Obstetric Anesthesia Subcommiee Minutes

September 16, 2026

1:00–2:00 pm ET – Zoom

Chair: Brandon Togioka, MD (MPOG OB Subcommiee Chair)

Vice Chair: Sharon Reale, MD (MPOG OB Subcommiee Vice Chair)

MPOG Coordinang Center Facilitator: Kate Buehler, MS, RN (MPOG Clinical Program Manager)

Aendees:

Aymen Alian, Yale New Haven Health

Heather LaLonde, Trinity Health

David Arnolds, University of Michigan

Allison Lee, University of Pennsylvania

Daniel Berenson, Mass General Brigham

Tiﬀany Malenfant, MPOG

Shobana Bharadwaj, University of Maryland

Michael McDonald, University of Pennsylvania

Cheyenne Booker, Henry Ford Health

Chrisne McKenzie, University of North Carolina

Kate Buehler, MPOG

Emily McKinney, Trinity Health

Meilou Calabio, MPOG

Mary McKinney, Corewell Health

Arthur Calimaran, Cleveland Clinic

Chris Milliken, University of Michigan Health

Megan Charee, MPOG

Kam Mirizzi, MPOG

Deborah Claybaugh, MyMichigan Health

Melinda Mitchell, Henry Ford Health

Kim Finch, Henry Ford Health

Diana O’Dell, MPOG

Cedar Fowler, Stanford Health

Rebecca Pans, MPOG

Jackie Goatley, University of Michigan

Jack Peace, Temple University

Daniel Gruer, Trinity Health

Sharon Reale, Mass General Brigham

Ashraf Habib, Duke University

Frances Guida Smiatacz, MPOG

Jerri Heiter, Trinity Health

Brooke Szymanski

Bogart, MPOG

Patrick Henson, Vanderbilt Health

Brandon Togioka, OHSU

Melanie Herren, MPOG

Lawrence Tsen, Mass General Brigham

Wandana Joshi, Baystate Health, Inc.

Pam Tyler, Corewell Health

Jeremy Juang, University of California San Francisco

Blake Wilson, MyMichigan Health

Rachel Kacmar, UC Health

Richard Wissler, University of Rochester

Teshi Kaushik, University of Alabama Birmingham

Andrew Zileman, MPOG

Tory Lacca, MPOG

1) Announcements

New QBL Phenotype

MPOG has created new Quantave Blood Loss (QBL) concepts, available for sites to map to. QBL is

considered the gold standard for objecve measurement of blood loss, as EBL tends to underesmate

blood loss, parcularly in large-volume hemorrhage. Mulple naonal sociees support the use of QBL.

 Two new QBL concepts are now available for mapping to account for site variaon. MPOG

Coordinang Center has begun reaching out to sites individually to map these variables; sites are

encouraged to do so proacvely.

 Two addional new OB concepts are available for mapping:

o DPE (Dural Puncture Epidural): A brand-new concept to diﬀerenate DPE from standard

epidurals, CSEs, and spinals.

o PDPH (Post-Dural Puncture Headache): Already mapped at several sites.

General Anesthesia (GA) Phenotype Update

The GA phenotype update is sll in progress. Previously, cases in which nitrous oxide was the only agent

administered were being incorrectly classiﬁed as general anesthesia. The update will correct this: nitrous

oxide given alone (without other inhaled agents, neuromuscular blockers, or airway placement) will no

longer be classiﬁed as GA.

 This change required approximately 12 underlying phenotypes to be updated.

 Score changes are ancipated to be minimal or represent improvement for most sites.

 Though the change has been released to producon, it will take some me for all historical cases

to process. Sites will connue to see inappropriately ﬂagged nitrous-only cases unl the update

is applied to all historical data.

 MPOG will post an update to the OB Subcommiee forum to announce this change.

Upcoming Meeng Dates

 2027 dates conﬁrmed: February, June, and September (Wednesdays, 10:00 am PT / 1:00 pm ET)

 MPOG Collaborave Meeng / Retreat: October 16, 2026 (Friday before ASA Annual Meeng)

2) June 2026 Meeng Recap

The following updates from the June 2026 meeng were reviewed:

 NCR-01-OB (Neuraxial Catheter Replacement): Discussed separaon into NCR-01 (labor

analgesia replacement) and NCR-02 (cesarean delivery anesthesia replacement); released to

producon this month with addional details forthcoming.

