Obstetric Anesthesia Subcommiee Minutes
December 3rd, 2025
1:00-2:00 pm EST - Zoom
Aendees:
Kate Buehler, MPOG
Mary McKinney, Corewell Health
Meilou Calabio, MPOG
Kam Mirizzi, MPOG
Arthur Calimaran, Cleveland Clinic
Melinda Mitchell, Henry Ford Health
Ruth Cassidy, MPOG
Allison Mootz, UT Southwestern
Johanna Cobb, Dartmouth
Katie O'Conor, Johns Hopkins
Laura Cohen, UMass Memorial
Jillian Printz, Cleveland Clinic
Rob Coleman, MPOG
Sharon Reale, Brigham & Women's
Heather Dobbs, Bronson Health
Nirav Shah, MPOG
Jackie Goatley, University of Michigan
Shashank Shettar, University of Oklahoma
Josh Goldblatt, Henry Ford Health
Sahar Siddik-Sayyid, American University of
Beirut
Ashraf Habib, Duke
Rachel Stumpf, MPOG
Jerri Heiter, Trinity Health
Brian Taussig, NYU Langone
Patrick Henson, Vanderbilt University
Brandon Togioka, OHSU
Michelle Huntington, Corewell Health
Lawrence Tsen, Brigham & Women's
Zachary Janik, Walter Reed
Pam Tyler, Corewell Health
Wandana Joshi, Dartmouth
Meridith Wade, MPOG
Teshi Kaushik, UAB
Christine Warrick, University of Utah
John Kowalczyk, Brigham & Women's
Nathan Woody, University of North Carolina
Heather Lalonde, Trinity Health
Amy Zheng, University of Maryland
Allison Lee, UPENN
Andrew Zittleman, MPOG
Kristyn Lewandowski, Corewell Health
Graciela Mentz, MPOG
Tiffany Malenfant, MPOG
Michael Furdyna, Brigham and Women's
Michael McDonald, UPENN
Anjana Sekaran, Johns Hopkins
Christine McKenzie, UNC
Rachel Kacmar, University of Colorado
Obstetric-Anesthesia Quality Subcommittee — Meeting Summary
Date/Time: 12/3/2025 1-2pm EST via Zoom
Chair: Dr. Brandon Togioka (OHSU) Vice Chair: Dr. Wandana Joshi (Dartmouth)
Facilitator: Kate Buehler (MPOG)
1. Announcements
• 2026 Meeting Dates:
o February 11th, 2026 1-2pm EST
o June 3
rd
, 2026 1-2pm EST
o September 16
th
, 2026 1-2pm EST
• Welcome to new OB Subcommittee members!
o OB Subcommittee is open to anyone, if interested in attending, please email Kate
Buehler (kjbucrek@med.umich.edu)
• Thank you to Dr. Joshi for her service over the last 2 years! She will be stepping down as of
December 2025 from her vice chair position.
• Seeking an OB Subcommittee Vice Chair:
o Obstetric Subcommittee Vice Chair Description: here
o Actively practicing OB anesthesiologist at current MPOG site
o Guide and support the work of the Obstetric Subcommittee
o Lead measure performance review, new measure development, measure revision
discussions
o Identify and participate in research opportunities
o Monthly meetings with Chair (Brandon Togioka) and the MPOG team
o Be able to devote 2 - 4 hours per month to this role for a 2 year term
o Interested faculty should submit their interest to MPOG QI Director (Nirav Shah) at
nirshah@med.umich.edu and MPOG Obstetric Subcommittee Chair (Brandon Togioka)
at Togioka@ohsu.edu
2. Literature Spotlight (In-the-News)
• The Mulcenter Perioperave Outcomes Group (MPOG) learning health system: a model for
promong evidence-based peripartum care (Togioka, Reale, Klumpner, Aziz, and Mathis, 2025)
• Highlights implications for using MPOG data for obstetric research and QI
• Excellent article to reference for future OB research
3. September Meeting Recap
• Reviewed Clinical Practice Guidelines for PDPH
• Voted to define pregnancy phenotype based on a threshold of 42 weeks prior to delivery
date/time as found in MPOG database.
• Reviewed updates to obstetric antibiotic administration measure time frames for ABX-01-OB
and ABX-06-OB.
• Voted to no longer consider nitrous oxide administration (alone) as general anesthesia.
