about this a lot in this series. There are many types of traumatic events that may occur during the peripartum period including OB-related hemorrhage, emergency, or severe maternal illness; anesthesia related including inadequate anesthesia, needle trauma or complication; and fetal/neonatal events, such as intrapartum emergency events or separation of mother and child. These traumatic events have real consequences for our patients including the following:

• Dissociation with no memory of childbirth experience
• Hyper-arousal with agitation and anger with caregivers
• Psychological harm impairing maternal-fetal bond
• Increased risk for maternal mental health consequences involving depression and suicide
• Negative alteration in pain perceptions leading to chronic pain states
• Life-long negative association
• Negative impact on future reproduction
• And avoidance of the operating room.

Anesthesia professionals may be impacted as well leading an increased risk of job dissatisfaction and burnout.

So, what can anesthesia professionals do? For primary prevention, we need to work to prevent birth trauma from ever occurring. Remember, this is that trauma-disrupting care. For secondary prevention, we need to identify when a traumatic event happened and then try to prevent the development of post-traumatic stress symptoms. For tertiary prevention, we need to take steps to minimize symptoms severity once PTSD has been diagnosed. These are important ways to work to help keep patients safe during obstetric anesthesia care.

Our next speaker is Brinda Kamdar, an assistant professor of Anesthesiology, to talk about Substance Use Disorder during pregnancy. Did you know that the prevalence of maternal opioid use doubled between 2010 and 2017 and there are increased risk for worse outcomes and challenges with pain control. There are also worse fetal outcomes including intrauterine growth restriction and stillbirth. In addition, Neonatal abstinence syndrome occurs in 60-80% of babies who are exposed to opioids in utero.

Treatment options include Methadone, Buprenorphine, and Naltrexone. We hope that you will check out the 2010 New England Journal of Medicine article, “Neonatal abstinence syndrome after methadone or buprenorphine exposure.” See the show notes for more details. For patients on these medications here are some treatments pearls.

• If on Methadone, continue throughout pregnancy.
• If on buprenorphine, continue throughout pregnancy. Patients may have good pain control especially with regional anaesthesia techniques even at doses greater than 16 mg/day.
• Do no switch medications.

Patients may require an increased dose of maintenance therapy in the 3^rd trimester to prevent withdrawal symptoms.

Keep in mind that that there is still a stigma about substance use disorder in prenatal care. Health care discrimination is very common due to old beliefs that addiction is a moral failing rather than a true diagnosis.

This is a vicious cycle of stigmatizing behaviours, such as bias and discrimination and stereotyping patients   leading to dismissing symptoms and premature tapering of maintenance medications with the resultant patient reaction of loss of trust in the healthcare system, avoidance of healthcare out of fear of being labelled or fear of family separation which then leads to missed prenatal care, continued or escalated substance use, poor maternal and neonatal outcomes, and long term disengagement

So, what can we do? Our words can create barriers to treatment and recover or they can convey support.

1. Instead of stigmatizing language, we can use safer words. Here are some examples.
   1. Instead of pregnant drug addict, we can say pregnant woman with substance use disorder
   2. Instead of IVDU, we can say person who injects substances
   3. Instead of addicted baby, we can say baby born to a mother with opioid use disorder.

2. Another important step is to see the person behind the pain. This involves the following:
   1. Connect before you assess. Find one point of genuine connection.
   2. Invite them to tell you their story. “I’d like to understand your journey. Can you share how fentanyl first became part of your life?”
   3. Move from measuring to understanding starting with the mindset that the patient’s report is real and worthy of attention.
   4. Impact over intensity. Use a functional pain score and discuss with your patient. “Can you walk me through what you can and can’t do because of the pain?”
   5. Participate in shared decision making by giving options and empowering patients

Thank you so much to Brinda for sharing these important considerations for caring for patients with substance use disorder.

