Authors: Nixon H et al.
Anesthesia Patient Safety Foundation Newsletter, volume 41, number 1, February 2026.
Summary
This article addresses pain during cesarean delivery as a major and underrecognized patient safety issue with significant short- and long-term consequences. The authors emphasize that inadequate intraoperative analgesia during cesarean delivery is not merely a technical failure but a systems-level problem involving bias, culture, communication, and fear of complications. Importantly, patient-reported pain during cesarean delivery has been linked to psychological trauma, including post-traumatic stress disorder, postpartum depression, impaired bonding, and long-term dissatisfaction with childbirth.
The authors note that traditional metrics for failed neuraxial anesthesia substantially underestimate the true incidence of pain during cesarean delivery. While neuraxial failure rates have historically been reported as low as 1% to as high as 24% depending on definitions used, patient-reported data suggest a much higher prevalence. A recent systematic review demonstrated that approximately 17% of patients experience pain during cesarean delivery, with rates as high as 33% when labor epidural catheters are converted for surgical anesthesia. These findings make pain during cesarean delivery the most common anesthetic complication encountered in obstetric practice.
The article draws heavily on patient narratives, including lessons highlighted in the 2025 podcast series “The Retrievals,” which brought public attention to patients’ experiences of undertreated intraoperative pain. These stories underscore how clinician bias, hierarchical culture, fear of general anesthesia, and ineffective communication contribute to delayed recognition and inadequate treatment of pain. Gender-based bias and the tendency to misattribute pain responses to anxiety are identified as major barriers to appropriate care.
Fear of general anesthesia remains a central theme. Despite modern advances that have significantly reduced risks associated with general anesthesia for cesarean delivery, outdated concerns continue to influence clinician decision-making. The authors argue that the exceedingly common complication of pain during cesarean delivery and its mental health sequelae must be weighed more realistically against the relatively rare complications of general anesthesia in contemporary practice.
Communication failures are highlighted as a critical contributor. The authors describe how ambiguous language, particularly the use of the term “pressure,” can minimize or dismiss patient pain. Shared decision-making is emphasized as an ethical and practical necessity, requiring clinicians to present general anesthesia as a legitimate and timely option when neuraxial techniques prove inadequate. Failure to validate patient experience and reluctance to escalate care are common themes in malpractice claims related to pain during cesarean delivery.
The authors conclude by calling for standardized approaches to recognizing and managing pain during cesarean delivery, including objective pain assessment, reliable neuraxial testing, early escalation strategies, and systems that support safe and timely conversion to general anesthesia. Listening to patient voices and prioritizing maternal mental health are framed as essential components of improving obstetric anesthesia safety.
Key Points
Pain during cesarean delivery is common and represents a significant patient safety issue
Patient-reported pain rates are substantially higher than traditional neuraxial failure metrics suggest
Undertreated pain is associated with long-term psychological harm, including PTSD and postpartum depression
Bias, hierarchical culture, and fear of general anesthesia contribute to delayed recognition and treatment
Clear communication and shared decision-making are essential when managing intraoperative pain
General anesthesia should be presented as a timely and appropriate option when neuraxial techniques fail
Systems-based protocols are needed to reliably identify, escalate, and treat pain during cesarean delivery
Thank you to the Anesthesia Patient Safety Foundation for allowing us to summarize and share this important APSF Newsletter article focused on obstetric anesthesia patient safety.