 UDP-01-OB (Unintended Dural Puncture): Voted to add surrogates (caﬀeine, Fioricet, SPG block,

and PDPH concept) to the numerator; measure speciﬁcaon now explicitly states PDPH is a

surrogate for UDP.

 2026 Priories conﬁrmed: (1) Separate NCR measure (labor vs. cesarean), (2) Pregnancy

gestaonal age phenotype, (3) OB-speciﬁc IONV/PONV prophylaxis measure.

3) NCR-01-OB & NCR-02-OB: Neuraxial Catheter Replacement – Measure Update

Status: NCR-01 released (Departmental Only); NCR-02 in development, ancipated release October

2026

Public spec: hps://measures.mpog.org/Measures/Public/102

Measure Logic Overview

Sharon Reale (OB Subcommiee Vice Chair) reviewed the updated NCR measure framework:

 NCR-01-OB: Neuraxial replacements for labor analgesia. Example: Labor epidural placed; 4 hours

later, replaced epidural → NCR-01 ﬂag.

 NCR-02-OB: Neuraxial replacements for cesarean delivery anesthesia. Example: Spinal placed for

repeat C-secon; epidural placed 1 hour later → NCR-02 ﬂag.

 Conversion scenarios: If a labor epidural is placed and a CSE is then placed before the paent

goes to the OR → NCR-01 (labor replacement). If a spinal is placed aer a labor epidural once

the paent is in the OR for C-secon → NCR-02.

 Mulple replacements: A case may ﬂag for both NCR-01 and NCR-02 if replacements occur in

both the labor and cesarean phases.

 Current speciﬁcaon: Any spinal placed aer a ﬁrst neuraxial in a conversion case ﬂags for NCR-

02. A future version may apply a 30-minute window between spinal and C-secon start for

improved precision.

Key Discussion Points

 Ashraf Habib, MD (Duke University): Asked how mulple replacements are handled. Sharon

conﬁrmed a case can ﬂag for both NCR-01 and NCR-02 when replacements occur in both labor

and cesarean phases.

 Patrick Henson (Vanderbilt Health): Asked whether elecng to place a spinal in place of a labor

epidural for cesarean (a known pracce at some sites) is automacally captured under NCR-02.

Sharon conﬁrmed yes — it ﬂags for NCR-02. These are departmental measures only, not

intended for individual provider aribuon.

 Kate Buehler (MPOG Coordinang Center): Clariﬁed these are ﬂagged for review only, and are

departmental-level only. Acknowledged Megan Charee for extensive case review work to

validate measure logic. NCR-02 ancipated for release in October 2026.

 Aymen Alian (Yale New Haven Health): Conﬁrmed the measure captures replacement of the

epidural regardless of the reason (e.g., catheter out, hub disconnected, inadequate analgesia).

 Cedar Fowler (Stanford Health): Asked about mestamp funconality to show duraon between

replacements. Kate conﬁrmed this is planned and currently in producon build. Noted Stanford

is mining their own data and ﬁnding issues with procedure note vs. mestamp documentaon;

oﬀered to discuss with Kate post-meeng.

4) UDP-01-OB: Unintended Dural Puncture – Measure Update

Status: Released (Departmental Only); Revision planned for 2027

Public spec: hps://datalibrary.mpog.org/Measures/Public/110

Measure Summary

Based on June 2026 commiee feedback, the following surrogates were added to the UDP numerator

logic:

 Fioricet (butalbital/caﬀeine/acetaminophen)

 Caﬀeine-containing medicaons

 Sphenopalane ganglion (SPG) block

 PDPH concept

Note: ICD-10 codes and epidural blood patch remain the largest contributors to case capture. The added

surrogates captured a modest number of addional cases.

Discussion: Measure Name and Scope

Daniel Berenson (Mass General Brigham): raised the queson of whether the measure should be

separated into disnct UDP and PDPH measures, nong the current approach “muddies the water.”

 Kate Buehler: Explained that rates are quite low per site per month; the majority of cases are

captured via ICD-10 codes (not discrete UDP concepts), so combining them is pragmac. Very

few sites have a discrete UDP variable mapped.