• Reviewed proposed specifications and preliminary data for two new measures:
o Unintended dural puncture
o Epidural replacement
4. Obstetric Phenotypes Update
• Obstetrics Delivery – Date/Time phenotype recently revised! Now returns a delivery date/time
for 100% of all obstetric cases in MPOG
• ‘Obstetric – Is Pregnant’ phenotype published December 1st
Preliminary data (January – December 2024) shared with the committee:
~2.7% of cases in the MPOG registry during this time period were performed on
patients who were likely pregnant (102,250 cases)
1574 cases were definitively not pregnant during their procedure
2078 (0.1%) were postpartum at the time of surgery
Unable to determine pregnancy status for 97.2% of patients undergoing a
procedure in this time frame (no delivery found in MPOG)
• Obstetrics – Pregnancy Trimester phenotype in development
o Proposed return values:
-999: Unable to determine trimester (no delivery found in MPOG)
0: Not pregnant
1: First Trimester (pregnant)
2: Second Trimester (pregnant)
3: Third Trimester (pregnant)
4: Fourth Trimester (postpartum)
o Discussion: Would a pregnancy trimester phenotype be helpful for QI or research
purposes?
o Ashraf Habib (Duke): I’m hesitant about creating a trimester phenotype. I think it would
be better to limit to pregnant vs. non-pregnant. If there is any possibility to have
gestational age at the time of delivery. If you have this data in the delivery encounter
that would help sort this out.
o Patrick Henson (Vanderbilt): Potentially helpful but seems challenging to do correctly
o Richard Wissler (University of Rochester): I would rather have it as a continuous
variable rather than categories
o Michael Furdyna (Mass General Brigham): There are ICD codes also for an encounter
for gestational age basically maternal care particularly towards the end so I know when
reviewing cases for deliveries and trying to estimate gestational age at least to the
week, that would give some of a ballpark. It may be off by one week off but at least if
they stop being reported that might indicate that they delivered already
Brandon Togioka (OHSU): That’s a really good point. We looked at this too with
the current study we’re working on. Rich: to your point, I like the descriptive
variable as it allows the individual investigator to make an inference themselves
versus relying on a phenotype that we create which has a lot of inaccuracy
variable
Kate Buehler (MPOG): using billing codes eliminates a fair number of cases
because a lot of times we don’t get billing reliably or quickly.
o Daniel Berenson (Mass General Brigham) [chat]: I’m sure this has been discussed
before, but out of curiosity: There is definitely no way to extract the mom’s gestational
age from anywhere in the records?
o Patrick Henson (Vanderbilt): Did you mention whether EGA and date of conception
could be extracted? Day of conception and EGA and things are really a fundamental part
of obstetric coding and documenting but there’s no way without putting that in some
anesthetic documentation. I know that our obstetricians put that in their notes, but I
guess that would have to be seen here. For that purpose as I think out loud about this. If
they came in and were not seen here, that would be information that couldn’t be
reliable.
Kate Buehler (MPOG): You can always add it manually to your extract but it’s
not part of the standard MPOG extract.
Nirav Shah (MPOG QI Director): Yea, it’s kind of exposing a weakness of the
MPOG extract, especially for EPIC sites. One of the strengths is that there’s a
standard EPIC extract umbrella it’s a relatively limited amount of work we can
get it up and running compared to having to build your own but the weakness of
that is boundaries and so if we want to extend it, for example, to include historic
data or OB data or floor/ICU data then either we have to rely on Epic to modify
the extract or sites will have to pull that manually. To do that at scale across
every site and ask them to do that has been challenging. That’s kind of the work
that MPOG is trying to figure out over the next few years: how do we reduce
that dependency so that when we want to get this additional important
information, we’re able to .
• Patrick Henson (Vanderbilt): I guess it seems like a lot to ask to have
this for what is a seemingly small change but if you think about this on a
broader population like I can think of fewer maybe more meaningful
groups to actually look at data in then early gestation surgical
procedure; this is a really potentially meaningful. Maybe I’m
overestimating that, but I wonder if there is some sort of solution to
actually getting this as opposed to just saying like ‘we don’t know’. I
don’t know what that answer is and I certainly don’t think it’s worth
making a dramatic change but at least worth exploring further.
