Presented September 3, 2025 at the 2025 APSF Stoelting Conference on “Transforming Maternal Care: Innovations and Collaborations to Reduce Morbidity and Mortality”
SUMMARY
Heather Nixon, MD’s presentation addresses the significant issue of inadequately treated pain during Cesarean delivery, a problem she argues is a form of preventable harm with severe long-term consequences, including Post-Traumatic Stress Disorder (PTSD). The core issue stems from providers’ tendency to misattribute pain to anxiety and a culture that normalizes discomfort (“just pressure”) or prioritizes fetal outcome over maternal comfort. Dr. Nixon outlines the necessity of changing cultural dogma, educating providers on using adjuncts to ensure adequate analgesia, and, crucially, empowering patients by discussing the risks of pain pre-operatively and validating their experience intra-operatively through structured, team-based protocols. She advocates for a patient safety bundle to address this issue nationally.
Key Points:
- Prevalence and Trauma
One in three patients with a neuraxial block may experience intraoperative pain during Cesarean delivery, the highest single risk factor from anesthesia for the procedure [12:57, 13:04]. This can lead to severe PTSD for the mother, impacting bonding, breastfeeding, and long-term relationships [22:16, 22:58]. - Visceral Pain and Testing Inadequacy
Standard skin-prick sensory tests only assess somatic pain blockade [07:36]. Neuraxial techniques may fail to block the deeper visceral pain from abdominal and uterine manipulation, leading to intense pain despite a “successful” skin test [07:29, 07:44]. - Provider Bias and Dismissal
Providers frequently misattribute or label patients’ pain as anxiety or “pressure,” especially for women [10:10, 11:46]. This is a cognitive bias that prevents appropriate treatment, as anxiety medications are incorrectly used to manage pain [12:04, 12:20]. - Fear of General Anesthesia (GA)
A major barrier to adequate treatment is the provider’s fear of converting to GA and facing a difficult or “lost” pregnant airway [16:07, 16:19]. This fear is exacerbated in resource-limited or community practice settings, leading to the dangerous choice to “muscle through” patient pain [16:55]. - Coercive Language and Culture
The use of language that minimizes pain (“just pressure,” “it’s almost over”) or prioritizes the fetus (“the baby’s all right, that’s all that matters”) is coercive [17:30, 17:52]. This societal and cultural pressure makes it difficult for patients to advocate for their comfort [18:22, 18:54]. - Systemic Solution: Patient-Centered Protocol
The recommended institutional changes include: Pre-operative risk discussion about pain [24:19]; use of adjuncts (e.g., fentanyl and clonidine) to densify blocks [08:30]; team-based communication with warnings for painful surgical steps [26:26]; and, critically, a requirement to stop surgery and intervene if the patient’s pain score is higher than 3/10 [28:25, 28:52].
ABOUT THE SPEAKER(S)
Heather Nixon, MD
Professor of Anesthesiology
University of Illinois at Chicago
Immediate Past President SOAP
Heather Nixon, MD is a Professor of Anesthesiology and the Division Chief of Obstetric Anesthesiology at the University of Illinois Hospital at Chicago where she has worked for the last 15 years.
She completed her residency at the University of Illinois at Chicago Medical School and her Obstetric Anesthesiology Fellowship at Northwestern Memorial Hospital – Feinberg School of Medicine. Her previous academic appointments at the University of Illinois at Chicago include Residency Program Director, Associate Head for Education and Obstetric Anesthesiology Fellowship Director. Nixon also served on the Illinois Maternal Mortality Review Committee for 6 years.
Nationally, she served six years as the Vice Chair for the American Society of Anesthesiologists Committee on Obstetric Anesthesia and on the Society of Obstetric Anesthesia and Perinatology Board of Directors for the last decade. Heather is the current Immediate President of the Society of Obstetric Anesthesia and Perinatology. She is a recognized national and international speaker and is a passionate advocate for patient safety as it relates to medication management in anesthesiology and the patient experience in obstetric anesthesia care. Notably, she is featured in the New York Time and Serial Productions “The Retrievals Season 2” for her quality improvement and safety work in the clinical area of intraoperative pain during cesarean delivery.