 Sharon Reale: Acknowledged the challenge of incomplete documentaon. Proposed that once

documentaon improves, separate UDP-01 and UDP-02 measures could be revisited.

 Daniel Berenson, Mass General Brigham (via chat): Could also call it “UDP-PDPH-01” since it

includes all! 蹖蹗×2

Decision

 UDP-01-OB will be maintained as-is for now, with a comprehensive review discussion planned for

2027 to allow site champions a chance to review departmental data.

 Measure speciﬁcaon will explicitly note that PDPH serves as a surrogate indicator for UDP.

 Sites are encouraged to review cases and provide feedback.

5) ABX-01-OB: Anbioc Timing for Cesarean Delivery – 3-Year Measure Review

Status: Acve/Released (Available for Provider Feedback)

Public spec: hps://datalibrary.mpog.org/Measures/Public/41

Background [Presented by Brandon Togioka (OHSU)]

ABX-01-OB measures the percentage of cesarean deliveries in which anbioc prophylaxis is

documented within one hour before surgery start, targeng surgical site infecon (SSI) prevenon. Key

background:

 Endometris and SSI are common post-cesarean complicaons; mely prophylaxis reduces rates

of maternal fever, UTI, SSI, endometris, pelvic abscess, and sepsis.

 Historical pracce of giving anbiocs aer cord clamping has been superseded; evidence

supports pre-incision administraon to achieve peak plasma concentraon at me of incision.

 Strongly supported by ACOG and the American Academy of Pediatrics.

 Inclusion: Cesarean deliveries and cesarean hysterectomies. Exclusion: Non-obstetric cases,

neuraxial analgesia cases not progressing to cesarean, paents on scheduled anbiocs (within 4

hours).

 Leniency for vancomycin (consistent with main OR pracce) and for emergent cases

(measurement window extends to anesthesia end).

 MOCA measure; available for provider feedback. Success threshold: ≥90%.

 Current overall performance: ~90%; the vast majority of instuons are meeng the threshold.

Review Findings & Recommendaons (Dr. Togioka)

 Clinical relevance: Appropriate; no change to inclusion/exclusion criteria recommended.

 Success criteria/ﬂagging logic: Current approach is appropriate. Vancomycin leniency and

emergent case leniency maintained. No evidence found to support requiring earlier post-incision

dosing.

 BMI/weight-based dosing: Literature reviewed (threshold studies at ≥110–120 kg, BMI ≥40). No

recommendaon to adjust measure criteria; 2g cefazolin re-dosed within 2 hours achieves

adequate MIC for common SSI pathogens (MSSA, MRSA, E. coli, Klebsiella) regardless of weight.

 Second-line agents (penicillin allergy — clindamycin-based regimens): Current measure allows

clindamycin alone to pass.

 Recommendaon: Require co-administraon of an aminoglycoside (e.g., gentamicin).

Raonale: ASHP and ACOG both recommend clindamycin + aminoglycoside; a study of

6,500 paents found odds of infecon 4–5x higher with clindamycin alone vs.

clindamycin + gentamicin.

Poll 1: Second-Line Anbioc Requirement

Queson: Should ABX-01-OB success criteria require aminoglycoside co-administraon when

clindamycin is given for prophylaxis?

 Yes (require aminoglycoside + clindamycin): 58% (11/19)

 No — create separate anbioc selecon measure: 26% (5/19)

 No — aminoglycoside + clindamycin does not need to be assessed at this me: 16% (3/19)

Follow-up queson:

 Kate Buehler (MPOG): If both clindamycin and an aminoglycoside are required, should at

least one be given before incision to count as a pass, or must both be given before incision?

 Consensus from chat responses (Chris Milliken, Michael McDonald, Daniel Berenson,

Cheyenne Booker, David Arnolds, Ashraf Habib): “Either” — if either agent is given on me,

the case passes.

 Brandon Togioka (OHSU)]: Either agent given on me is suﬃcient, as gentamicin is a longer

infusion and may be documented later. If clindamycin is given alone (on me), it will ﬂag

moving forward.

Poll 2: Overall Measure Direcon

Queson: OB Subcommiee ABX-01-OB Measure Review — what should be done with this measure?