Daniel Berenson (Mass General Brigham): I agree, exploring possibilities for
including this data more widely would definitely be very helpful. We’re already
needing to exclude like 98% of patients because they just don’t have a delivery
documented which could be because they’re not pregnant or could be, because
their delivery was outside MPOG or whatever so we’re already kind of
narrowing the patients we really are confident into a small subset and I think it
would be better to further narrow it to patients where we can more confidently
say what their gestational age is. If there is some fraction of patients where the
data is obtainable through the current system and really know what’s going on
with them rather than having the guesswork.
Josh Goldblatt (Henry Ford) [chat]: Back to previous conversaon, Henry Ford is
collecng pregnancy as gestaonal age as a discrete field in the pre-op
evaluaon. This is fairly new, and I don't know about its actual use.
Vote:
5. PONV-05 Updates
• Dr. Shashank Shettar (OU Health – University of Oklahoma) presented recent updates to the
PONV guidelines (5
th
Consensus Guidelines for the Management of Postoperative Nausea and
Vomiting: Executive Summary) and posed questions to the subcommittee regarding
modifications to the existing MPOG PONV prophylaxis measure (PONV-05) for cesarean delivery
patients
• Discussion:
o Richard Wissler (University of Rochester) [via chat]: Very nice presentation on
anticholinergics. My question to MPOG: Why are we only giving credit for certain anti-
emetics. Isn't there room for differing clinical approaches, as long as N/V prophylaxis is
being addressed?
Kate Buehler (MPOG): Scopolamine patch is included in the success criteria for
PONV05 for cesarean delivery as an acceptable antiemetic for prophylaxis, but
you’re correct that atropine and glycopyrrolate are not included currently
Ashraf Habib (Duke): My understanding is that ondansetron between what the
recommendation first practice but it is not, I think all antiemetics should be
included is that correct?
Kate Buehler (MPOG): That’s correct. In the specification we list the
recommended antiemetics to align with the SOAP-specific recommendations
but we do include all of them for consideration when determining if a case
passes.
o Wandana Joshi (Dartmouth): Dr. Shettar, if you are giving glycopyrrolate and
scopolamine? What is the rate of patients complaining about a dry mouth?
Shashank Shettar (OU Health): It’s not much to be honest. For some reason, at
least for cesarean surgery, we’ve not seen much. I do not know the exact
mechanism but they do not complain so much. Maybe it’s multifactorial the
baby being born, but there have been some academic literature in terms of one
of the textbooks they also mentioned the use of anticholinergic like
glycopyrrolate and atropine specifically helps decrease, at least, the
intraoperative nausea and vomiting.
Ashraf Habib (Duke): There are two or three studies out there about
glycopyrrolate and cesareans. One is an older study from a group in Glasgow
that showed that it reduced instances of intraoperative nausea and vomiting
but this was at the time when vasopressors were given as rescue boluses before
the time of phenylephrine infusion. There was another study that looked at
phenylephrine infusions and examined the ways to address the bradycardia that
happens with phenylephrine infusion. In one study, they did give all patients
glycopyrrolate in the setting of phenylephrine infusion and what they found that
those patients who got glycopyrrolate did have higher cardiac output but there
was more variability in blood pressure, more reactive hypertension and more
dry mouth in the glycopyrrolate group. As a result, they found that this was not
a clinically beneficial intervention. They did not recommend its routine measure
in the setting of phenylephrine infusion which is very commonly in practice
currently.
o Josh Younger (Northwell): One of our sites introduced scopolamine as part of the ERAS
process and there was some objection from the lactation consultants because of mixed
evidence in terms of it affecting the lactation. So the compromise that we came to was
that it could be used for 24 hours opposed to the 3 days that you can usually apply the
scopolamine patch. The other objection was that some obstetricians had patients that
experienced hallucination for some form of negative secondary effect from it. Those are
two experiences that we had with it.
Shashank Shettar (OU Health): Yes, we also as part of our ERAS protocol, do
just apply scopolamine for 24 hours, we did have a similar objection basically
from lactation consultants and MFM also and most of them went home on day
2 or 3 and they just didn’t want that patch to be gone home so we take out
within 24 hours after delivery. As far as hallucinations, I don’t think it has been
reported but it’s a known side effect that’s worth considering.
