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Statement on Providing Psychological Support for Obstetric Patients

Developed by: Committee on Obstetric Anesthesia
Original Approval: October 23, 2024

Executive Summary

This statement highlights the importance of providing psychological support to obstetric patients, a key aspect of a positive birth experience, by providing the best patient-centered care in the perioperative and perinatal periods. Up to 6% of postpartum patients have childbirth-related post-traumatic stress disorder, with 12% reporting post-traumatic stress. Anesthesiologists play a prominent role in delivering patient-centered care, particularly in addressing the psychological needs of patients with pre-existing mental health conditions or past traumatic experiences. This statement helps clarify terminology, summarize data on patient-centered outcomes, and suggest guidance and some best practices to help anesthesia professionals meet these goals. A holistic approach helps provide a positive birth experience supporting the psychosocial well-being of patient and family as well as health care providers. Additional resources are provided.

Key points include the following:

  1. Risk Factors and Prevention: Multiple factors contribute to traumatic birth experiences, including obstetric complications, inadequate pain management, and poor communication. This statement advocates for early identification of at-risk patients through screening and collaborative care planning, involving obstetric, mental health, and anesthesiology professionals.
  2. Trauma-Informed Care: This statement highlights how the best practices of trauma-informed care (TIC) can be applied by anesthesiology professionals in obstetric settings. The principles of TIC can help avoid exacerbating prior trauma and to promote a positive childbirth experience for all patients.
  3. Pain Management and Anxiolysis: Effective pain management is important in reducing the risk of poor birth experiences. This statement outlines strategies for both pain control and anxiolysis, including the use of pharmacologic anxiolysis, while balancing the potential risks and benefits to both the mother and neonate.
  4. Systems of Care and Provider Wellbeing: Integrated systems of care should address maternal mental health comprehensively, ensuring immediate and long-term mental health needs are met, including providing support for anesthesiology professionals working to improve their health systems. The importance of recognizing the emotional toll of providing healthcare in challenging settings is discussed. Healthcare providers can be affected and a comprehensive list of additional resources for self-care to maintain empathy and compassion in challenging clinical settings provided.
  5. Patient Experience and Empowerment: Empowering patients through shared decision-making, clear communication, and respecting patient autonomy is critical to improving their overall birth experience. Strategies and additional resources are provided to enhance patient experience.

Introduction

Anesthesiologists are trained to deliver high quality maternal healthcare in the perioperative and perinatal periods. Delivery of high-quality maternal healthcare requires “person-centered care” which includes “respectful and responsive care” and superb communication.1,2 Patients with pre-existing psychological issues including prior traumatic experiences present special challenges to achieving optimal care. Anesthesiologists may furthermore be confronted with demands to deliver high-quality care in an era of increased pressure and scrutiny around workload and productivity.3 Application of trauma-informed care practices (realize interpersonal trauma is common, recognize acute and chronic trauma stresses, institute policy and protocol changes, avoid re-traumatization)3A may positively impact the childbirth experience, a profound life event that often involves a high degree of physical and psychological stress. Striving for a positive birth experience is essential to promoting psychosocial wellbeing for the pregnant patient-infant dyad and family. A positive birth experience, as defined by Leinweber et al., is “a woman’s [pregnant person’s] experience of interactions and events directly related to childbirth that made her feel supported, in control, safe, and respected; a positive childbirth can make women [pregnant person] feel joy, confident, and/or accomplished and may have short and/or long-term positive impacts on woman’s [pregnant person’s] psychosocial well-being.”4 Anesthesiologists are uniquely positioned to support optimization of the birth experience through trauma-informed care practices.

Terminology

Trauma results from an event, a series of events, or a set of circumstances that is experienced as physically and/or emotionally harmful or threatening.5 Up to 50% of women view their childbirth experience as traumatic, defined as “a woman’s [pregnant persons] experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions; leading to short and/or long-term negative impacts on a women’s [pregnant persons] health and wellbeing.”4,6,7 Traumatic birth can lead to anxiety, depression, and childbirth-related posttraumatic stress disorder (CR-PTSD) defined as symptoms of PTSD that develop after, or as a direct consequence of, having had a traumatic birth.8,9 Given the high rate of preventable mortality ascribed to mental health (22.5%), it is crucial to focus on opportunities for prevention as a component to decrease morbidity and mortality.10,11

Awareness & Sequelae

The perception, processing, and internalization of trauma is multifaceted (Infographic 1). Improved understanding and awareness of the evidence-based components that contribute to trauma can improve anesthesia professionals’ ability to improve maternal outcomes. Patients may experience trauma due to a variety of factors associated with a history of childhood and adult experiences including former childbirth experiences. Previous adverse life experiences such as a history of trauma (violence, childhood sexual trauma, traumatic stress in pregnancy, intimate partner violence), pre-existing mental health conditions (depression, anxiety, PTSD), negative birth experiences or negative perception of childbirth (fear, loss of control, pain), and lack of social support (partner, family, staff) in addition to antepartum complications within the pregnancy contribute to pre-birth vulnerability for developing childbirth-related posttraumatic stress disorder (CR-PTSD).6,8,12 Childbirth-related posttraumatic stress disorder (CR-PTSD) impacts up to 6% of postpartum patients with 12.3% reporting posttraumatic stress.8,9,13 Sociodemographic factors and other pregnancy factors also contribute: socially defined race, in particular Black patients, young age, low income, primiparity, and multiparity.12,14,15

