ASPIRE Obstetric Anesthesia
Subcommittee Meeting
May 14, 2025
Agenda
Announcements
February meeting recap
PONV-05 Revision Update
2025 Measure Build Priorities
Pregnancy Phenotype Updates
In the News: WOMAN-2 trial
• 15,068 women enrolled. Intervention vs placebo after vaginal delivery of anterior
shoulder. 1 GM TXA over 10 minutes within 15 minutes of cord clamping. 35 hospitals
in 4 countries (Nigeria, Pakistan, Tanzania and Zambia)
• Primary outcome: PPH > 500 ml blood loss or sufficient EBL causing instability within 24
hours of delivery.
• Results: PPH occurred in 530 (7%) of 7579 women with TXA and 497 (6.6%) of 7487
women in the placebo group. (RR.1.05, 95% CI 0.94-1.19)
PONV-05 Revision Discussion
• PONV-05: Percentage of patients who had a procedure requiring general anesthesia OR
cesarean delivery and received appropriate prophylaxis for postoperative nausea and
vomiting.
– Measure was reviewed in February 2025 by the Quality Committee.
– Recommendation to add midazolam as an acceptable antiemetic for prophylaxis for
adult patients undergoing general anesthesia
1
1
Au et al The Effect of Perioperative Benzodiazepine Administration on PONV; Systematic Review and Meta-
Analysis of Randomised Control Trials. BJA 2024;132(3):469-482
PONV-05-OB
• Discussion: Would the subcommittee recommend adding midazolam as an
acceptable prophylactic agent for PONV-05 for cesarean delivery patients?
• Current PONV-05 Score (all sites) filtered to obstetric surgical service = 75%
PONV-03 Outcome Measures
• PONV-03: Percentage of patients, regardless of age who undergo a procedure and have a
nausea/emesis documented occurrence OR receive a rescue antiemetic in the immediate
postoperative period.
• PONV-03-b: Percentage of patients, regardless of age who undergo a procedure and have a
documented occurrence of nausea/emesis with or without receiving an anti-emetic in the
immediate postoperative period.
• 132 patient for elective CD.
• Grp M: IV midazolam 30 mcg/kg
• Grp O: IV ondansetron 8 mg
• Grp MO: IV midazolam and ondansetron
• Pts received treatment if a pt had vomiting or VAS of nausea > 3 during surgery or after cord
clamping. Incidence and severity of vomiting episodes were evaluated at 2 hrs, 6 hrs and 24hrs
after study drug.
Jabalameli M, Honarmand A, Safavi M, Chitsaz M: Treatment of postoperative nausea and vomiting after spinal anesthesia for cesarean delivery: A randomized, double-blinded comparison
of midazolam, ondansetron, and a combination. Adv Biomed Res 2012; 1:2
Results
• Incidence of nausea was significantly reduced in the MO grp
compared to the other grps at 6 hours. P= 0.01
• No differences at 2 hrs and 24hrs.
• Comments:
• Treatment of nausea rather than prophylactic treatment
• OB anesthesiologist are hesitant to use midazolam due to amnestic effects
• No difference in sedation in the study but what about amnesia?
Jabalameli M, Honarmand A, Safavi M, Chitsaz M: Treatment of postoperative nausea and vomiting after spinal anesthesia for cesarean delivery: A randomized, double-blinded comparison
of midazolam, ondansetron, and a combination. Adv Biomed Res 2012; 1:2
PONV-05 Revision
Should midazolam be added as an acceptable
prophylaxis antiemetic for patients undergoing
cesarean delivery?
• 1 vote/site
• Continue as it/modify
MPOG OB Subcommittee 2025 Goals
New Measure Development Discussion
1. Epidural replacement measure: Proportion of patients that require a second neuraxial
procedure prior to delivery
2. Temperature 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
o SOAP COE Application: "Describe your system used to track labor epidural
replacement rates"
• Longstanding interest in this measure on the OB subcommittee
• Poorly functioning epidural catheters are associated with:
o Increased parturient pain
o Worse patient experience and satisfaction
1,2
o Greater risk of GETA for intrapartum CD
3
o GETA for CD increases maternal risk for SSI, VTE, and postoperative pain
4
o GETA is associated with a higher incidence of low (< 7) 5-min Apgar
5
1
Yurashevich M. Anaesthesia 2019;74(9):1112.
