Transcript of When Anesthesia Fails and the Patient Is Cut Open

From the New York Times, I'm Rachel Abrams, and this is The Daily. C-sections are the most common surgery in the United States, but it turns out, in a shocking number of them, the anesthesia is failing, and that's leaving women to feel a major surgery as it is being performed. Writer Susan Burton made a series about this phenomenon for our colleagues at Serial Productions. And today, she tells us about some of the women she spoke to and the new research on how common their experiences are. It's Friday, February sixth.

Susan, thank you so much for being here. Of course. Thank you for having me.

You have You've done so much tremendous reporting on something really horrific, which is all of these women who have gotten C-sections and could actually feel them, which sounds like something literally out of a nightmare, out of a horror movie. And recently, there was a study that came out that actually backed up some of these anecdotes that you had been collecting. So how did you even get started talking to these women in the first place?

So in the summer of 2023, I did a story published as a podcast series that on the surface had this true crimey plot. A nurse had stolen fentanyl from a fertility clinic run by Yale University and replaced that fentanyl with saline. Essentially, what this meant was that a lot of patients at this clinic who had surgical procedures experienced excruciating pain during those procedures. That was the underlying theme of the podcast, the routine dismissal of women's pain in medicine that resonated with a lot of and hundreds of them, mostly women, began to send me stories about their own experiences of inadequately treated or ignored pain. So lots of stories about things like IUD insertions or experiences with endometriosis. These emails were moving, they were upsetting, they were raw. Then one afternoon, I opened an email that was unlike any of the others I'd received so far. The writer said that she had felt everything during C-section. She had felt the doctor cutting into her. She had felt, she said, her organs being moved around.

Oh, my God. Because we should remind people this is a major abdominal surgery.

Yes. I'm really glad you pointed that out because a lot of times people think like, Oh, a C-section, that's not a real surgery. It is a very real surgery, and it's a major abdominal surgery. A third of women who give birth in the United States will have a C-section, so it's also a surgery that a lot of people have. I get this email, and it was so disturbing. I thought, Was this maybe a one-off? I wrote back to the listener. Then within 24 or maybe 48 hours, I had opened two more e-mails describing something really similar. That was the point where I was like, Okay, is this a thing? I started talking to people about it, and I came to recognize that there were patterns in these experiences.

I was rushed into this C-section. My husband was there, and I could feel them starting the operation. I could feel the incision.

So, for example, feeling the surgery in a way that was just totally shocking.

It was burning. It was like someone took a hot piece of metal and put it against my stomach. There was this nurse on my right side. I just remember holding her hand and telling her over and over again that I can feel everything, that I still feel it. I still feel it.

Speaking up and After you've spoken up, being told that what you're feeling is just pressure. So having your pain mischaracterized as something else.

And they said, Well, that's not possible. If you were feeling it, you would pass out from the pain. And I was like, I wish I could pass out from the pain.

When When I took my son out, I was shaking and I was so much in pain that I could not hold him.

I'm shaking just talking about it. It was a major abdominal surgery without full anesthesia.

Some of the really unsettling things were happening in the aftermath of the surgery, like experiences never being acknowledged, nobody apologizing, nobody explaining what had happened.

You're hearing the same horrifying through line in a lot of these different stories. Tell us about one person who maybe stood out to you.

Sure. One of the women I spoke to, her name is Vanessa Leonard. She was in her late 30s when she got pregnant, she lives in Florida. She works as a physician's assistant, and her husband is an engineer who works in aerospace. Just like that? She showed up at the hospital to give birth.

I was induced at 39 weeks. I think it was 39 weeks in one day. Super exciting. First baby. We got to the hospital, and I think I was only like 1 centimeter dilated.

She had a scheduled induction, which is when you get drugs to start your labor. She gets the drugs. Everything's going fine.

We had dinner. It was close to Halloween, so Hocus Pocus was playing on the TV. Everything was really… It started really good.

Hours pass, things get more intense. She's in pain. She gets an epidural. When you get an epidural during labor, that's to reduce your discomfort. But for Vanessa, the epidural isn't really working right. She's in the hospital overnight. She's a lot of discomfort moving around in the bed. It's the next day. It's been 24 hours since this all started. Vanessa's heart rate is rising a little bit. The baby's heart rate is rising a little bit. The baby's not moving down. The doctors are like, Well, I think it's time to do a C-section.