Infographic 1. Risk Factors for Traumatic Birth

Infographic Legend: Multi-faced approaches to trauma.
Design: Dominique Y. Arce,  MD, MPH

Although any birth event can be experienced by a patient as traumatic, specific intrapartum events and complications are more commonly associated with traumatic birth experiences, including obstetric, neonatal, and anesthesia related events. Notably, a patient’s perception, including their perception of time, may not correlate with the physicians’ experience of events.14 Cesarean delivery (unplanned and planned), instrumented vaginal delivery, long duration of labor, hemorrhage, manual extraction of the placenta, pressure for induction of labor or epidural placement, negative subjective birth experience, dissociation, complications of pregnancy such as preeclampsia, neonatal complications such as preterm birth, stillbirth, or neonatal ICU admission have been identified as risk factors for development of PTSD following childbirth.6,12 Anesthesia-related complications may also be risk factors for CR-PTSD, specifically pain during cesarean delivery, nerve injury, and post dural puncture headache (PDPH).16,17 Pain during cesarean delivery may occur in up to 15-23% of cesarean deliveries and has been associated with significant psychological adverse outcomes.18 Discordance between patient expectations and treatment of pain during birth is a risk factor for traumatic birth, and may also impact future perceptions of pain.19 Postpartum risk factors include depression, presence of additional stressors, and poor coping.6 Patients screened in the antepartum period to be at risk for CR-PTSD may benefit from resilience-enhancing interventions.20,21 Protective intrapartum factors include perceived control during labor and satisfaction regarding partner’s support.22

Peripartum stress, including traumatic stress from a pre-existing traumatic history or retriggering of past events, can increase a patient’s risk for a traumatic birth experience and postpartum mental health complications, including post-traumatic stress disorder, anxiety, depression, OCD and suicidal ideation.15 Therefore it is essential that anesthesiologists and all anesthesia professionals understand the risk factors and strategies for preventing further psychological harm for these patients. 

Table 1. Peripartum Events Contributing to Traumatic Birth

 Table 1. Peripartum Events Contributing to Traumatic Birth

Psychological stress and CR-PTSD may occur alongside depression, and lead to fear of future births and even requests for cesarean delivery in subsequent pregnancies.6 Impaired bonding and reduced breastfeeding are reported as well in addition to a potential impact on child development and sleep disorders although further research is necessary.6

Childbirth trauma and CR-PTSD not only impacts the pregnant person-infant dyad, it may also impact the co-parent and the entire family, both of which are under-studied entities in the childbirth process.9 In a systematic review and meta-analysis of studies addressing fathers, 1.2% had PTSD and 1.3% had posttraumatic stress.9 In addition to depression, anxiety, pregnancy complications, and poorer subjective birth experiences, lower job satisfaction, higher job burden, being a first-time father, lower education, and mother’s lower support during birth are predictors for CR-PTSD in the father.23 The relationship between the pregnant person and partner may also be impacted by the experience of CR-PTSD including sexual dysfunction, disagreements, and blame for birthing events.24

Prevention and Mitigation

Evidence suggests that supportive care during birth is a protective factor for CR-PTSD and focusing on prevention of traumatic experiences is important.22 Trauma informed care (TIC) is a broader body of work that aims to avoid exacerbating or triggering trauma in the healthcare setting.6 The principles of TIC can be extrapolated to the obstetric anesthesia setting to provide recommendations for care.25 A trauma-informed approach to patient care is a

"strengths-based service delivery approach that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both practitioners and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment."26

The literature around traumatic birth identifies complications as an important risk factor, thus when complications do arise, it is important that providers employ collaborative decision-making and continue to encourage the patient to use coping skills.16,27 The relationship built with the provider during the antepartum period can be highly valuable for ensuring that trust is maintained.

The Substance Abuse and Mental Health Service Administration (SAMHSA) defines trauma informed care with 4 “Rs”28 which can be used as a framework for aiding women in the obstetric environment:

  1. Realize that a significant proportion of women are survivors of trauma, and that this previous trauma can negatively impact their current birthing experience
  2. Recognize established risk factors in collaboration with our obstetric colleagues for identifying vulnerable populations early in pregnancy and planning for antenatal obstetric anesthesia consultation to facilitate conversations surrounding shared decision-making to address fears and triggers while also maintaining safety and quality care
  3. Respond
  4. Resist re-traumatization by providing transparency and education about management, optimizing pain relief, effectively managing catheters in labor
     

The suggested best practices are organized according to the following topics: Screening and Planning, Anxiolysis and Managing Acute Stress, Pain Management for Cesarean, Labor Management, Postpartum Pain Control and Follow-Up, Systems of Care, Patient Experience. A simplified overview of these strategies is summarized in Figure 1.