 Keep as is — no changes: 43% (9/21)

 Modify — changes to measure speciﬁcaon and/or logic: 57% (12/21)

 Rere — eliminate enrely: 0% (0/21)

Decision

 ABX-01-OB will be modiﬁed to require aminoglycoside co-administraon (e.g., gentamicin or any

aminoglycoside) when clindamycin is used as prophylaxis.

 Success criteria: Either the clindamycin or the aminoglycoside given on me will count as a pass.

 Clindamycin given alone will ﬂag moving forward, even if given on me.

6) BP-04-OB: Hypotension Aer Neuraxial Placement for Cesarean Delivery – 3-Year Measure Review

Status: Acve/Released (Departmental Only)

Public spec: hps://datalibrary.mpog.org/Measures/Public/45

Background & Literature Review (Presented by Teshi Kaushik, MD – University of Alabama -

Birmingham)

Current measure: Flags cases where SBP < 90 mmHg persists for more than 5 minutes from neuraxial

placement to neonatal delivery.

Dr. Kaushik presented a literature review (2020–2026) supporng a threshold change to SBP < 100

mmHg:

 2024 retrospecve study (n=332): Sustained hypotension (SBP <100) associated with neonatal

acidemia.

 2026 mulcenter RCT (n=≈1,000): Both ght and less-ght BP control groups maintained SBP

≥100 mmHg throughout; IONV and maternal hypotension noted when BP control was less

stringent.

 2025 systemac review of 6 RCTs (preeclampc paents): Most studies deﬁne maternal

hypotension as SBP <100.

 2020 Cochrane Review (n=9,000): Maternal hypotension deﬁned as SBP <90, <100, or relave to

baseline.

 2018 Consensus Statement (opmal hypotension management): Deﬁned maternal hypotension

as SBP <100.

 2020 study (n=≈3,000): Sustained hypotension (SBP <100) associated with neonatal acidosis.

Limitaons noted: Most studies include only healthy parturients with healthy fetuses; limited data for

urgent/emergency secons, fetal anomalies, or preeclampsia. No studies directly link maternal

hypotension to poor APGAR scores.

Discussion: SBP vs. MAP

Daniel Berenson (Mass General Brigham): raised the queson of why SBP rather than MAP is used as

the quality metric:

 Teshi Kaushik: Literature predominantly uses SBP; only one study found MAP should be

maintained within 80% of baseline, but no absolute MAP value was deﬁned.

 Wandana Joshi, Baystate Health (via chat): Interesng that no one studies MAP vs systolic BP

蹒蹓蹔蹕×1

 Allison Lee’s iPhone, University of Pennsylvania (via chat): Tradion, is what I’ve always heard

 Aymen Alian, Yale New Haven Health (via chat): Even criteria of Diagnosis of PEC is related to

SBP

 Arthur Calimaran, MD, Cleveland Clinic (via chat): When I looked into this in the past: SBP

compared to MAP can reﬂect earlier hemodynamic changes — placental perfusion. 蹖蹗×1

Discussion: BP Measurement Frequency & Flagging Logic

Patrick Henson (Vanderbilt Health) raised quesons about how the 5-minute ﬂagging window interacts

with BP measurement frequency:

 Kate Buehler (MPOG) clariﬁed: The current speciﬁcaon uses a cumulave approach — each

incidence of hypotension accounts for a maximum of 5 minutes, with carry-forward if there is a

gap in BP measurement. A second low reading within that window constutes a ﬂag. The

measure window runs from neuraxial placement to neonatal delivery — not the enre case.

 Blake Wilson, MyMichigan Health (via chat): It’s total me for OR

 Brandon Togioka (OB Subcommiee Chair): The measure is intenonally designed to encourage

more frequent BP assessment, which is an indicator of higher-quality care. Instuons are

currently performing well overall.

Discussion: Blood Pressure Monitoring Frequency

Parcipants shared their instuon’s pracce for BP monitoring frequency post-spinal:

 Ashraf Habib (Duke): Every 1 minute aer spinal placement.

 Brandon Togioka (OB Subcommiee Chair): SOAP Center of Excellence recommends every 1–2

minutes aer spinal.

 Patrick Henson (Vanderbilt Health): ASA recommends every 2 minutes for the ﬁrst 10 minutes

post-spinal.

 Wandana Joshi (Baystate Health): Every 2 minutes unl spinal is set, then may extend to every

3–5 minutes as case progresses; 1-minute intervals are rarely used due to paent discomfort.