I was pretty much okay with that. I just wanted a healthy baby, and I was very tired at that point.

Vanessa isn't that nervous about the surgery. She told me she's a health care provider. She works in a hospital. She trusted her medical team. The thing she is concerned about is her epidural. It just hadn't been working that well during her labor.

I personally was concerned because I could move my legs with the epidural. Even before we went into the C-section, I told the anesthesia, I said, I can move my legs. I don't think this is normal. He's like, No, it has nothing to do with the pain management.

I think a lot of us know in general what an epidural is. It's the thing that controls pain. But what an epidural actually is, it's a little plastic tube, a catheter that goes into your back, and doctors push medicine through that, too. During labor, the medicine is lighter to allow you to move around. During surgery, the medicine is more potent. The idea is to numb your midsection, but to allow you to remain awake for the birth of your child. As she tells it, she'd asked two different anesthesia providers about this epidural. One of them had been like, Should I change it? Maybe I should change it. I'm not sure if I should change it.

Then they had to change shift, and then by the time he came back, he's like, No, we don't have time to change it.

Ultimately, it's decided there's not enough time to change it, and Vanessa goes into the operating room. Vanessa is in the OR, and The anesthesiologist needs to test that she's numb. Often this test is something like putting a broken tongue depressor on a patient's body and seeing whether the patient can feel it.

It's sharp, but they're not cutting into you. Correct.

I remember We're feeling something, but it wasn't excruciating pain.

Vanessa says she feels a little prick, and then the doctor cuts into her, and she definitely feels that.

Everybody kept telling me, Oh, you're just feeling a lot of pressure. I was like, No.

It's extremely painful. Now, I feel like before I keep going with Vanessa's story, maybe I should just describe what actually goes during a C-section? Please. Okay. I don't want to be too graphic, but I think it's also important to be able to visualize what's going on. In a C-section, there's an incision. It's called a bikini incision, which sounds like something really tiny, but it's actually a fairly sizable incision. Then the doctors open the abdomen. There's a pair of muscles they need to separate to access the uterus. These muscles are hard to separate. Doctors told me this is a really physical surgery. Sometimes you see the doctors leaning back like in tug-of-war to separate the muscles. That's what happens at the beginning of the surgery. Then as the surgery goes on, the baby is eventually pressed out of this hole in the patient's body. After that, there's still a lot of the surgery left. Seven layers of muscle and skin need to be sewn back up. And as Vanessa says, she feels everything. She feels way too much.

I remember this intense, severe pain and screaming and telling them to stop. And the anesthesia guy was like, It's okay. It's just pressure. And I remember the doctor saying, What's going on? And he's like, I'm just pushing more meds, and they're not working. And the anesthesia doctor was telling me, Just hold on, and I can't I'll give you anything else. We need to wait to get the baby out, and then I'll give you all anything that you can. Just hold on, hold on.

For some reason, her husband is outside the OR. He's not in the surgery from the very beginning. Once he comes in, what he sees, he sees Vanessa strapped to the table, and she's screaming and crying. Vanessa's husband, he comes to her side, and she says, Talk to me.

He's like, Talk to you about what? I'm like, I don't know. Talk to me about your work. Just talk to me about anything.

Part of the reason she's asked him to talk to her, it's to distract her from the pain. But it's also because this is a teaching hospital, and she can overhear the obstetrician teaching the resident.

I could hear the whole time, Cut here, move here, do this, do that, move this over. Let me show you how to do this.

She hears him say, I'm cutting through fascia. So just imagine this, right? You're lying open on an operating table and you feel what's going on and you hear somebody describing what they're doing to your insides. It's frightening. It's scary.

When you have a patient screaming and yelling in pain, there's a time to teach and there's a time to do this really, really fast. And so that also told me this doctor, he just thinks I'm hysterical. He doesn't acknowledge that I'm screaming and yelling, and he's not really moving fast enough.

Finally, the baby is born. Vanessa is relieved. Vanessa is relieved the baby is healthy. She's relieved it's over, and that she does get a lot of drugs. But then what happens is she's out of it. She's high. She doesn't have that moment of elation or joy that you want to have when your baby is born, and she's in shock.