Figure 1. “Super” Strategies for a Positive Birth Experience: Support (from Partner and Providers); Sense of Control (or Sovereignty); and Outstanding Communication, Validation and Sharing.

Design: David L. Stahl, MD, FASA
Graphics: Mark I. Zakowski, MD, FASA

Screening and Planning

Anesthesiologists have an opportunity during the preoperative and intrapartum evaluation to assess patients for psychological stress. Additionally, given anesthesiologists’ crisis management training and intimate knowledge of the pharmacokinetics and pharmacodynamics of anxiolytics, anesthesia professionals are uniquely skilled to provide a physically and psychologically safe environment for patients.

Screening and recognizing signs of preexisting trauma can allow for shared decision making with an awareness and understanding of how previous individual or collective trauma impacts an individual’s mental, physical, social and emotional health. Screening for current or previous traumatic experiences can often be challenging because most health care providers currently are untrained in how to elicit a history of certain types of interpersonal trauma/violence such as sexual assault or rape and may lack a framework for responding to a pregnant person's disclosure. However, the anesthesiologists' interaction with a pregnant patient is unique from that of the obstetrician, and therefore can serve an important role in eliciting these histories and responding to patient disclosures. Even if a health care provider has not yet achieved a level of competency in this area, basic approaches to all pregnant patients include validating her previous negative experience, offering support, establishing an environment of safety, and developing care plans in a collaborative manner, and can be offered by anyone.29

Early identification of particularly vulnerable populations is important to patient centered care. Patients, such as those with mental health disorders, opioid use disorder (OUD), and severe fear of childbirth, benefit from a clearly communicated, multidisciplinary approach involving obstetric, mental health providers and anesthesiologists to address expectations and management for pain during labor. Patients may also benefit from familiarizing themselves with the environment through interventions such as tours of the labor floor. Early selection and introduction of team members may help build trust. Additional topics to discuss include nicotine management, opioid maintenance, support from significant others, the need for private space, use of anxiolytics, and coping mechanisms for stress. For patients where cesarean delivery is anticipated or possible, early communication may mitigate the increased risk of a traumatic experience, and in some cases is more effective at preventing long term consequences than anxiolysis in this population.7,16,30

Anxiolysis and Managing Acute Stress

Pregnant patients with a history of trauma or a diagnosis of PTSD often present with acute stress. However, acute stress responses are not limited to those patients with histories of prior trauma. Concern for neonatal well-being, although well-intentioned, has discouraged the use of pharmacologic anxiolysis to protect maternal psychological safety despite evidence showing that severe peripartum fear and anxiety can have devastating physical and psychological consequences on the mother and ultimately the maternal-neonatal bond.24 When considering whether or not to administer an anxiolytic, all health care providers need to balance the potential for direct drug effects on the mother, fetus, and neonate, against maternal risk if the drugs are withheld. Untreated anxiety can lead to maternal acute stress response with physical and psychological consequences: (1) physical manifestations may include increased blood pressure and heart rate, hyperventilation and vasoconstriction, unexpected/uncontrolled shaking, exaggerated startle response, and movement due to panic31 (2) psychological manifestations may include hostility, irritability, fear, and an increased risk for dissociation and subsequent risk for postpartum PTSD/anxiety/depression and suicidal ideation.15 Alternatively, pharmacological overtreatment of maternal anxiety could potentially cause amnesia for the birth experience, maternal sedation and inability to participate in early skin-to-skin bonding and breastfeeding. Neonatal sedation from placental transfer or via breastmilk is also a concern. Propofol produces anxiolysis in subhypnotic doses but has a narrow therapeutic window. Therefore, an expert understanding of the safety profiles of available anxiolytics is essential in order to balance unwanted maternal effects of acute stress—both physical and psychological—with negative fetal and neonatal consequences (Table 2).32

Table 2. Management of Anxiolysis in the Peripartum Period

Table 2. Management of Anxiolysis in the Peripartum Period

Pain Management for Cesarean

Pain management is the cornerstone of obstetric anesthesiology and may pose additional challenges in this population for both cesarean and vaginal deliveries. One of the most significant predictors of CR-PTSD is pain during cesarean delivery.6,12 ASA has provided thorough guidance in this area in the Statement on Pain During Cesarean Delivery40 and Statement on the Use of Adjuvant Medications and Management of Intraoperative Pain During Cesarean Delivery.

