ASPIRE Obstetric Anesthesia
Subcommittee Meeting
February 26, 2025
Agenda
Announcements
December meeting recap
Days before delivery (Pregnancy Phenotype) update
OB Champion role discussion
ABX-06 measure released
2025 Goals
In the News
•Reported incidence of pain during cesarean delivery is approximately 15-23%.
•Adverse outcomes:
• PPD
• PTSD
• Chronic pain
•There are multiple reasons for this of which some are preventable. As physicians, we
underestimate the incidence of intra-op pain. Need to address and mitigate risk factors for intra-op
pain. Shared decision making and good communication between patient/partner and anesthesia.
December Meeting Recap
• OB Patient Blood Management Toolkit now available! Adapt as needed to share this
educational resource with your department.
• OB PCRC update: All OB Subcommittee members from active MPOG sites will be invited
to Perioperative Clinical Research Committee
(PCRC) meetings when obstetric anesthesia
research projects are proposed. Attendance is optional.
• GA-01-OB: General Anesthesia During Cesarean Delivery will remain an informational
measure with no threshold to define ‘success.’
• SOAP/OB Subcommittee: Support overall alignment with SOAP Centers of Excellence
(COE)
• TXA measure- Subcommittee voted against building TXA measure – percentage of cases
with TXA administered with EBL > 1000 ml.
• Transfusion ≥ 4 units blood products measure- Subcommittee voted against building
measure to assess percentage of cases with transfusion of ≥ 4 units of any blood products.
Pregnancy Phenotype: Days Before Delivery Update
• Description: Determines the number of days before delivery using our Obstetric
Anesthesia Type
(OBAT) Phenotype to determine if a patient had a delivery in
MPOG within 42 weeks of an OBAT procedure.
• Enumerations:
– 0= No delivery found in MPOG
– 1= Delivery found in MPOG within 42 weeks of procedure
– 2= Delivery found in MPOG more than 43 weeks before procedure
– 3= Delivery found in MPOG 12 weeks after procedure
• Phase I- Coming soon- we anticipate this will be available in DataDirect for
researchers to use in the next few weeks!
• For access to DataDirect, please fill out this form: SignNow – please note, this require your site’s
Hospital Leader approval (Chair or Director of Research)
Case Examples
Cholecystectomy
11/1/2023
Pregnant Phenotype
Result: 2
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: 3
Days after delivery:
31
Enumerations:
0= No delivery found in MPOG
1= Delivery found in MPOG within 42 weeks after
procedure
2= Delivery found in MPOG more than 43 weeks before
procedure
3= Delivery found in MPOG 12 weeks after delivery
OB Champion Role Description
Role Summary
• Each participating site that provides obstetric anesthesia
care is encouraged to select an Obstetrics (OB) Champion
to participate on the MPOG OB Subcommittee.
• The primary role of an OB Champion is to understand
and use MPOG tools and data to improve anesthesia care
for laboring mothers.
• The OB Champion can work alongside their MPOG
Quality Champion to implement local QI initiatives
supported by MPOG data.
OB Subcommittee Member vs. Champion
MPOG OB Anesthesia
Champion
MPOG OB Subcommittee
Member
Obstetric
anesthesiologist
(Does not need to be
OB fellowship trained)
OB anesthesia provider,
administrator, or QI leader
interested in participating in
MPOG OB Subcommittee
Votes on behalf of site
at OB Subcommittee
meetings
Serves as backup to champion for
OB Subcommittee votes
Attends MPOG OB Subcommittee meetings
Conducts measure reviews
Sites without a named MPOG OB Champion:
American University of Beirut Medical Center
Atrium Health (Wake Forest)
Columbia University
Corewell Health: all except Butterworth
Holland Hospital
University of Maryland
Massachusetts General Hospital
Michigan Medicine
MyMichigan - all sites
Nebraska
NYU Langone Medical Center
Temple University Hospital
University of Alabama
University of Arkansas
UCLA
University of Chicago
University of Florida
University of Wisconsin
University of Tennessee
UT Southwestern
Vanderbilt University
Please reach out to your Quality Champion, Dr. Togioka, Dr. Joshi or
Nicole if you are interested in being your site’s OB Champion.
Departmental Dashboard Access
• Subspecialty dashboard access (Obstetrics, Pediatrics and
Cardiac) was removed in December 2024.
• Many OB Champions and ACQRs have full departmental
dashboard access and may not have noticed a change in
access.
• If you have noticed a change in access, please reach out to
your Quality Champion and Nicole and we can help get
access re-established.
OB Champion Key Responsibilities
Review Performance Data
• MPOG reviews/provides ongoing measure performance data via reports,
dashboards, and collaborative meetings.
• OB Champions can review case data using several different tools:
– QI Reporting Tool
– Measure Case Report
– DataDirect
• If interested, please contact Nicole to learn more.
ABX-06-OB -Azithromycin Administration for Non-Elective
Cesarean Deliveries
• Description: Percentage of standalone cesarean deliveries in which azithromycin was administered
60 minutes before surgical incision
• Inclusion: Enumerations 1 and 7 using OBAT (Non-elective cesarean cases.)
