Obstetric Anesthesia Subcommiee Minutes

September 10th, 2025

1:00-2:00 pm EST - Zoom

Aendees:

Sharon Abramovitz, Weill Cornell

Michael McDonald, University of Chicago

Kate Buehler, MPOG

Christine McKenzie, UNC

Arthur Calimaran, Cleveland Clinic

Mary McKinney, Corewell Health

Ruth Cassidy, MPOG

Christopher Milliken, Sparrow Health

Johanna Cobb, Dartmouth

Kam Mirizzi, MPOG

Rob Coleman, MPOG

Melinda Mitchell, Henry Ford Health

Leanna Delhey, MPOG

Katie O'Conor, Johns Hopkins

Heather Dobbs, Bronson Health

Diana O'Dell, MPOG

Kim Finch, Henry Ford

Rebecca Pantis, MPOG

Jackie Goatley, University of Michigan

Jack Peace, Temple University

Josh Goldblatt, Henry Ford Health

Jillian Printz, Cleveland Clinic

Frances Guida-Smiatacz, MPOG

Sharon Reale, Brigham & Women's

Ashraf Habib, Duke

Laurence Ring, Columbia University

Jerri Heiter, Trinity Health

Rachel Stumpf, MPOG

Patrick Henson, Vanderbilt University

Brian Taussig, NYU Langone

Danish Jaer, WUSTL

Brandon Togioka, OHSU

Wandana Joshi, Dartmouth

Pam Tyler, Corewell Health

Jeremy Juang, UCSF

Meridith Wade, MPOG

Teshi Kaushik, UAB

Christine Warrick, University of Utah

John Kowalczyk, Brigham & Women's

Jennifer Woodbury, UCSF

Heather LaLonde, Trinity Health

Joshua Younger, Northwell Health

Tiany Malenfant, MPOG

Amy Zheng, University of Maryland

Obstetric-Anesthesia Quality Subcommittee — Meeting Summary

Date/Time:

Chair: Dr. Brandon Togioka (OHSU) Vice Chair: Dr. Wandana Joshi (Dartmouth)

Facilitator: Kate Buehler (MPOG)

1. Announcements

• Next meeting: December 3, 2025 at 1pm EST

• Welcome to new OB Subcommittee members: 24 new members joined since the last meeting

held in May.

• OB Subcommittee is open to anyone, if interested in attending, please email Kate Buehler

(kjbucrek@med.umich.edu)

2. May Meeting Recap

• Reviewed results of the WOMAN-2 Trial relative to tranexamic acid use

• Voted not to include midazolam as an antiemetic for PONV-05 (Adult PONV Prophylaxis

measure)

• Discussion:

o Patric Henson (Vanderbilt): Not sure about the history of midazolam and PONV but does

that apply to all benzodiazepines? We use more lorazepam than midazolam in our

obstetric patients who need anxiolysis.

 Wandana Joshi (MPOG OB Subcommittee Vice-Chair): We voted not to include

midazolam at this time and are waiting for the updated guidelines to be

published.

• Discussed and voted on OB Subcommittee measure priorities for 2025. Will focus on the

following topics for measure development:

o Unintended dural puncture

o Epidural replacement

3. Literature Spotlight (In-the-News)

• Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report

from a multi-society international working group (Uppal et al., 2024)

• Reviewed recommendations from recent publication for preventing and treating postdural

puncture headache

4. Obstetric Phenotypes Update

• Obstetrics Delivery – Date/Time phenotype is now available!

o Returns date & time of delivery for cesarean or vaginal delivery for cases in MPOG

o Only considers ages 12-56

o Limited concepts evaluated – version 2 of this phenotype currently underway. Will post

to the OB Subcommittee Forum when updated version is available.

• ‘Obstetric – Is Pregnant’ phenotype development in progress

o Proposed updates to primary and secondary results as follows:

 Primary result: Pregnancy – Likely Pregnant/Not Pregnant/Postpartum/UTD

 Secondary result: # of days before or after delivery

o Discussion: What is the appropriate threshold for ‘likely pregnant?’ 39, 40, or 42 weeks

 Danish Jaffer (WashU): Could she have been pregnant with a prior pregnancy

for that chole? A lot of high-risk institutions will have earlier inductions like 34

weeks.

• Brandon Togioka (MPOG OB Subcommittee Chair): If they delivered

within an MPOG site yes but if not we wouldn’t know. This brings up a

good question as to whether we want to optimize sensitivity or

specificity for this phenotype?

o Laurence Ring (Columbia): Some places are so busy they may

not get to induction before 40+ weeks so limiting it to < 40 may

impact some centers

o Brandon Togioka (MPOG OB Subcommittee Chair): True.