You see this stuff in movies where people joy is when their baby is born, and I think that's how it's supposed to be. But she came out and I was just relieved like, Oh, this is over. The pain is over. I really didn't feel that joy of like, Oh, my gosh, my baby. I've been waiting for nine months here, and No. You almost feel, too, that you've been robbed of an experience and completely out of your control.

How did she make sense of what had happened to her?

I mean, for a while, she really couldn't. She had to ask her husband, Was that real? Did that really happen?

She couldn't believe that it could have happened.

Yeah, she couldn't believe that it could have happened. He would say, Yes, that was real. It happened. You were in pain. You were screaming. It was bad. She's having PTSD symptoms. She's having flashbacks. She told me that at one point, she had this dream that she was pregnant.

I remember clearly, the fear in this dream was like, How are they going to get this baby out of me? How? I just I just won't go through that again.

The scary thing in the dream was, How are they going to get the baby out of me?

We're not having more children because we're in our 40s and we're happy and we have a healthy little girl. But part of me also feels like that is not the only reason why I don't want more children, but it's one of the biggest reasons because it really scares me to have to go through that again.

Over time, She was able to start talking about it, and she heard from other people that this is the thing that goes on. Like, her lactation consultant said, Oh, this has happened to other clients. Her therapist said, I've heard this from other people. It was On the one hand, reassuring to Vanessa that this is a thing that happens.

To know she's not alone.

To know she's not alone. But on the other hand, Vanessa says it was infuriating that this happens more than most people know. Vanessa, remember, she's a health care provider herself, and now she's like, Doctors should know about this. There should be a protocol for this. Something could have been done to address my pain. Why wasn't anything done for me?

We'll be right back. Susan, before the break, you told us both how upsetting and comforting it was for Vanessa to learn that she wasn't alone because it raised all these new questions like, if she's not alone, why isn't more done for people like her? Presumably, You did talk to a lot of doctors about what they were experiencing in these OR. Tell us what they told you this is like from their perspective.

Yes. I talked to a lot of doctors trying to understand why this happens and also what it feels like for them when it does. No doctor wants a patient to be in pain. Most of them were not seeing extreme cases like Vanessa's in their operating rooms, but they'd all been in situations where a patient was feeling too much, especially early in their careers. I just see all these women in my head when I think about it. I was a resident.

It was 2: 00 in the morning. We took a patient back for a pretty urgent C resection. There's a case that stands out to me of a patient who came in through the emergency room.

In the moments when you can tell someone is uncomfortable, it usually starts with just a little grimace. The patient was grasping my grasping, my squeezing my hand.

We started the case and the patient is just screaming, and I am also screaming, not panic, but you need to put her to sleep. She needs to go to sleep.

She's feeling this. One thing we haven't talked about yet is that during a C-section, the anesthesia you have, most likely you will feel sensation.

We were taught that maybe we can't be perfect in this. Maybe some of the pressure sensations that they feel, we really can't completely block, and that's expected or normal.

Most of the time, that sensation is tolerable. But because doctors expect sensation, including the sensation of pressure, it can become this slippery very slow.

I remember when I trained, I had a very impressive professor who used to tell all the patients, Pressure's normal.

Pressure's normal.

I'm like, How does he know that it's pressure, not pain? As I got deeper into these conversations with these doctors, they helped me understand the whole range of things that might be going on in the OR. Some of the things are systemic things in hospitals. There's an anesthesiologist who's on call in the middle of the night. There's an emergency on another floor. They're stretched thin. They helped me understand power dynamics within the OR. It can actually be hard to speak up and say, Stop, she's uncomfortable. We need to do something. There are power dynamics between anesthesiologists and surgeons. Maybe there's a nurse in the room who doesn't feel empowered to speak up. Then there's actually power dynamics between patients and providers. When you are a cesarean patient, you are lying open on a table. You are so vulnerable. Maybe you're scared that something is going to happen to your baby. In some of these situations, you've been told it's an emergency that this needs to happen now to protect your baby's health. Do you really want to say something that might slow down the surgery? Patients often don't speak up about pain.

Okay, so doctors that you talk to sound like they are aware of cases like Vanessa's, at least, even if they haven't experienced them themselves. Do they have any idea why the pain meds are failing these women?