Labor Management

A complicated bidirectional relationship exists between prenatal anxiety levels and labor pain32 in that increases in anxiety may increase pain sensitivity, and pain may increase anxiety. Depression, substance use disorders, and fear of childbirth are associated with higher pain ratings before epidural analgesia.41 Preexisting anxiety and depression, chronic pain, opioid tolerance, and tobacco use have also been shown to predict severe acute postoperative pain especially in the 24-48 h following surgery.27,42 For laboring patients, adjustments may be required to standard neuraxial block techniques. For example, altering the concentration of local anesthetics and increasing opioid concentration may be needed to optimize pain control. Awareness of extreme fear and hyperalgesia during block placement may prompt the use of preprocedural anxiolysis. Preserving patient perception of control and clear open communication are also important in the time around a procedural intervention (e.g. epidural placement). Careful dosing of local anesthetic to preserve motor strength can be especially important for survivors of sexual trauma where preventing feelings of immobility can improve the patient's sense of control. At the same time, it is important to frequently evaluate and anticipate altered responses to standard pain regimens.

Cesarean Delivery

For cesarean delivery, while evidence-based interventions are limited, consider non-pharmacologic strategies (e.g. music therapy, breathing techniques) as well as the presence of a support person. Use of arm restraints should be avoided, if at all possible. Pharmacologic anxiolysis should be used judiciously and not as a treatment for pain. Ensuring effective pain control is essential; with neuraxial anesthesia, higher doses of local anesthetic, intrathecal morphine, and the addition of an alpha-2 agonist may be considered. Alternatively in the absence of neuraxial opioids, a fascial plane block such as transversus abdominus plane or quadratus lumborum and or local anesthetic infiltration/infusion along the incision may be considered.

Postpartum Pain Control and Follow-Up

The clearly communicated multimodal plan including the first 24-48 hours of postpartum pain control can help alleviate concerns around pain. Enhanced recovery after cesarean protocols include neuraxial morphine and scheduled acetaminophen and NSAIDS. For patients who require additional pain control consider epidural analgesia and low thoracic or lumbar blocks. Some patients may require anxiolytics to be continued for 24-48 hours postpartum. Frequent pain assessments should be accompanied by clear and consistent communication, no disruption of psychotropic medications, and continuation of Medication-Assisted Treatment (MAT) for opioid use disorder (OUD). Patients with severe acute postoperative pain may benefit from extended follow-up or consultation with pain specialists, especially for patients with a history of OUD since relapse is more common in the postpartum period.42 While current evidence-based interventions are limited, involving mental health experts early if there is concern for traumatic birth or PTSD provides the best opportunity to optimize treatment.7

In a systematic review and meta-analysis, Dekel et al. found that brief trauma-focused and non-trauma-focused psychological therapies provided in the early postpartum period, optimally during delivery hospitalization, after traumatic childbirth experience may reduce or prevent CR-PTSD with only small treatment effects seen beyond the early postpartum period.12 Obstetric anesthesia evaluation in the postpartum period presents an opportunity for meaningful communication, validation of experiences, identification of at-risk patients, and provision of psychological support and referral for support services. Evidence suggests these strategies of support, sovereignty, and sharing offer the strongest protection against traumatic birth experiences. 

Systems of Care

Since 2003, maternal mortality has been climbing steadily in the United States with few short-lived minor declines.27 Even more remarkable has been the surge in maternal mortality occurring during the COVID pandemic.27,42 Data from the Maternal Mortality Review Committees (MMRCs) indicates that 68% of pregnancy-related deaths are preventable and that most are due to mental health conditions including substance use disorder.11 In the last 5 years, a preventive approach to mental health in pregnant persons, including increased research to identify risk factors, has been emphasized.43 A recommendation to screen for mental health concerns on hospital admission was added in 2023.44 Johnson et al outline an implementation strategy to build holistic systems of care that address maternal mental health and trauma informed care in a manner similar to how cardio-obstetrics programs tackle maternal cardiac mortality.45,46

Patient Experience

Person-centered care is a multidisciplinary effort that empowers patients and means “treating patients as individuals and as equal partners in the business of healing; it is personalized, coordinated and enabling.”47 While all patients want and deserve to be treated with respect, empathy and listened to, this is especially meaningful for patients with a history of psychological trauma. 

Factors shown to influence a patient’s overall subjective birth experience include autonomy over exposure of their bodies, fear of restraints and oxygen masks, nausea/vomiting, and separation from loved ones for procedures. Negative language and perceived lack of support from medical personnel can also be stressors. Inadequate anesthesia for surgical delivery, challenging neuraxial placement and severe post dural puncture headaches have been noted as increased factors for patients to have negative birthing experiences.16

Suggested strategies for anesthesiologists and anesthesia professionals to improve patient experience include the domains of Sovereignty, Support and Sharing:

Sovereignty

  • Minimize the use of upper extremity restraints in the operating room environment
  • Conduct pre-oxygenation in the immediate time-frame prior to induction of general anesthesia. 
    • Supporting patient autonomy by offering the patient the option of the patient applying the face mask themselves if possible.
  • If feasible, arrange for neuraxial procedures to be conducted such that the exit to the room is visible to the patient
  • Utilize best practices in the treatment of anxiety
    • Judicious use of anxiolytics in conjunction with obstetric/neonatal teams to attenuate anxiety at the patients request 
    • Shared decision-making regarding use of anxiolytics should balance the recognition for the adverse effects of the physical and psychological stress response with the risk of amnesia for the childbirth experience, excessive maternal sedation and neonatal depression.32