– 1- Conversion (Labor epidural and cesarean delivery charted under one case ID)
– 7- Conversion (cesarean delivery portion, labor epidural documented on another case ID)
• Exclusion: Obstetric Anesthesia Type phenotype:
– 0 - No
– 2- Cesarean delivery without a preceding labor epidural
– 3- Labor Epidural
– 4- Cesarean Hysterectomy
– 5- Obstetric Case Unable to Determine
– 6- Conversion (labor epidural portion)
– 8- Conversion (cesarean hysterectomy portion)
• Cases with Chorioamnionitis ICD codes: O41.12-O41.1299
MPOG OB Subcommittee 2025 Goals
SOAP COE Core Metrics-General Anesthesia Rates
• GA rate for all cesarean deliveries
– Available as MPOG metric: GA-01-General Anesthesia During Cesarean
Deliveries
• GA rate for unscheduled cesarean deliveries
– Can be estimated from MPOG metric GA-02
– MPOG metric GA-02 (% of CD cases where GA was administered after
neuraxial labor analgesia)
– Would miss unscheduled CD not proceed by NA
• GA rate for scheduled cesarean deliveries
– Can be estimated from MPOG metric GA-01 – OBAT enumeration #2
– OBAT enumeration #2 (CD without preceding NA)
– Would errantly include unscheduled CD not preceded by NA
SOAP COE Core Metrics-Neuraxial Labor Analgesia Rates
• Epidural replacement rate
– MPOG measure does not exist
– We could review the data, may be possible to create
• Percentage of laboring patients receiving neuraxial labor analgesia
– Unable to estimate due to lack of data on patients that deliver without
neuraxial labor analgesia
• PDPH rate & Epidural blood patch rate for PDPH
– Difficult to estimate due to lack of data on conservatively treated PDPH
• Accidental dural puncture rate
– MPOG measure does not exist
– Measure would always underestimate true rate
New Measure Development Discussion
1. Epidural replacement measure: Proportion of patients that require a second neuraxial
procedure prior to delivery
2. Temp measure: Proportion of patients undergoing cesarean delivery with at least one core
body temperature measured
3. Pain Measure: Two options for pain measures.
– Multimodal: PAIN- Proportion of patients administered at least two non-opioid adjuncts
preoperatively or intraoperatively (multimodal)
– Inadequate pain control: Proportion of patients undergoing cesarean delivery with
inadequate anesthesia (supplemental analgesia)
4. Accidental dural puncture measure: Proportion of patients receiving neuraxial labor analgesia
with an unintentional dural puncture
Epidural Replacement Rate
• SOAP COE core metric for neuraxial labor analgesia
• Longstanding interest in this measure on the OB subcommittee
• Methods to capture replacement
o Two neuraxial procedure notes in a single record or admission
o Two timestamps for "neuraxial procedure start" or "end"
o Medications administered?
o Free text search, challenging
o Other ideas?
• Questions:
o How do you document neuraxial procedures?
o For a CSE or DPE, do you document two procedure notes?
o Should there be a time threshold?
Core Body Temperature
• Proportion of patients undergoing cesarean delivery with at
least one core body temperature measured
o SOAP COE measure
o TEMP-02: Percentage of patients receiving GA that have at least
one core body temperature documented
 Measurement time period: "anesthesia start" to "out of room"
 Excludes cases < 30 minutes
 Threshold for success, > 90%
• Questions:
o Modify to include all CD patients (NA+GA)?
o Does this impact patient outcomes?
o How do you measure temperature?
Multimodal Analgesia during CD
• Proportion of patients administered multimodal analgesia
during cesarean delivery
o SOAP COE measure
o PAIN-02: % patients receiving at least one non-opioid adjunct
between "preop start" and "anes end"
 Non-opioid analgesics: APAP, NSAIDs, ketamine, clonidine
[not dexmedetomidine], local infiltration, any regional block
 Threshold for success, > 85%
• Questions:
o Is the measure for success appropriate?
o Should we include postoperative adjuncts, end +60 min?
o Should surgeon placed local infiltration count?
Inadequate Anesthesia during Cesarean Delivery
• Untreated intraoperative pain is a significant problem & the #1
cause of litigation in OB anesthesia
• The incidence of intraoperative pain is ≥20%
• Potential measure:
o Proportion of CD patients having intraoperative pain defined as:
• Any dose of Ketamine, Nitrous Oxide, or Intraperitoneal Chloroprocaine
• Propofol > 20 mg, Midazolam > 2 mg
• Morphine > 10 mg, Fentanyl > 100 mcg, Hydromorphone > 1.5 mg
• Other ideas?
 Measurement time-period: "incision" to "surgery end"
• Questions:
 Should this measure include intraoperative pain assessments?
 Should we penalize sites that treat intraoperative pain?
Incidence of Accidental Dural Puncture
• The following proxies for dural puncture can be used
– Free flow of CSF at time of placement
– Blood patch within 1 week of neuraxial placement
• Measure would miss PDPH treated conservatively
• Seeking Volunteers:
– Interest? Send 5-10 cases of confirmed accidental dural puncture to
Nicole
– Send MPOG case IDs only, NO MRNs!
• Questions
– Ideas for other proxies to identify accidental dural puncture?
– How does your site document unintentional dural puncture?
2025 OB Subcommittee Focus
• Will review epidural replacement rate data, PDPH, and wet tap data from
MPOG sites with hopes of creating a wet tap measure (likely in 2026).
• We are seeking volunteers to send 5-10 cases of confirmed wet taps to Nicole,
MPOG case IDs only (no MRNs!). The Coordinating Center will assess this
information to determine next steps for capturing this data.
High reliability, Low effort High Reliability, High Effort
Low Reliability, Low Effort Low reliability, High effort
Core Temp
Inadequate pain control
during cesarean delivery
Multimodal Analgesia
Measure build effort
Data Reliability
Development effort
Epidural replacement
Unintentional dural
puncture