Our next speaker is Grace Lim, an obstetric anaesthesiologist and Chief of OB and Women’s Anesthesiology at the University of Pittsburgh to talk about the Elevate Project: Advancing patient-centred anesthesia choices during caesarean delivery. This project focuses on how we show up at the patient’s bedside with trauma-informed care combined with substance use disorder management. Not only at the bedside, but also at the system level involving patient-centred care and with research projects. Grace highlights the problem of pain during C-section delivery keeping in mind that this is an area where patients may have not had a chance to engage in shared decision making. Remember, pain is only one outcome. Patients may have different priorities including how they are spoken to, what they heard said about them, or the way information was communicated to them. The focus is to empower patients through informed anesthesia choices for c-section delivery to help bridge the gaps between the maternal experience, patient safety, and equitable care access. The elevate team tackled this problem from different angles including stakeholder queriers, interviews, and an in-person summit. The summit was held in January 2025 and covered shared decision-making in caesarean anesthesia, addressing health disparities in maternal care, and policymaking and reimagining reimbursement models.

We hope that you will check out their website elevate-project.org. Here is the introduction to the project on the website. The big goals for Elevate is to use collaborative research, stakeholder engagement, and innovative strategies to address knowledge gaps, improve clinical practices, and work together so that all birthing individuals receive respectful, informed, and high-quality anesthesia care aligned with their preferences and needs.

Grace reminds us that patients and clinicians are not always on the same page when it comes to obstetric anaesthesia goals. For example, during a C-section, anesthesia professionals’ goals include timely administration of anaesthetic, appropriate monitoring, oxygen delivery, but for the patient they may have different goals. This is likely an opportunity to partner with the patients better. We can ask ourselves, “How can I do the things that I need to do, but also meet the patient’s needs? Can we get creative about the people in the delivery room to help the patient have a good outcome?”

For more information, head over to the Elevate website. You can find the link in the show notes. If this is something that interests you, you can even join the project by signing up on their website. The Elevate project is expanding and looking for collaborators, clinicians, patients, researchers, and stakeholders to join upcoming studies and funded initiatives.

We have time to cover one more talk today. Miranda Klassen is the executive director of the Amniotic Fluid Embolism or AFE Foundation, which she founded in 2008 after surviving an AFE during childbirth. The mission for the AFE Foundation is to support research and families as well as clinicians and anesthesia professionals providing care for patients with AFE. The foundation offers education with AFE courses, a simulation toolkit, and tools for effective communication. Research support includes the AFE registry which is an international registry of more than 250 cases of AFE as well as a biorepository with specimen studies that are underway. There is still so much that we do not know about amniotic fluid embolism cases. The goal is to transform AFE into something that is predictable, preventable, and treatable.

For more information, we hope that you will check out their resources over at afesupport.org. One of the resources is a hotline that you can call to reach a HIPAA compliant hotline to quickly connect healthcare providers with the AFE foundation to offer crisis support for the patient, family, or healthcare team, guidance on how to collect AFE specimens for the AFE Biorepository, and expertise to aid with the treatment and management of an AFE patient.

There is also an AFE Stabilization Checklist to help during emergent management of a patient with an AFE. This is an uncommon event and having a checklist is a great way to make sure that you provide the necessary care during the emergency.

Let’s go through the checklist now. The first box is breathing and recognition is important. Patients may present with acute shortness of breath, increasing respiratory rate, and new oxygen requirement. The response includes Activate the Rapid Response Team, bring in the crash cart, frequent vital sign monitoring and listen for breath sounds, administer oxygen, prepare for intubation.

The next box is blood pressure and patients may develop unexplained acute hypotension or cardiac arrest. In the setting of declining blood pressure, it’s time to activate the rapid response team, monitor vital signs, and perform uterine displacement. For cardiac arrest, call the obstetric code team including peds or neonatal response teams. Note the time and begin chest compressions with manual left uterine displacement. Begin CPR and follow the ACLS algorithm. Deliver within 5 minutes of pulselessness if greater than 20 weeks gestation or fundus at the umbilicus.

The final box is bleeding which may present with declining blood pressure and maternal tachycardia, or pulse pressure less than 30mmhg. The response involves notifying the rapid response team including the anesthesiologist and activating the massive transfusion protocol. Transfusion with pRBCs, FFP, platelets, and cryo as needed as well as TXA administration and ordering labs when appropriate.

If possible, before transfusion, draw 5ml in a red and purple top tube and set aside for AFE specimen research. For more information, you can call the hotline when you are able. Check out the show notes for more details about the AFE foundation, the hotline, checklist, and more resources.

If you have any questions or comments from today’s show, please email us at [email protected]. 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.

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Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2025, The Anesthesia Patient Safety Foundation