Support

  • Maintain vigilance in the efficacy of all neuraxial techniques
    • Goal: Optimize pain relief using both subjective and objective methods
  • Ensure prompt recognition of inadequate anesthesia/analgesia during both operative and non-operative surgical deliveries
    • Deliver active management of untreated pain
  • Respect modesty
    • Keep gowns tied, if possible, while performing neuraxial procedures
    • Ask permission/consent to expose the patient’s back before initiating neuraxial procedures
  • Allow the patient’s support person to be present whenever possible and desired
  • Implement prompt evaluations and active management for patients with postdural puncture headaches

Sharing

  • Initiate (or continue) conversations
    • Goal: Patient and provider should agree on their anesthesia care goals and plan of action for managing their needs. 
    • The patient’s goals (e.g., limiting lower extremity motor block during labor) should be heard and the clinician can collaborate to develop a feasible plan to meet those preferences.
    • These conversations require excellent skills in listening, communication and negotiation to respond optimally to patient needs. 
  • Take care to explain care management plan
    • Especially in emergency situations
    • Avoid jargon and medical terminology
  • Offer patient focused communication
    • Avoid trauma triggers (including language) that have been identified 
  • Utilize the postpartum day 1 visit for early identification of women at high-risk for developing PTSD and to allow for discussion surrounding events that may have been confusing for patients
    • Enlist early referral to support services for at risk patients
  • Provide transparency surrounding events, education, and follow-up care if complications arise

Resources

Adequate psychological support in the peripartum period involves direct care by obstetricians, midwives, nurses, anesthesia professionals, et al. and ensuring patients have access to ongoing mental health and well-being resources. Identifying and sharing these resources can significantly enhance patient outcomes and experiences. Table 3 summarizes these resources in a format that can be shared directly with patients.

Table 3. Patient Support Resources

Table 3. Patient Support Resources 

1. Patient-Facing Education and Support

Providing patients with accessible and reliable information about psychological health is crucial. This education can empower patients to understand their needs and seek appropriate support. Key resources include:

  • ACOG Resources: The American College of Obstetricians and Gynecologists (ACOG) offers patient-facing education on various mental health issues, including general information on depression and anxiety during pregnancy and postpartum. Although there is limited information specifically on PTSD, the available resources can be a good starting point for patients seeking help.48
  • Postpartum Support International (PSI): PSI provides comprehensive resources for women experiencing postpartum depression, anxiety, and PTSD. Their website offers educational materials, support groups, and access to professional help.49
  • PATTCh (Prevention and Treatment of Traumatic Childbirth): PATTCh focuses on the prevention and treatment of traumatic childbirth experiences. Their resources include information on recognizing trauma, finding support, and connecting with healthcare providers experienced in trauma-informed care. 50
  • Empowerment Equation: Founded by obstetric anesthesiologist Dr. Tracey Vogel, this resource provides education and support for patients dealing with traumatic birth experiences. It offers insights into trauma-informed care practices and patient advocacy.51
  • Painless Push: The official podcast of the Society for Obstetric Anesthesia and Perinatology is patient-focused, includes high-quality information, and is available in multiple languages.52

2. Hospital-Based Resources

Hospitals can be pivotal in providing immediate and ongoing psychological support for obstetric patients. Hospital-based resources include but are not limited to:

  • Women's Behavioral Health Services: Access to specialized mental health professionals, such as psychologists and social workers, who are trained to deal with perinatal mental health issues. These services can offer counseling, therapy, and crisis intervention as needed.
  • Birth Trauma Specialists: Some hospitals may have specialists who focus on the psychological impact of traumatic births. These professionals can provide targeted support and interventions for patients who have experienced or are at risk of experiencing birth-related trauma.
  • NICU Teams: For patients with newborns in the Neonatal Intensive Care Unit (NICU), collaboration with NICU teams can ensure that the psychological needs of the parents are addressed, alongside the medical care of their infants.

3. Community and Online Resources

Connecting patients with community and online resources can provide additional support layers, including peer support and educational materials.

  • Local Support Groups: Encouraging patients to join local support groups for new mothers or parents dealing with postpartum depression and anxiety can provide a sense of community and shared experience.
  • Trusted Websites: It can be valuable to direct patients to reputable websites with evidence-based information on mental health during and after pregnancy. Websites like the CDC's mental health section and PSI's online resources are excellent places to start.
  • Mental Health Hotlines: Providing patients with contact information for mental health hotlines, such as the National Maternal Mental Health Hotline and the 988 Suicide & Crisis Lifeline, ensures they have access to immediate support in times of crisis.53,54

4. Provider Resources and Self-Care

Healthcare providers, including anesthesiologists, need to be equipped with resources to manage their own mental health in order to provide the highest degree of empathy and compassion. This is especially important when dealing with challenging cases.