 Jillian Printz (Cleveland Clinic): Do D&C’s and miscarriages alter this data? I have

noticed EPIC warnings stating a patient is pregnant when they present for

surgery following a miscarriage. This may be a site-specific issue.

• Josh Goldblatt (Henry Ford): Same thought. This phenotype seems

limited by deliveries. While a good start, we might be missing a

significant number of pregnancies.

• Kate Buehler (MPOG OB Subcommittee Lead): These will not be

considered deliveries in MPOG so will not flag a patient as 'pregnant'

prior to the miscarriage or D&C. We can modify to consider these in the

future if wanting to identify these pregnancies.

• John Kowalczyk (Brigham & Women's): This may be very tricky to flag

D&C vs D&E for AB, missed AB, retained products, and REI purposes,

etc.

• Brandon Togioka (MPOG OB Subcommittee Chair): Jillian, great

comment. With our working phenotype we would never know the

patient was pregnant because we are only looking at timestamps for

delivery. Agree, we also would not be able to determine gestational age

at time of D+C, D+E

o Vote:

Decision: Maintain phenotype definition of 42 weeks before delivery to determine

pregnancy.

5. Antibiotic Measure Updates

• Recently aligned success criteria for ABX-01-OB and ABX-06-OB to assess azithromycin

administration 60 minutes prior to surgical incision through surgical incision.

• Also updated ABX-06-OB measure time period to no longer consider uterine incision or neonate

delivery. If procedure start or surgical incision are not documented, the case will be flagged for

review.

• Score changes were minimal for most sites – sites with significant score changes were notified

via email prior to the release of these measure updates.

• Discussion:

o Danish Jaffer (WashU): Does it catch start or completion of azithro?

o Kate Buehler (MPOG OB Subcommittee Lead): both are considered - if either are within

60 minutes prior, will pass

6. General Anesthesia Definition for Obstetrics

• General anesthesia measures for cesarean delivery (GA-01-OB, GA-02-OB, GA-03-OB) are

currently defined using the Anesthesia Technique: General phenotype

• All cases resulting in value >0 for the phenotype are considered as ‘general anesthesia’

• If inhaled agent alone is administered (no airway placed, no propofol infusion, no NMB), should

this be considered GA for cesarean delivery?

• Discussion:

o Johanna Cobb (Dartmouth): Curious about nitrous oxide vs. other halogenated agents.

Those feel different whether you can be using them with or without an ETT whereas

with nitrous you’d be using intermittently as an adjunct so I would move towards not

considering that as general anesthesia.

 Wandana Joshi (MPOG OB Subcommittee Vice-Chair): I agree

o Josh Younger (Northwell Health): Completely agree as well

o Danish Jaffer (WashU): Does the FGF issue remove all of these corner cases?

o Kate Buehler (MPOG OB Subcommittee Lead): Yes, we would add logic to assess for FGF

for all other inhaled agents to determine if agent was administered. Nitrous is a

separate issue.

o Johanna Cobb (Dartmouth): Then if there’s no FGF then we don’t pay attention to the

inhaled agents.

 Kate Buehler (MPOG OB Subcommittee Lead): Correct.

o Danish Jaffer (WashU): What’s the problem with using an airway procedure note in

distinguishing these cases?

o Brandon Togioka (MPOG OB Subcommittee Chair): Great thought. There are a ton of

phenotypes in MPOG, most of them have been created without subcommittee review.

The GA phenotypes is being used for all cases, not just OB, so we are starting with this

one to see if we can improve the results. The phenotype considers airway placement,

NMB administration, and inhaled agent use most likely because of documentation issues

where airway alone cannot determine GA.

o Christine Warrick (University of Utah): We reviewed something similar at our institution

and unfortunately airway notes were not a reliable marker of GA - some were missing

o Danish Jaffer (WashU): The FGF issue seems like it should be resolved MPOG wide. Pedi

ear tubes likely have sevo without ETT but with high FGF

o Danish Jaffer (WashU): So even if they don’t get gas, will it still end up flagging as a

general anesthetic?

o Brandon Togioka (MPOG OB Subcommittee Chair): There are multiple ways to capture

and define a general case.

• Vote:

• Decision: Update GA-OB measures to pass cases if only indicaon of GA is nitrous oxide

administraon OR if sevo/iso/des is given without FGF running.

7. New Measure Build Updates

• The subcommittee voted to move forward with measure build for a measure to assess

unintended dural puncture and neuraxial catheter replacement at the last meeting in May.