 Cedar Fowler, Stanford Health (via chat): We do Q1min unl delivery

 Shobana Bharadwaj, University of Maryland (via chat): we do q1 unl delivery

 Melinda Mitchell, Henry Ford Health (via chat): We use phenyl g so q2 min is suﬃcient

 Brandon Togioka, OHSU (via chat): us too

 Chris Milliken, University of Michigan Health (via chat): 1-2 minutes depending on baseline for

10 minutes

 Aymen Alian (Yale New Haven Health): Noted that Epic typically prints BP averages at 5-minute

intervals, so MPOG may not see every 2-minute reading even when clinically obtained.

Dr. Kaushik’s Recommendaon:

Increase the success threshold from SBP ≥90 mmHg to SBP ≥100 mmHg. Cases where SBP falls below

100 mmHg for more than 5 minutes (cumulave, from neuraxial placement to neonatal delivery) would

be ﬂagged.

Poll: BP-04-OB Measure Direcon

Vote: OB Subcommiee BP-04-OB Measure Review — what should be done?

 Keep as is — no changes: 16% (3/19)

 Modify — update references & success criteria to SBP <100 for ≤5 minutes: 84% (16/19)

 Rere — eliminate enrely: 0% (0/19)

Decision

 BP-04-OB will be modiﬁed to update the success threshold from SBP <90 mmHg to SBP <100

mmHg for ≤5 minutes, from neuraxial placement to neonatal delivery.

7) Measure Review Schedule & Future Meengs

Brandon Togioka provided an update on the ongoing 3-year measure review cycle:

 MPOG policy requires all acve measures to be reviewed every 3 years. A rered measures

secon is available on the MPOG website.

 Next meeng (February 2027): Will be led by Daniel Berenson on neuraxial failure and general

anesthesia for cesarean delivery — an area in which he has considerable research experse.

 June 2027: Dr. Cobb has agreed to lead the TEMP-05 review.

 PONV measure (PONV-06-OB): Deferred to a future meeng due to me constraints today.

 MPOG Collaborave Meeng/Retreat: October 16, 2026 (Friday before ASA Annual Meeng).

Aendees are encouraged to stop by and say hello; a secon highlighng OB Subcommiee

work will be featured.

Decisions

 NCR-01-OB & NCR-02-OB: Framework for labor vs. cesarean replacement conﬁrmed as

described; NCR-02 release ancipated October 2026.

 UDP-01-OB: Maintain as-is; PDPH surrogates remain in numerator; measure speciﬁcaon to

explicitly note PDPH as surrogate; comprehensive revision planned for 2027. Measure name to

be reconsidered (e.g., PDPH-01 or UDP-PDPH-01).

 ABX-01-OB: Modiﬁed to require aminoglycoside co-administraon with clindamycin; either

agent given on me counts as a pass; clindamycin alone will ﬂag.

 BP-04-OB: Modiﬁed to update success threshold to SBP ≥100 mmHg; cumulave 5-minute

window clariﬁed in speciﬁcaon.

Acon Items

 MPOG Coordinang Center:

 Implement ABX-01-OB modiﬁcaon to require aminoglycoside co-administraon with

clindamycin; update success criteria logic accordingly.

 Implement BP-04-OB modiﬁcaon to update success threshold to SBP <100 mmHg <= 5

minutes

 Release NCR-02-OB; ancipated October 2026.

 Update UDP-01-OB measure speciﬁcaon to explicitly note PDPH is used as a surrogate

for UDP.

 Connue outreach to sites for QBL, DPE, and PDPH concept mapping.

 Post GA phenotype update to OB Subcommiee forum.

 Subcommiee Members: Review NCR-01-OB dashboard cases locally and report any incorrectly

ﬂagged or passed cases to MPOG Coordinang Center (kjbucrek@med.umich.edu) .

 Daniel Berenson (Mass General Brigham): Prepare to lead next meeng discussion on neuraxial

failure and GA for cesarean delivery.