  • ASA Well-being Resources: The ASA offers various resources to support anesthesiologists' well-being. This includes access to counseling services, peer support programs, and educational materials on maintaining mental health.
  • Committee on Ethics Resources: The ASA Committee on Ethics provides guidance and support for ethical dilemmas that may arise in practice, which can also impact mental health.
  • Professional Development: Encouraging participation in workshops and training sessions focused on trauma-informed care and provider wellness can enhance the ability of anesthesiologists to support their patients and themselves effectively.
  • Hospital Well-being Resources: Providers can seek emotional support and help from wellness services available in their own healthcare organizations. These services may guide providers to deal with stress, emotional fatigue, grief, and burnout. These resources can also empower providers to create systems to remove themselves from clinical scenarios when needed, while also ensuring excellent patient care.
  • By identifying and sharing these resources, healthcare providers can create a supportive environment that addresses the psychological needs of patients and providers alike. This comprehensive approach ensures that immediate and long-term mental health needs are met, promoting better outcomes in obstetric anesthesia care.

Conclusion

Anesthesiologist leadership in delivering the highest quality maternal healthcare includes holistic efforts to ensure a positive birth experience for all patients. Consideration of how to care for at risk patients, and active screening for patient history of traumatic experiences can assist in identifying patients who may benefit from targeted care. Best practices for this population include balanced approaches to anxiolysis, active pain management for Cesarean and labor, and continued follow-up and pain control in the postpartum period. This document outlines strategies that can bolster patient sovereignty, support patient experience, and communicate shared plans. Additional resources are provided for patients and providers. We hope this document offers strategies to support patients by empowering providers with best practices to deliver a positive birth experience, mitigate the emotional stress surrounding birth, and to provide individualized patient support and care.

Key Points

  • Striving for a positive birth experience for all patients can ensure the highest quality maternal healthcare and ultimately reduce maternal morbidity and mortality.
  • Applying the best practices from trauma-informed care can assist in the management of patients with a history of trauma, pre-existing mental health conditions, or other risk factors associated with mental health conditions.
  • Strategies to provide support, empower patient sense of control, and establish inclusive communication may help prevent childbirth-related posttraumatic stress disorder and other complications.
  • Shared decision making around anxiolysis, attentive and proactive pain control, and robust follow-up can help improve patient experience during and after childbirth.
  • Systems of care should also support provider wellbeing particularly when providing care in challenging settings.

References:

1. Jones E, Lattof SR, Coast E. Interventions to provide culturally-appropriate maternity care services: factors affecting implementation. BMC Pregnancy Childbirth. 2017;17:267. doi:10.1186/s12884-017-1449-7
2. Mohamoud YA. Vital Signs: Maternity Care Experiences — United States, April 2023. MMWR Morb Mortal Wkly Rep. 2023;72. doi:10.15585/mmwr.mm7235e1
3. Kowalczyk JJ, Lipman SS, Carvalho B. Estimating Obstetric Anaesthesia Workload: Number of Deliveries Compared to Time-Based Workload. Turk J Anaesthesiol Reanim. 2021;49(4):292-297. doi:10.5152/TJAR.2021.924
3A. Vogel TM, Coffin E. Trauma-Informed Care on Labor and Delivery. Anesthesiol Clin. 2021 Dec;39(4):779-791. doi: 10.1016/j.anclin.2021.08.007. PMID: 34776109.
4. Leinweber J, Fontein-Kuipers Y, Karlsdottir SI, et al. Developing a woman-centered, inclusive definition of positive childbirth experiences: A discussion paper. Birth Berkeley Calif. 2023;50(2):362-383. doi:10.1111/birt.12666
5. Trauma and Violence. Published January 14, 2019. Accessed May 28, 2024. https://www.samhsa.gov/trauma-violence
6. Horsch A, Garthus-Niegel S, Ayers S, et al. Childbirth-related posttraumatic stress disorder: definition, risk factors, pathophysiology, diagnosis, prevention, and treatment. Am J Obstet Gynecol. 2024;230(3S):S1116-S1127. doi:10.1016/j.ajog.2023.09.089
7. De Graaff LF, Honig A, Van Pampus MG, Stramrood CAI. Preventing post‐traumatic stress disorder following childbirth and traumatic birth experiences: a systematic review. Acta Obstet Gynecol Scand. 2018;97(6):648-656. doi:10.1111/aogs.13291
8. Ertan D, Hingray C, Burlacu E, Sterlé A, El-Hage W. Post-traumatic stress disorder following childbirth. BMC Psychiatry. 2021;21(1):155. doi:10.1186/s12888-021-03158-6
9. Heyne CS, Kazmierczak M, Souday R, et al. Prevalence and risk factors of birth-related posttraumatic stress among parents: A comparative systematic review and meta-analysis. Clin Psychol Rev. 2022;94:102157. doi:10.1016/j.cpr.2022.102157
10. Wisner KL, Murphy C, Thomas MM. Prioritizing Maternal Mental Health in Addressing Morbidity and Mortality. JAMA Psychiatry. 2024;81(5):521-526. doi:10.1001/jamapsychiatry.2023.5648
11. Trost S, Beauregard J, Chandra G, et al. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017-2019.
12. Dekel S, Stuebe C, Dishy G. Childbirth Induced Posttraumatic Stress Syndrome: A Systematic Review of Prevalence and Risk Factors. Front Psychol. 2017;8:560. doi:10.3389/fpsyg.2017.00560
13. Seng JS, Low LMK, Sperlich M, Ronis DL, Liberzon I. Prevalence, trauma history, and risk for posttraumatic stress disorder among nulliparous women in maternity care. Obstet Gynecol. 2009;114(4):839-847. doi:10.1097/AOG.0b013e3181b8f8a2
14. Waller R, Kornfield SL, White LK, et al. Clinician-reported childbirth outcomes, patient-reported childbirth trauma, and risk for postpartum depression. Arch Womens Ment Health. 2022;25(5):985-993. doi:10.1007/s00737-022-01263-3
15. Sun X, Fan X, Cong S, et al. Psychological birth trauma: A concept analysis. Front Psychol. 2022;13:1065612. doi:10.3389/fpsyg.2022.1065612
16. Lopez U, Meyer M, Loures V, et al. Post-traumatic stress disorder in parturients delivering by caesarean section and the implication of anaesthesia: a prospective cohort study. Health Qual Life Outcomes. 2017;15(1):118. doi:10.1186/s12955-017-0692-y
17. Orbach-Zinger S, Eidelman LA, Livne MY, et al. Long-term psychological and physical outcomes of women after postdural puncture headache: A retrospective, cohort study. Eur J Anaesthesiol. 2021;38(2):130-137. doi:10.1097/EJA.0000000000001297
18. Zakowski MI, Fardelmann K, Hofkamp MP. Pain during Cesarean Delivery: We Can and Must Do Better. Anesthesiology. 2024;140(6):1236-1237. doi:10.1097/ALN.0000000000004968
19. Sutton E, Detering K, East C, Whittaker A. Women’s expectations about birth, requests for pain relief in labor and the subsequent development of birth dissonance and trauma. BMC Pregnancy Childbirth. 2023;23(1):777. doi:10.1186/s12884-023-06066-7
20. Sexton MB, Hamilton L, McGinnis EW, Rosenblum KL, Muzik M. The roles of resilience and childhood trauma history: main and moderating effects on postpartum maternal mental health and functioning. J Affect Disord. 2015;174:562-568. doi:10.1016/j.jad.2014.12.036
21. Tong S, Rao C, Min S, et al. Obstetric anesthesia clinic childbirth course combined with labor epidural analgesia is associated with a decreased risk of postpartum depression : a prospective cohort study. BMC Anesthesiol. 2022;22(1):389. doi:10.1186/s12871-022-01931-y
22. Chabbert M, Panagiotou D, Wendland J. Predictive factors of women’s subjective perception of childbirth experience: a systematic review of the literature. J Reprod Infant Psychol. 2021;39(1):43-66. doi:10.1080/02646838.2020.1748582
23. Kress V, von Soest T, Kopp M, Wimberger P, Garthus-Niegel S. Differential predictors of birth-related posttraumatic stress disorder symptoms in mothers and fathers - A longitudinal cohort study. J Affect Disord. 2021;292:121-130. doi:10.1016/j.jad.2021.05.058
24. Ayers S, Eagle A, Waring H. The effects of childbirth-related post-traumatic stress disorder on women and their relationships: a qualitative study. Psychol Health Med. 2006;11(4):389-398. doi:10.1080/13548500600708409
25. Vogel TM, Coffin E. Trauma-Informed Care on Labor and Delivery. Anesthesiol Clin. 2021;39(4):779-791. doi:10.1016/j.anclin.2021.08.007
