ASPIRE Obstetric Anesthesia
Subcommittee Meeting
September 10, 2025
Agenda
Announcements
May meeting recap
In the News
Obstetric Phenotypes Updates
Antibiotic (ABX) Measure Updates
General Anesthesia Definition for Obstetrics
New Measure Build Updates
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)
• Discussed & voted on OB Subcommittee Measure Priorities. Will focus on the following topics
to develop measures in 2025-2026:
– Unintended dural puncture
– Epidural replacement
Obstetric Phenotypes Update
Recently released an Obstetrics
Delivery - Date/Time phenotype -
helpful first step to build upon for
the ‘Pregnancy’ phenotype
• Date/Time of Delivery phenotype
now returns the date and time of
a cesarean or vaginal delivery
• Only considers ages 12-56
• Limited concepts evaluated
• Version 2 in progress – more
updates to come!
Pregnancy Phenotype: In-progress
Developing an ‘Obstetric – Is Pregnant’ phenotype
Proposed Update:
– Primary Result: Pregnancy – Likely Pregnant/Not pregnant/Postpartum/UTD
– Secondary Result: Number of days before or after delivery
Value Value Code Definition
Unable to Determine -999 No delivery found in MPOG
Not Pregnant or postpartum 0 Delivery found in MPOG, procedure occurred >42
weeks before the delivery date or >12 weeks after
the delivery date
Likely Pregnant 1 Delivery found in MPOG <= 42 weeks after
procedure
Postpartum 2 Delivery found in MPOG, procedure occurred <=12
weeks after delivery
Case Examples
Cholecystectomy
11/1/2023
Pregnant Phenotype
Result: 0
Days before delivery:
-335
ORIF – Femur
8/1/2024
Pregnant Phenotype
Result: 1
Days before
delivery: -61
Labor Epidural w/
Vaginal Birth
10/1/2024
Pregnant Phenotype
Result: 1
Days before
delivery: 0
Appendectomy
11/1/2024
Pregnant Phenotype
Result: 2
Days after delivery:
+31
Enumerations:
-999 = No delivery found in MPOG.
0 = Not Pregnant or postpartum (Delivery found in
MPOG >42 weeks before delivery OR >12 weeks after
delivery)
1= Likely Pregnant (Delivery found in MPOG ≤42
weeks after procedure)
2= Postpartum (Delivery found in MPOG, procedure
occurred ≤12 weeks after delivery)
What is the appropriate threshold for "likely pregnant"?
• Currently set at 42 weeks. Should we decrease the window to 39 or 40 weeks?
• Conceptional age is 2 weeks shorter than gestational age
o Obstetric gestational age is calculated from the first day of a woman's last menstruation, not the
date of conception, conception occurs ~14 days after a woman's last menstruation
o This is a historical term dating back to the 19th century, based upon a 28-day ovulation cycle
o Gestational age, duration of time from last menstruation to birth: 40 weeks at full term
o Fetal age (conceptional age), fertilization to birth: 38 weeks at full term
• In 2023, 4.97% of birth occurred at GA ≥ 41 weeks (CDC)
• Median and mode gestational age is 39 weeks (PMID 37067897)
ABX Measure Updates
• Recently published updates to ABX-01-OB to align azithromycin administration to 60
minutes prior to surgical incision through surgical incision.
– Score changes minimal
– Previously, success criteria specified that all other antibiotics be administered prior to surgical
incision except azithromycin.
– Measure now aligns with ABX-06-OB success criteria
• Updated ABX-06-OB measure time period to 60 minutes prior to surgical incision or
procedure start.
– Score changes minimal for most sites
– A few sites decreased scores ~30% due to no documented surgical incision or procedure start time
– Cases without surgical incision or procedure start time will now be flagged for review.
– Uterine incision no longer considered in the measure start time logic
General Anesthesia Definition for Obstetrics
• General Anesthesia measures for
cesarean delivery (GA-01, GA-02,
GA-03) are currently defined
using the
Anesthesia Technique:
General phenotype
• All cases resulting a value >0
considered as ‘general
anesthesia’ (standard MPOG
definition of GA)
• If inhaled agent alone is
administered (no airway, no
propofol infusion, no NMB),
should this be considered GA for
cesarean delivery?