Contact Informaon

 Kate Buehler, MS, RN – MPOG Clinical Program Manager (kjbucrek@med.umich.edu)

 Brandon Togioka, MD – Chair (togioka@ohsu.edu)

 Sharon Reale, MD – Vice Chair (screale@bwh.harvard.edu)

Meeng Adjourned: ~2:09 pm ET

Next Meeng: Wednesday, February 3, 2027 1-2pm EST

Appendix A — Full Transcript

MPOG Obstetric Anesthesia Subcommiee Meeng

September 16, 2026

Sharon Reale (Mass General Brigham): Okay, it is 1 o'clock. Would you like for me to start?

Brandon Togioka (OHSU) [chat]: Thank you Kae O'Connor for championing the QBL phenotype :)

Sharon Reale (Mass General Brigham): Welcome, everyone. People are sll joining, but we’ll get started — as Kate

menoned, we have a lot on the agenda. This is our meeng agenda. We’ll start with announcements and a

meeng recap, then Brandon and others will present measure reviews, and we’ll discuss a new PONV measure,

which we hope to get to today. These are the future meeng dates. Kate has sent the links and they’re posted as

well. If you know anyone who’d like to join, we’d love to have them — Kate can add them to the invites.

1) Announcements

New QBL Phenotype

Sharon Reale (Mass General Brigham): We have excing news: a new QBL variable is now available for both QI

measures and research purposes. Previously, QBL wasn’t included in the data sites were uploading, but we’re

increasingly able to capture it — and as everyone here knows, QBL is now the gold standard.

EBL tends to underesmate blood loss, parcularly with larger volumes, and mulple research studies conﬁrm that

QBL provides a more objecve signal of signiﬁcant hemorrhage. Brandon also thanked Kae O’Connor for

championing this important phenotype. Mulple naonal sociees support QBL, and most instuons have now

transioned to measuring it. MPOG has created a QBL phenotype, and we’d love for sites on this call to look for this

variable in their local MPOG data and map these new concepts. Kate and the MPOG team are available to assist

with any quesons.

Sharon Reale (Mass General Brigham): There are two new QBL concepts — two to account for site variaon. Kate

has begun reaching out to sites individually to map these variables, but proacve mapping is even beer. We also

have two other new obstetric concepts available: DPE, which is brand new, and PDPH. Diﬀerenang DPE from

standard epidurals, CSEs, and spinals is something we’ve all been wanng to do, so we encourage sites to begin

mapping. The more sites that do, the faster development and relevance improve. PDPH has been a recurring topic

at recent meengs, and we already have several dozen sites mapped to it, which is great.

General Anesthesia (GA) Phenotype Update

Sharon Reale (Mass General Brigham): We’ve also been discussing the general anesthesia (GA) phenotype update

at recent meengs. Daniel Berenson, who I see has joined the call, helped bring this to our aenon. Previously,

cases with nitrous oxide administraon alone were being included as GAs. On review, these cases are typically not

true GA — nitrous oxide may be used for sedaon for various indicaons, but nitrous-only cases will no longer be

classiﬁed as GA. Kate and the team have been working hard to update the underlying phenotypes to reﬂect this

change.

Sharon Reale (Mass General Brigham): There is signiﬁcant behind-the-scenes work involved, as this change aﬀects

12 phenotypes, including pediatrics. The process has taken longer than ancipated, but the updated phenotypes

will be released soon. We discussed score changes with Kate: most sites will see minimal impact, while some may

actually see improvement. Thank you all for your paence, and thank you, Kate and the MPOG team, for all your

hard work.

2) June 2026 Meeng Recap

Sharon Reale (Mass General Brigham): Next is a recap of our last meeng, which was a busy one. We discussed

updates to NCR01 (neuraxial catheter replacement) and the decision to separate it into NCR01 and NCR02 — we’ll

review that on the next slide. We also voted to incorporate sphenopalane ganglion blocks, caﬀeine, and Fioricet

as surrogates for UDP, and requested that the UDP01 measure explicitly note that PDPH is used as a surrogate

indicator alongside these medicaons. We cannot conﬁrm with certainty whether a case involved an unintended

dural puncture, but these surrogate measures are our best available tools. We also discussed this year’s priories:

connuing UDP measure development, revising NCR01, and developing NCR02.

Sharon Reale (Mass General Brigham): Addional priories include: developing a pregnancy gestaonal age

phenotype to idenfy at what gestaonal age a case occurred; developing an IONV/PONV prophylaxis measure,

similar to what exists for non-OB cases; and incorporang OB research presentaons into the agenda when

possible, given the outstanding MPOG-based OB anesthesia research many of you are conducng.