26. Caring for Patients Who Have Experienced Trauma: ACOG Committee Opinion, Number 825. Obstet Gynecol. 2021;137(4):e94-e99. doi:10.1097/AOG.0000000000004326
27. Hoyert DL. Maternal Mortality Rates in the United States, 2022. Published online 2024.
28. Substance Abuse and Mental Health Services Administration: Practical Guide for Implementing a Trauma-Informed Approach. SAMHSA Publication No. PEP23-06-05-005. Rockville, MD: National Mental Health and Substance Use Policy Laboratory. Substance Abuse and Mental Health Services Administration, 2023.
29. Centers for Disease Control and Prevention (U.S.). Office of Public Health Preparedness and Response. 6 guiding principles to a trauma-informed approach. Published online June 28, 2018. Accessed May 28, 2024. https://stacks.cdc.gov/view/cdc/56843
30. Grisbrook MA, Dewey D, Cuthbert C, et al. Associations among Caesarean Section Birth, Post-Traumatic Stress, and Postpartum Depression Symptoms. Int J Environ Res Public Health. 2022;19(8):4900. doi:10.3390/ijerph19084900
31. Smith H, Peterson N, Lagrew D, Main E. 2016. Toolkit to Support Vaginal Birth and Reduce Primary Cesareans: A Quality Improvement Toolkit. Stanford, CA: California Maternal Quality Care Collaborative.
32. Vogel TM. Unique Pain Management Needs for Pregnant Women with Pre-existing PTSD and Other Mental Health Disorders. Curr Anesthesiol Rep. 2021;11(1):1-11. doi:10.1007/s40140-020-00430-5
33. Frölich MA, Burchfield DJ, Euliano TY, Caton D. A single dose of fentanyl and midazolam prior to Cesarean section have no adverse neonatal effects. Can J Anaesth J Can Anesth. 2006;53(1):79-85. doi:10.1007/BF03021531
34. Mokhtar AM, Elsakka AI, Ali HM. Premedication with midazolam prior to cesarean delivery in preeclamptic parturients: A randomized controlled trial. Anesth Essays Res. 2016;10(3):631-636. doi:10.4103/0259-1162.191117
35. Oliveira PSC, Sant’Anna BC, Seixas NB, Mendonça JA. Low-dose midazolam for anxiolysis for pregnant women undergoing cesarean delivery: a randomized trial. Braz J Anesthesiol. 2021;72(4):450-456. doi:10.1016/j.bjane.2021.07.039
36. Senel AC, Mergan F. Premedication with midazolam prior to caesarean section has no neonatal adverse effects. Braz J Anesthesiol Engl Ed. 2014;64(1):16-21. doi:10.1016/j.bjane.2012.08.005
37. Yu HY, Wang SY, Quan CX, et al. Dexmedetomidine Alleviates Postpartum Depressive Symptoms following Cesarean Section in Chinese Women: A Randomized Placebo-Controlled Study. Pharmacotherapy. 2019;39(10):994-1004. doi:10.1002/phar.2320
38. Ao L, Shi J, Bai Y, Zheng Y, Gan J. Effectiveness and safety of intravenous application of dexmedetomidine for cesarean section under general anesthesia: a meta-analysis of randomized trials. Drug Des Devel Ther. 2019;Volume 13:965-974. doi:10.2147/DDDT.S197165
39. Buhre W, Disma N, Hendrickx J, et al. European Society of Anaesthesiology Task Force on Nitrous Oxide: a narrative review of its role in clinical practice. Br J Anaesth. 2019;122(5):587-604. doi:10.1016/j.bja.2019.01.023
40. Statement on Pain During Cesarean Delivery. Accessed June 4, 2024. https://www.asahq.org/standards-and-practice-parameters/statement-on-pain-during-cesarean-delivery
41. Borges NC, de Deus JM, Guimarães RA, et al. The incidence of chronic pain following Cesarean section and associated risk factors: A cohort of women followed up for three months. PLoS ONE. 2020;15(9):e0238634. doi:10.1371/journal.pone.0238634
42. Han B, Compton WM, Einstein EB, Elder E, Volkow ND. Pregnancy and Postpartum Drug Overdose Deaths in the US Before and During the COVID-19 Pandemic. JAMA Psychiatry. 2024;81(3):270. doi:10.1001/jamapsychiatry.2023.4523
43. Vogel TM, Homitsky S. Antepartum and intrapartum risk factors and the impact of PTSD on mother and child. BJA Educ. 2020;20(3):89-95. doi:10.1016/j.bjae.2019.11.005
44. Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 4. Obstet Gynecol. 2023;141(6):1232-1261. doi:10.1097/AOG.0000000000005200
45. Johnson S, Kasparian NA, Cullum AS, et al. Addressing Adverse Childhood and Adult Experiences During Prenatal Care. Obstet Gynecol. 2023;141(6):1072-1087. doi:10.1097/AOG.0000000000005199
46. Meng ML, Smiley R. The Cardio-Obstetrics Patient and the Cardiothoracic Anesthesiologist. J Cardiothorac Vasc Anesth. 2022;36(2):546-548. doi:10.1053/j.jvca.2021.11.009
47. Coulter A, Oldham J. Person-centred care: what is it and how do we get there? Future Hosp J. 2016;3(2):114-116. doi:10.7861/futurehosp.3-2-114
48. ACOG Explains: Mental Health and Pregnancy. Accessed June 4, 2024. https://www.acog.org/womens-health/videos/mental-health-and-pregnancy
49. Home. Postpartum Support International (PSI). Accessed June 4, 2024. https://www.postpartum.net/home/
50. Prevention & treatment of traumatic childbirth. PATTCh. Accessed June 4, 2024. https://pattch.org/
51. Empowerment Equation - The Empowerment Equation. Accessed June 4, 2024. https://www.theempowermentequation.com/
52. Painless Push. Spotify. Accessed June 4, 2024. https://open.spotify.com/show/42P496UNuX3Zc2Itr3FGwB
53. SAMHSA’s National Helpline. Published June 9, 2023. Accessed June 4, 2024. https://www.samhsa.gov/find-help/national-helpline
54. 988 Suicide & Crisis Lifeline. 988 Suicide & Crisis Lifeline. Accessed June 4, 2024. https://988lifeline.org/

 

Curated by: Governance

Last updated by: Governance

Date of last update: October 23, 2024