• Measure specification for Unintended Dural Puncture shared with the subcommittee as well as

preliminary data.

o Discussion:

 Josh Goldblatt (Henry Ford): This shouldn’t include intentional dural puncture

correct?

 Wandana Joshi (MPOG OB Subcommittee Vice-Chair): Correct. We are looking

for unintentional

 Jeremy Juang (UCSF): We chart DPEs at our institution (separate from CSEs). will

this be included?

• Kate Buehler (MPOG OB Subcommittee Lead): We currently don’t

separate dural punctures from CSEs in MPOG. We would need to add

that additional enumeration to the neuraxial phenotype. Currently,

most DPEs result as CSE for the neuraxial phenotype.

• Ashrab Habib (Duke): I think the point is that some patients would

develop a headache from the spinal component, but I don’t see a point

we can differentiate which is something we have to deal with. I think it’s

a limitation we just need to deal with. If we exclude CSE we would be

excluding too many patients.

o Kate Buehler (MPOG OB Subcommittee Lead): We are currently

under reporting since there are so few flagged cases so I would

err on including more cases than not so we would be able to

review these and could decide which ones are legitimate UDPs

vs. Not based on case review.

• Laurence Ring (Columbia): I do think we will be including extra patients

who have a blood patch.

o Brian Taussig (NYU Langone): I completely agree

• Jillian Printz (Cleveland Clinic): CSE or DPEs with just the intended dural

puncture, while much less likely, could still result in a spinal headache

and eventual blood patch. (As others are saying). But if you compare the

rates across anesthesiologists, the data is still significant

 Danish Jaffer (WashU): Why not make a PDPH phenotype (rather than UDP

phenotype) that is agnostic to neuraxial type?

• Laurence Ring (Columbia): In our procedure notes, we’ve added a lot of

details regarding dural puncture. I worry about unintentionally raising

our rates of UDP.

• Michael McDonald (UChicago): I would report all - if a CSE/DPE results in

PDPH regardless of if there was an identified dural puncture with the

Touhy needle, I think that’s data that should be flagged and sent to

department/provider

• Brandon Togioka (OHSU): Do we want to create a measure that’s

imperfect but provides more data than we currently have? After

discussions the current data we have is underreported. The idea is to

align with QI metrics that other institutions are using

 John Kowalczyk (Brigham & Women's): It seems like, depending on flags and how

things are set, that it may be best for all "providers" to receive feedback that the

patient developed a PDPH. I would rather know from a personal standpoint to

potentially review.

• Katie O’Conor (Johns Hopkins): If 45% want it for provider feedback,

could we make it available and just let the majority opt to exclude it

from provider feedback emails?

• Jillian Printz (Cleveland Clinic): Provider attribution seems confusing if,

for example, a different provider from the original replaces an epidural

and then the patient is flagged for UDP.

o Vote:

• Decision:

o Flag all cases (not just the ﬁrst case) for the UDP

o UDP-01-OB will be released as a departmental only measure inially.

o Subcommiee would like provider aribuon assigned. Will specify logic at the

upcoming subcommiee meeng in December.

• Measure specification for Neuraxial Catheter Replacement shared with the subcommittee as

well as preliminary data

o Discussion:

 Danish Jaffer (WashU): What is the rationale for excluding C-hyst from this

metric?

• Brandon Togioka (MPOG OB Subcommittee Chair): They are treated a

little bit differently clinically with some sites placing thoracic epidurals

for these procedures. They potentially could be included, if desired by

the subcommittee.

 Laurence Ring (Columbia): Epidural catheter replacement for suboptimal

analgesia/anesthesia but a repeat procedure might happen for initial IV catheter

or for ADP

o Preliminary Vote:

o Decision: Re-visit for discussion at the December Meeting

Action Items

1. Pregnancy Phenotype: Maintain phenotype deﬁnion of 42 weeks before delivery to determine

pregnancy.

2. Update GA-OB measures to pass cases if only indicaon of GA is nitrous oxide administraon OR

if sevo/iso/des is given without FGF running.

a. Flag any case associated with the UDP (not just the ﬁrst case)

b. Release as a departmental only measure inially.

c. Specify logic for provider aribuon at the upcoming subcommiee meeng in

December.

4. Connue to reﬁne logic for neuraxial catheter replacement measure (NCR-01-OB) - discuss at

upcoming subcommiee meeng in December.

Next meeting: Wednesday, December 3, 2025 — 1 p.m. ET / 10 a.m. PT