3) NCR-01-OB & NCR-02-OB: Neuraxial Catheter Replacement – Measure Update

Sharon Reale (Mass General Brigham): This is the updated NCR01 — it is a bit complex. I just reviewed this with

Daniel, and Kate and Brandon, please jump in as needed. Based on our last meeng discussion, there will be NCR01

and NCR02. NCR01 captures replacements for labor analgesia, and NCR02 captures replacements for cesarean

delivery. I’ll walk through some examples.

 NCR01 — Failed Labor Analgesia (simple example): A labor epidural is placed. Four hours later, it is replaced.

This ﬂags for NCR01, failed labor analgesia.

 NCR02 — Failed Cesarean Anesthesia (simple example): A paent goes to the OR for a planned repeat

cesarean, a spinal is placed, and one hour later an epidural is placed. This ﬂags for NCR02, failed cesarean

anesthesia.

 NCR02 — Slightly more complex example: A paent has a labor epidural placed. A cesarean is then called for

failure to progress, and one hour aer going to the OR, a CSE is placed. This ﬂags for NCR02.

 NCR01 — Another slightly more complex example: A paent has a labor epidural. Four hours later, there is a

replacement CSE. Four hours aer that, they go to the OR for failure to progress. This ﬂags for NCR01 — even

though there was a cesarean, the CSE was placed during the labor analgesia phase, before the paent went to

the OR. One important nuance: currently, any spinal placed aer a ﬁrst neuraxial in a conversion case will ﬂag

for NCR02.

In the rare scenario where a labor epidural is replaced with a spinal and the paent later goes to the OR for failure

to progress, this could be captured incorrectly. However, in Kate’s review, this scenario did not occur — all cases

were within minutes of the cesarean, with minor documentaon variaons. We believe ﬂagging these for NCR02

will be more accurate, since a spinal placed in the context of a conversion is almost certainly for the OR, not a labor

epidural replacement.

We wanted to release this as quickly as possible given interest in using it for research. In a future version, we can

add a 30-minute window between the spinal and cesarean start for more precise capture. I’ll pause here for

quesons, as this is fairly complex.

Ashraf Habib (Duke University): Thanks, Sharon, this is great. How are mulple replacements handled?

Sharon Reale (Mass General Brigham): It depends on the scenario. Kate, jump in if I get this wrong. For example

— and this is not uncommon — a paent has a labor epidural, it’s replaced 2 hours later while sll in labor, then 4

hours aer that they have a cesarean for failure to progress and receive another epidural one hour into the OR.

That would ﬂag for both NCR01 and NCR02. That scenario is not uncommon, and it should ﬂag for both — there

was a replacement for labor analgesia and a replacement for cesarean anesthesia.

Any other quesons? Yes, Patrick?

Patrick Henson (Vanderbilt Health): Thanks. I may have missed this in the descripon, but in situaons where you

elect to place a spinal — as some pracces do, removing a laboring epidural and placing a spinal rather than dosing

it up —

is that automacally captured under NCR02, or is it excluded? And how do we evaluate that as a quality measure

when it may be an intenonal pracce?

Sharon Reale (Mass General Brigham): That would automacally ﬂag for NCR02. We’re not placing value

judgments on these numbers — in fact, if your NCR01 and NCR02 rates are 0%, that’s probably not a good sign,

because you do want to be replacing catheters that aren’t working. It’s worth knowing the numbers, and Brandon,

feel free to oﬀer a diﬀerent perspecve — but it may be worth nong whether the replacement rate for cesarean

anesthesia is high in cases where the original catheter could have been used.

Patrick Henson (Vanderbilt Health): Fair enough.

Kate Buehler (MPOG): They are ﬂagged for review — that’s how we frame it. These are departmental-only

measures at this me, Dr. Henson, precisely for that reason. We don’t want individual providers to receive this

feedback and think they shouldn’t have replaced a catheter because it’s ﬂagging high. This should remain at the

departmental level for quality champions and obstetric champions to review — both to validate accuracy, since this

is a new measure, and to ensure the logic makes sense. NCR02 is coming soon. I also want to credit Megan

Charee — I believe she’s on the call — for the signiﬁcant me she’s spent helping review these cases. There are

deﬁnite corner cases, including documentaon irregularies: if labor converted to cesarean is documented

mulple mes and one entry is inaccurate, a case may ﬂag for NCR02 when it should ﬂag for NCR01. We encourage

case review and feedback on both measures. NCR02 is expected within the next month, likely in October, at which

point you’ll be able to see which cases ﬂagged for NCR01 versus NCR02.