Case Example #1
Isoflurane ‘on’ but no fresh gas flow running – patient not receiving inhaled agent
- Currently will flag for GA-OB measures
- Minimally, need to add a check for FGF
- Consider excluding all cases that only have inhaled agent running from being
considered as GA
Case Example #2
Nitrous administered at the beginning of the cesarean delivery portion of the case
- Will currently flag for GA-OB measures
- Exclude cases that only have inhaled agent running from being considered as GA (no
airway placed, NMB, or TIVA)?
General Anesthesia Definition - Vote
If inhaled agent alone is administered (no airway, no propofol infusion, no NMB), should
this be considered GA for cesarean delivery?
a) Yes, administration of any inhaled agent should be considered GA. (artifact values
removed)
b) No, if nitrous oxide (alone) is administered, it should not be considered as GA. All
other inhaled agents (iso, des, sevo) should be considered as GA. (artifact values
removed)
c) No, inhaled agents alone should not be considered as GA.
Recap of Measure Build Priority Discussion
At the last meeting, subcommittee members ranked the following measure options:
1. Epidural Replacement: Proportion of patients that require a second neuraxial procedure prior to
delivery
2. Core Temperature: Proportion of patients undergoing cesarean delivery with at least one core body
temperature measured
3. Multimodal Pain: Proportion of patients administered at least two non-opioid adjuncts preoperatively
or intraoperatively
4. Inadequate pain control: Proportion of patients undergoing cesarean delivery with inadequate
anesthesia (supplemental analgesia)
5. Accidental dural puncture: Proportion of patients receiving neuraxial labor analgesia with an
unintentional dural puncture
Each measure was assigned a ranking between 1-5: 1 = Low priority -> 5 = High priority
2025 Measure Build Vote Results
Next Steps
1. Review specifications for Epidural Replacement and Unintended Dural Puncture
measures.
2. Discuss modifications needed to each specification.
3. Updated specification will be sent to MPOG programmer to update measure code.
4. Measure results re-validated.
5. Share findings with subcommittee to decide if modifications are needed.
6. Additional modifications to measure specification/code per subcommittee
recommendation. Additional validation is needed if code is modified.
7. Publish measure.
UDP-01-OB: Unintended Dural Puncture
Description: Percentage of patients undergoing neuraxial epidural anesthesia for an
obstetric procedure with evidence of an unintended dural puncture.
Threshold: ≤ 2%
Available for Provider Feedback Emails: No - Departmental Only
Measure Time Period:
Obstetric Neuraxial Anesthesia Start
to 14 days after Obstetric Neuraxial Anesthesia Start
Success: Neuraxial epidural anesthesia administered without evidence of unintended
dural puncture.
UDP-01-OB Inclusion Criteria
All patients requiring neuraxial anesthesia for one of the following obstetric procedures:
– Childbirth (includes both labor epidurals and cesarean deliveries as determined by
Obstetric Anesthesia Type
value codes >0)
– Postpartum Tubal Ligation
– Surgical CPT: 58600, 58605, 58611, 58615, 58661, 58670, 58671
– Anesthesia CPT: 00851
– External Cephalic Version
– Surgical CPT: 59412
– Anesthesia CPT: 01958
– Transvaginal Cerclage Placement
– Surgical CPT: 59320
– Anesthesia CPT: 00948
Neuraxial Inclusion Criteria
• The following neuraxial procedures are considered for this measure:
– Combined Spinal Epidural
– Epidural
– Caudal
– Multiple (will likely include cases with spinal + epidural or unclear documentation)
• The following neuraxial procedures are NOT considered for this measure:
– Spinal
– Neuraxial – Unknown Type (neuraxial procedure performed but MPOG is unable to determine
type)
UDP-01-OB Exclusion Criteria
Excludes:
• Patients receiving epidural anesthesia for non-obstetric indications
• Patients not receiving epidural anesthesia (as determined by Anesthesia Technique:
Neuraxial value code 0- None)
• Patients receiving spinal or neuraxial technique is unknown (as determined by Anesthesia
Technique: Neuraxial value codes 3-Spinal or 5-Unknown Type)
• Obstetric cases with neuraxial start time documented after anesthesia end
Other exclusions to consider?