• Vote:
• Ashraf Habib (Duke): I have a few thoughts. There is a bit of complexity in deciding in a database
seng what is given for intraoperave and what’s given postoperave NV and most commonly
they do overlap significantly. I can think of probably one anemec that is helpful for intraop
and not postop NV is metoclopramide but other than that people will give ondansetron to help
for both intraoperave and postoperave nausea and voming. Maybe dexamethasone is for
postop and then there is the complexity of paents receiving anemecs intraop. You don’t
really know if this was because of prophylaxis or whether this is because they actually did have
symptoms and they were treated. So there is significant complexies of looking at this in a
database seng without somebody collecng this data prospecvely for cesarean populaon
determining what was given for intraop vs. what was given for postop. That’s why I actually
voted no for those. Also because I think there’s significant complexity to it. Also voted ‘no’ for
adding glycopyrrolate for this reason- too much complexity.
o Wandana Joshi (Dartmouth): I also see that it wasn’t menoned in the 5
th
Consensus
guidelines either. I tend to use glycopyrrolate intraoperavely, just if the paent gets
bradycardic from the phenylephrine infusion, but I don’t consider it an anemec in my
pracce.
o Josh Younger (Northwell): Ashraf – I have a queson for you. I mean, it seems that your
objecon is that the primary reason that it’s given should be considered, not the
secondary effects but couldn’t a medicaon serve two funcons? Let’s say
benzodiazepines. Most people aren’t going to be geng a benzo for PONV, we’ll be
giving it for some degree of anxiety. But if it aids in PONV, do we want to rule that out?
o Nirav Shah (MPOG): I’d just chime in here to say that I don’t know that we want to
incenvize providers to give something like midazolam as a prophylacc anemec as
the primary purpose. We want the measure to support administraon of medicaons
that work best for PONV, not happen to have a side effect of PONV prophylaxis.
o Ashraf Habib (Duke): Yes, giving a benzodiazepine, specifically for cesarean delivery is
controversial in that it can impact the paents memory of the event. I sll remain
concerned about that. It would not be my first choice for PONV prophylaxis in the
obstetric populaon.
o Josh Younger (Northwell): My only last comment is, that’s why I like the idea of not
lisng these meds as recommended in the measure but also not excluding them from
the success criteria.
• John J. Kowalczyk (Mass General Brigham) [chat]: Does the measure include anemecs given
by nursing in the "pre-op" period on labor and delivery? I can imagine that the scopolamine
patch may be given early by nurses prior to the case.
o Brandon Togioka (OHSU) [chat]: As long as it is administered within the 4 hour period
before preop start, an-emecs administered would count [Note: Documentaon from
the L&D nursing record may not be included in your site’s MPOG extract as this varies
from site to site. MPOG recommends confirming your extract me period of obstetric
cases specifically, as the standard MPOG extract includes 4 hours before anesthesia start
through 6 hours aer anesthesia end for cases performed in the operang room and
diagnosc imaging suites. Data extracts for NORA and L&D areas may differ.]
• Johanna G. Cobb (Dartmouth) [chat]: I agree with Dr. Younger regarding preferred medicaons
and acceptable medicaons. You may have a very good reason for using lorazepam as an
anemec - perhaps an anxious paent with long QT
6. New Measure Discussion – Postponed to the February meeting due to time
Meeting Adjourned: 1407
Action Items
1. Hold on further development of the pregnancy trimester phenotype as currently specified and
invesgate alternave opons for capturing gestaonal age at me of delivery, potenally using
ICD-10 codes.
2. MPOG Coordinang Center with support from OB Subcommiee leadership will develop an
inial measure specificaon to assess IONV/PONV prophylaxis for cesarean delivery paents.
a. Will include glycopyrrolate in the list of acceptable anemecs for prophylaxis in the
new measure.
b. Will exclude atropine & midazolam as acceptable anemecs.
3. Will move forward with excluding cesarean delivery paents from PONV-05.
4. MPOG Coordinang Center to release neuraxial catheter replacement (NCR-01-OB) as a
departmental measure (not available for provider feedback emails) once validated. Will post to
forum when available for Obstetric Champions to review.
5. Contact Brandon Togioka or Nirav Shah if interested in the OB Subcommiee Vice Chair Posion.
Next meeting: Wednesday, February 11, 2026 — 1 p.m. ET / 10 a.m. PT
