Episode #317 Setting Expectations For Safer Cesarean Anesthesia with Dr. Ruthi Landau Revisited, PART 2

Opening Clip: [Landau] “So I would say this is what I would like everyone to think about is that patients don’t come to deliver thinking that they’ll have surgery. Some of them don’t think they’ll have surgery, they’re there to have a baby. And I want this to be the centerpiece of how we come to work and how we are there to support a family’s experience of childbirth.”

The APSF recently published a new video featuring Dr. Ruthi 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. We are on a roll talking about keeping patients safe and comfortable during caesarean delivery for the past couple of weeks and today we are going to continue on the theme by returning to my conversation with Dr. Ruthi Landau. This interview show first aired on December 9^th, 2025 for episode #284. Dr. Ruthi Landau joined me for a great conversation all about keeping patients safe and comfortable throughout the peripartum period and especially when it comes to pain management during and after caesarean delivery.

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

And now, we are returning to the rest of my conversation with Dr. Ruth Landau.

[Insert Interview Show from Episode #284]

[Bechtel] If we think about the whole peripartum time period, there seems to be an increasing role for anesthesia professionals. So is there something that anesthesia professionals can do to ensure safe and effective pain management throughout that time period? And kind of thinking about this in terms of are there longer-term effects for patients after discharge from the hospital directly related to the anaesthetic management?

[Landau] So obviously, my answer is that we have a tremendous role. I think, I think what we’re discovering more and more, which is no surprise, is that setting expectations is so important. You know, we consent patients talking about the rare events, right? We talk about the epidural hematoma, we talk about the infection, we talk about all these things, you know, the risks that we always mention when we consent patients for neuraxial procedures. I think that when we consent a patient for neuraxial labor analgesia, we do tell them that maybe the epidural will need to be replaced, it might, you know, might get dislodged, might not work well. I think it’s very important to use maybe, you know, 30 seconds more to say, and just in case you do go for cesarean delivery, we will communicate around whether we think this epidural is working well enough and maybe it will need to be replaced. Now, I know women probably don’t want to hear this because they’re not thinking about a cesarean delivery. And now we’re telling them that maybe the epidural won’t work. That seems terrible. But I think we need to own this. I think we need to talk about it because they are there are opportunities to replace the epidural. And by the way, it’s very important to perform what we call now active management of neuraxial labor analgesia or epidural analgesia. In other words, you can’t just place an epidural and expect it to be an autopilot because you gave the patient, you know, she has her infusion or the program intermittent bolus, and then she has the button, and then the nurse will call us if the patient is in pain. It should not work this way. We have to, you know, we have to assess whether the catheter is working, not just for labor, but bearing in mind that maybe the patient will need to go to the operating room. I didn’t mention it specifically, but the latest studies looking at pain during cesarean delivery really showed that the women the most at risk are those who have an intrapartum caesarean delivery with an epidural that is topped up. So the epidural top-up for cesarean delivery. And there’s a paper that was just accepted for publication in anesthesiology three days ago. It’s not yet even online, but you can look for it by published by our colleagues from Stanford. It’s a soap research network study. 15 centers across the United States contributed data looking at pain during cesarean delivery. And clearly, again and again, it’s not the only study that shows that, but this one shows it again that patients who have an epidural topped up for c-section are the most likely to experience discomfort during cesarean delivery. So we need to make sure that the epidural is working. If it’s not working for labor, it will not work for C-section miraculously. We have an opportunity if we communicate well with the obstetrician, if we see that the tracing is starting to be not great, if we see that labor is stalling, we have the opportunity to check the epidural to make it work. To also explain to patients that the I want to feel nothing is not possible. They will feel sensations and it will be important to communicate around these sensations. Is it comfortable? Is it uncomfortable? And to remember to dose the epidural.

If the C-section is lasting longer, we need to redose the epidural, not to forget to redose the epidural, not to forget to give adjuvants and opioids short acting are important intra-operatively for the visceral sensations. Alpha 2 agonists, including dexmedetomidine, will be helpful as well. And talk and reassure with patients.

But your question was about what happens after. So I think that patients, first of all, patients with a c-section are likely to come back. So not only do we have the responsibility to ensure that they don’t leave the hospital with a traumatic experience, but this patient that went home with a traumatic experience might be the one you’ll see again in 18 months or two years later for a repeat C-section. And she is coming terrified into the experience of having another delivery. Maybe she’ll try to have, you know, to have a TOLAC because she’s so afraid of a c-section. Maybe she will fail the TOLAC, and now it’s another, you know, another um added um fear, which brings me to the third statement of ASA, which I didn’t mention yet. But this is about uh traumatic birth experiences and the psychological impact and how to avoid uh traumatic birth experiences, but also how to apply trauma-informed care for those women who did have a previously traumatic experience. And sometimes they will not express it, but it can be recognizable if you know how to recognize symptoms of PTSD. So the patient that you might have not taken care of, but now comes back, you need to be able to have this conversation with her, and or the patient you took care of, who did unfortunately have a suboptimal experience. It is absolutely essential to offer a debrief, to offer maternal mental health services for the patients to be able to talk about these things and not build, you know, build up the emotions and have full-blown childbirth-related PTSD. So, and we talk about it more and more and we see it more and more. We know better how to look for it. They’re now questionnaires of patient-reported experiences. So, not just the proms of patient-reported outcome measures, but the patient-reported experience measures that some of us are, you know, applying to try and better identify women at risk and also better learn what the experiences are and who you know, what are the risk factors for those childbirth PTSD.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thank you so much to Ruth for joining us on the show today and sharing your expertise. We covered a lot of information. We hope that you will check out the show notes for links and citations to the resources that we talked about on the show today. Before our next podcast drops, you can check out the three ASA statements or the August 2025 expert review article in the American Journal of Obstetrics and Gynecology, “Neuraxial Anesthesia and Pain Management for Caesarean Delivery.”

[End of Interview Show Clip]

We may have given you a lot to think about over the past couple of weeks. The next time you are providing obstetric anesthesia care, we hope that these resources, the podcast episodes, the YouTube video, APSF Newsletter articles, and literature review, are resources that you can use to help you keep your patients safe and comfortable. Are there any changes that you need to make in your OB anesthesia practice? Is there anything that your institution needs to do differently? Does this change how you talk to your patient about the anesthesia for c-section?

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.

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

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