Yes, they do have ideas about why anesthesia can fail. For instance, with an epidural, maybe the needle was inserted off center, maybe the catheter moved. They also have ideas about how the system is failing patients. But as far as what exactly is going wrong, basically, there's not one simple eureka, this is the problem, this is the one thing we need to tweak. So right now, they're at a stage where they're looking at all these different areas, trying to find solutions.

What are they looking at exactly? How are they examining this?

Well, so they're starting to do studies. That was actually one of the things I was really interested in doing in my reporting is making a timeline of this, following it through the medical literature. For years, there wasn't much about this in the medical literature at all. It seemed like the story of that research really began in 2016 when a patient actually She published her account of a painful cesarean in which she felt everything. From there, you can track increasing interest over time. For example, there was an editorial published in 2021 that has this title that I think is really telling, are we finally tackling the problem of pain during cesarean section? It gets at this hush-hush quality of this thing unspoken, and now are we finally paying attention to it. But just recently, just last month, there was a really important study released. It was published in the journal Anesthesiology, and it tries to measure how often patients are feeling pain during C-sections.

Because by now, we know this is happening, but there's been no real effort to quantify it.

There have been efforts, but they've been smaller scale efforts. They've been efforts to measure it within one institution, for example. They have most often been efforts that rely on doctors assessments of patient pain. This study is important because it was a big study. It was at 15 hospitals in the US and Canada. It enrolled almost 4,000 patients, and it asked patients whether they were in pain during C-section.

Which seems pretty crucial to understanding if women are feeling pain, to ask them directly.

Exactly. The study found a couple of really important things. It found that 8% of patients experience significant pain. There are 1. 2 million C-sections in the US a year. So 8% means that 100,000 women a year experience significant pain.

By significant pain, we mean what exactly?

As the study defined it, this was when women report a pain score of six or above.

Out of 10.

Correct. Actually, the study's lead author, his name is James O'Carroll, he told me that the incidence of pain, that 8% number, that That was what he expected. But what was surprising to him was the level of pain reported. I saw the research presented at a medical conference, and one of the really striking pieces of it is this word cloud that the researchers made. The word cloud shows the words that women used to describe the pain they felt. So Some of those words, searing, blinding, wretched, tearing, cramping, grueling, radiating, vicious, cruel, drilling, smarting.

I can't believe we're talking about 21st century medicine right now.

Yeah, I know. That was a feeling that I had when I first started looking into this. So one of the other really important findings is that pain differed depending on the anesthetic technique that was performed. What I mean by that is when you have a C-section, maybe you have an epidural. We've talked about epidurals. Another common anesthetic technique for a C-section is a spinal. A spinal goes deeper, it works more quickly, it offers what anesthesiologists call a denser block, and it's what you're more likely to have if you're having a scheduled C-section. Epidurals for C-sections, that's typically a patient who starts out intending to have a vaginal delivery, but something changes. Often doctors will use that same labor epidural for surgery. They'll just top it up to more fully numb you. It turns out that's your highest chance of feeling pain. This study found that patients who had epidurals, 13% of those patients reported pain, versus with spinals, only 4% of patients who got and their spinals reported pain.

That is a huge difference, right? Because if you think about how many women have this procedure, if I'm understanding you correctly, what you're saying is that if somebody goes to the hospital and they want to have a vaginal birth, they get an epidural Then for whatever reason they have to go into the OR, maybe they have to have an emergency unplanned C-section, they are more likely to have pain.

Yes, that is what this study found, that those patients who use those existing labor epidurals are more likely to have pain. But I also want to point out that there are plenty of patients who have C-sections with existing labor epidurals, and their pain is well managed. Patients in this study reported pain. We know that, but We don't know anything about how this pain was addressed. A patient might have felt pain and somebody might have intervened quickly and managed their pain appropriately.

Okay, so now that we have this study that is more comprehensive, and now that we know how prevalent this issue is of having so much pain during a C-section, does anybody have an idea of what happens next, what the solutions might be, where we go from here?