UDP-01-OB Logic for determining UDP
Documentation of inadvertent dural puncture includes any of the following:
o Inadvertent dural puncture (ID: 50291) documented on the case
o Epidural Blood Patch (ID: 50507) documented on a subsequent case within 14 days after initial
procedure
o A secondary case for Epidural Blood Patch (CPT: 62273) is found in MPOG within 336 hours (14 days )
of neuraxial procedure start for the initial obstetric case where a neuraxial procedure was
performed.
o ICD-10 codes:
 G96.0 Cerebrospinal fluid leak, unspecified
 G97.0 Cerebrospinal fluid leak from spinal puncture
 G97.41 Accidental puncture or laceration of dura during a procedure
 O74.5 Spinal and epidural anesthesia-induced headache during labor and delivery
 O89.4 Spinal and epidural anesthesia-induced headache during the puerperium
o ICD-9 code: 349.31 Accidental puncture or laceration of dura during a procedure
Discussion
• When there are multiple cases with neuraxial anesthesia within a 14-day
window, difficult to accurately attribute the unintended dural puncture
to the correct neuraxial technique.
– If there is documentation of inadvertent dural puncture for a case, that case
will be flagged and any other case within 14-day period will pass.
– If UDP is determined based on diagnosis code or epidural blood patch, only
the first case with a neuraxial procedure will be flagged.
– Is this appropriate?
• For this reason, should be measure be departmental only with no
provider attribution assigned?
NCR-01-OB: Neuraxial Catheter Replacement for OB
Description: Percentage of patients undergoing neuraxial anesthesia for labor or cesarean
delivery with evidence of neuraxial catheter replacement.
Threshold: ≤6%
Measure Time Period:
Obstetric Neuraxial Anesthesia Start
to Obstetrics Delivery Date/Time*
*If Obstetrics Delivery Date/Time is not available, will default to anesthesia end.
Success: Epidural anesthesia administered without evidence of a second epidural
placement procedure for the same obstetric delivery.
NCR-01-OB Inclusion Criteria
All patients requiring neuraxial catheter anesthesia for childbirth (includes both labor
epidurals and cesarean deliveries as determined by Obstetric Anesthesia Type
value codes 1, 2,
3, 5, 6, or 7) with neuraxial anesthesia (as determined by Anesthesia Technique: Neuraxial
value
codes 1 [CSE], 2 [Epidural], 4[Caudal], & 6 [multiple neuraxial techniques]
NCR-01-OB Exclusion Criteria
Excludes:
• Cesarean hysterectomy (as determined by Obstetric Anesthesia Type value codes 4 & 8)
• Patients receiving neuraxial anesthesia for any procedure other than labor epidural or
cesarean delivery
• Patients undergoing obstetric procedures without neuraxial anesthesia (as determined by
Anesthesia Technique: Neuraxial
value codes 0[none], 3[spinal], or 5[unknown])
• Obstetric cases with neuraxial start time documented after Obstetrics Delivery Date/Time
Other exclusions to consider?
• Emergency cases (as determined by Emergency Status value code 1)
o Should we exclude these?
NCR-01-OB Logic for determining Neuraxial Replacement
Documentation of multiple neuraxial procedures for the same delivery determined by any of the following
criteria being met:
o Two (or more) neuraxial concepts documented more than 20 minutes apart for the same MPOG
Case ID (as determined by Obstetric Anesthesia Type
value codes 1, 2, 3, or 5)
o Two (or more) neuraxial procedure notes for the same patient under separate MPOG case IDs (as
determined by Obstetric Anesthesia Type
value codes 6 & 7)
Documentation issues that still need to be addressed in final version of the measure:
o In situ notes are currently false flagging cases - need to refine logic to ensure in situ documentation is
not considered as replacement note
o Timing between notes – 20 minutes may be too soon to trigger ‘replacement.’ Many cases are false
flagged due to notes for a single epidural placement documented > 1 hour apart (event notes vs.
procedure notes)
NCR-01-OB Attribution Survey Questions
1) Should emergency cases be excluded from the neuraxial catheter
replacement measure?
2) Should quality data be available for individual provider feedback, or
should this measure be limited to department level feedback?
3) Should attribution be to the provider(s) signed in at the time of first
placement or all providers signed into the case between neuraxial
procedure start and delivery?
4) Should this measure include both a lower and upper threshold 3-6%, or
just an upper level < 6%?
Request for Collaboration
• If you have a case with confirmed documentation of neuraxial replacement, please
contact Kate
.
– We can review case together and see if there are data elements that could be mapped to an
MPOG concept to improve identification of these cases.
• If your site documents ‘replacement,’ please send screenshots to Kate of your EHR
field (no PHI!). May need a new MPOG concept created for sites that have this field
available.