2
Tan D. BMC Anesthesiol. 2018;18(1):50.
3
Bauer ME. IJOA 2012;21(4):294.
4
Guglielminotti J. Anesthesiology
2019;130(6):912.
5
Palmer E. Anaesthesia 2018;73(7):825.
Epidural Replacement Rate
• What is the appropriate rate of replacement?
o SOAP COE 3-6%
• Methods to capture replacement
o Two neuraxial procedure notes in a single record or admission prior to delivery
o Two timestamps for "neuraxial procedure start" or "end"
o Medications administered?
o Free text search is 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 between procedure notes?
Epidural Replacement Discussion Summary (2.25)
How to capture?
– Two notes documented at most sites
– Built into procedure note with option to label as ‘replacement’ or ‘not
replacement’
– Potentially include time threshold (20 min?) below which multiple procedure
notes would be considered as a single neuraxial procedure or technique
– Use delivery time to decipher between replacement vs. second epidural
placed for secondary procedure
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
â–ª Measurement time period: "anesthesia start" to "out of room"
â–ª Excludes cases < 30 minutes
â–ª Threshold for success, > 90%
• Questions:
o Modify to include all CD patients (NA+GA)?
o Should we have a measure specific to cesarean delivery for patients
undergoing GA?
o Does this impact patient outcomes?
o How do you measure temperature?
Core Temperature Discussion Summary (2.25)
Summary of concerns raised:
• At some institutions, temperature is not routinely measured for CD
performed under neuraxial anesthesia
• Question about correlation to outcomes
• Hypothermia for a long period of time is not good for patients, but
cesarean delivery is typically a short procedure.
• This measure was suggested as it is currently a SOAP COE measure.
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"
â–ª Non-opioid analgesics: APAP, NSAIDs, ketamine, clonidine [not
dexmedetomidine], local infiltration, any regional block
â–ª 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?
â–ª Measurement time-period: "incision" to "surgery end"
• Questions:
â–ª Should this measure include intraoperative pain assessments?
â–ª Should we penalize sites that treat intraoperative pain?
Incidence of Unintentional Dural Puncture
• SOAP COE core metric for neuraxial labor analgesia
– SOAP COE Application: "A quality assurance review of all unintentional dural
punctures and post-dural puncture headaches (PDPH) should be in place"
• Unintentional dural puncture is associated with:
– Acute HA, backache, neck ache, auditory, and visual symptoms
1
– Acute dizziness, nausea and vomiting, neck and shoulder stiffness
1,2
– Persistent (> 6 weeks) HA, back ache, and neck ache
3,4,5,6,7
– Major neurologic complications including cerebral venous thrombosis,
SDH, bacterial meningitis, and postpartum depression
8
1
Vilming ST. Cephalgia 1989;9:99.
2
Ljubisavljevic S. World Neurosurg 2020;133:e540
. 3
Ranganathan P. J Clin Anesth 2015;27:201.
4
Ansari J. BJA 2021;127:600.
5
MacArthur C. BMJ 1993;306:883.
6
Webb C. Anesh Analg 2012;115:124.
7
PNiraj G. Anaesthesia 2021;76:1068.
8
Guglielminotti J. Anesth Analg 2019;129:1328.
Incidence of Unintentional Dural Puncture
• What is the appropriate rate of unintentional dural puncture
– SOAP COE ≤ 2%
• 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:
– Send 5-10 cases of confirmed accidental dural puncture to Kate
– 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?
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
2025 Measure Build Results
Please rank the following from 1 (low priority) to
5 (high priority) based on your site’s interest.
Each ranking (1-5) should only be assigned once
for the entire poll.