Yeah, there's actually a really active effort to come up with those solutions. Some of those solutions involve identifying risk factors for pain, like an epidural that's not working well during labor is probably not going to work well during a C-section, and maybe there should be a lower threshold for replacing it. There are other medical solutions like that. Okay, so this patient felt this pain, and at this level, what drugs did we give her, and what does that tell us? Another thing, most doctors have been taught to avoid putting a C-section patient to sleep at all costs. While doctors As I spoke to, emphasize that general anesthesia isn't the first choice for C-sections, there was agreement that putting a C-section patient to sleep when it's safe and necessary, that should be less of a taboo. Then there are solutions that revolve around communication, too. What can be done to help doctors listen to patients? And what can be done to make it possible for patients to speak up about their pain? I spent some time talking to a doctor in Chicago who would come up with essentially a system to make sure that this happened. Patients.

Doctors at her hospital ask patients about their pain at regular intervals during the C-section, and that gets doctors to pay attention to pain, and also gives a patient an opportunity to speak up.

The solution is literally talk to the patients more.

Yeah, talk to the patients more, but also give doctors and patients a system that helps doctors listen and helps patients speak up.

Throughout this whole conversation, I have been wondering about a more essential question here, which is, what is the appropriate amount of pain that a woman should feel during childbirth? Who gets to decide that level of pain?

Yeah, I think that's a really critical question. The answer to It is really individual. Pain is really subjective. We all have different tolerances. I think it points to something else, too, that came up in my reporting. I would ask people, Why does this happen? One of the things we would talk about is we expect women to suffer during childbirth. We expect them to be in pain. C-sections are birth, but they are also major abdominal surgeries. Surgical pain is very different from the pain one experiences during a vaginal birth and has this assumption that women will suffer during childbirth allowed us to rationalize the pain of C-sections. When I say this, I actually don't just mean doctors, right? I mean patients, too. It's what might convince a patient that, I guess this is just what women go through. A mother will endure a lot of pain to have a baby, to have a healthy baby. A mother will silence herself in the operating room, not speak up about her pain to protect her baby. After that baby is born and a mother talks about her experience, so what's the thing you hear so often? Well, all that matters is you a healthy baby.

You have a beautiful baby. People say that, and they really mean well, and of course, that's what you want, a healthy baby. But it's this cultural silencing. It says, let's not talk about that other part of your experience. When I think about my own reporting journey here, I started out, and one of my questions was like, Wait, how do I not know about this? I think that one of those reasons is because people don't talk about it. People start silencing themselves.

Oh, my God. I'm tearing up thinking about my own mother. When you say women are just used to doing a million different things for the sake of their child, including not thinking about their own pain. I mean, that's almost a metaphor for the experience of motherhood.

Yeah. What do you know about your mother's experience, your mother's birth experience?

She never complained about it. Your reporting was the first time I ever actually asked her what her C-section was like, and she was just very matter of fact, I did it, I had to, I got it over with, and that was it. Maybe that's a generational thing, or maybe that's a mother thing. I don't know.

Yeah. When we think about solutions to this problem, one of them is how do we enable people to talk about these experiences that reverberate long after we leave the delivery room.

Susan Burton, thank you so much for joining us.

Oh, Rachel, thank you so much for having me. It was my pleasure.

We'll be right back. Here's what else you need to know today. Health Secretary Robert F. Kennedy Jr. Claimed on Wednesday that the keto diet could cure schizophrenia, an assertion that vastly overstates preliminary research, according to experts. Kennedy made the comments in Tennessee as part of his national tour to urge Americans to, quote, eat Real Food, a message that is meant to boost his recent overhaul of federal dietary guidelines to emphasize protein and fats over carbohydrates. Our mom is our heart and our home. The TV anchor, Savannah Guthrie and her siblings made an anguished plea to whoever had abducted their mother. She is without any medicine. She needs it to survive. She needs it not to suffer. In the video, Guthrie said she had heard reports about a ransom note and asked for proof that their mother was still alive. Please reach out to us. Guthrie's mother was reported missing on Sunday, and police have said they are investigating the case as a kidnapping. We love you, Mom.

We love you, Mom.

We love you, Mom. Stay strong.

Today's episode was produced by Alex Stern, Olivia Nat, and Michael Simon Johnson. It was edited by MJ Davis Lynn with research help from Susan Lee. Contains music by Dan Powell, Sophia Landman, Marion Lozano, Alicia Beatup, and Ron Niemistow, and was engineered by Chris Wood.

That's it for The Daily.

I'm Rachael Abrams. See See you on Sunday.