Aymen Alian (Yale New Haven Health): So you’re talking about the replacement itself — not the reason for

replacement, whether the catheter was out, the hub was disconnected or the paent is not adequately controlled

with the analgesia.

Sharon Reale (Mass General Brigham): Exactly.

Cedar Fowler (Stanford): Will there be a mestamp feature so we can see the duraon between replacements?

Kate Buehler (MPOG): Yes, that’s the goal. We plan to add this to the measure case report and to the case detail

view in the QR reporng tool. If you open a case within the case list, there’s a caret that shows addional details —

we plan to add the duraon between replacements, as well as the number of replacements. This is sll building in

producon — it was released this month thanks to Megan’s work, but some tweaks remain, including the NCR02

release. Dashboard updates should reﬂect this soon.

Cedar Fowler (Stanford): Kate, I can follow up with you separately. We’ve had some documentaon issues on our

end — we’re not fully incorporated on the MPOG side yet, but we’ve been reviewing our own data and I’d be

happy to discuss those issues with you.

Kate Buehler (MPOG): Sure. Right now I have two cases for you in MPOG, so the score won’t be very reliable given

the small denominator.

Cedar Fowler (Stanford): We’re mining our own data through a separate mechanism. We’ve idenﬁed issues

where the procedure note and mestamp are not always documented consistently, and as you roll this out across

instuons, it may be worthwhile to look at how mestamp documentaon is validated.

Ashraf Habib (Duke University) [chat]: Thanks for working on this, it will be a great addion!

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Sharon Reale (Mass General Brigham): Thank you all so much for your great feedback at the last meeng and

during this meeng, to help really reﬁne this measure, but I think we're… we're in a good place now. So, like I

menoned before, we have released this unintended dural puncture measure, and based on feedback from the

June meeng, we are… we did add some surrogates for UDP, so the, Fioricet, other caﬀeine medicines, and SPG

block. However, so, and then also, we included PDPH as a surrogate for UDP, So, spinal… basically these, these

codes for PDPH. I will say not a huge number of gains from the ﬁrst two bullet points. The ICD codes and epidural

blood patch were by far the biggest contributors. So, you know. these deﬁnitely helped capture a few more cases,

but the vast majority we were capturing. And like I said before, it also would be great if people can look at their

cases and give feedback on the measure. We'll do a big revision in 2027 based on, feedback.

Perfect, and now I'll hand it over to Brandon to go over his anbioc, metro review.

Daniel Berenson (Mass General Brigham): Can you hear me? I may have missed the last meeng, but regarding the

UDP measure — it seems like it would make more sense to have a UDP measure focused speciﬁcally on UDP and a

separate PDPH measure focused on PDPH. The current approach of using Fioracet and back-calculang for UDP

seems like it muddies the water unnecessarily. I don’t know if that’s been discussed, but I wanted to raise it.

Kate Buehler (MPOG): We did discuss that, and you’re right. The decision came down to the fact that there are

very few ﬂagged cases per site per month. Dr. Berenson, some of that can be addressed with manual review, but

most cases are picked up via ICD-10 codes, as Dr. Reale noted. Very few sites have been able to capture true UDP

using a speciﬁc concept or variable. Rates are quite low, and we’re likely not fully capturing either UDP or PDPH in

MPOG. They are currently lumped together, so the bucket remains small. We hope this improves over me as sites

create and map site-speciﬁc variables. It’s sll early.

Daniel Berenson (Mass General Brigham): If what’s primarily being captured is PDPH rather than UDP, why not call

the measure PDPH?

Kate Buehler (MPOG): It’s probably closer to 50-50, because they’re all captured via ICD-10 codes, as well as

follow-up epidural blood patch cases, which we ﬂag for this. There are mulple surrogates, all lumped into one

measure.

Sharon Reale (Mass General Brigham): Based on how UDP is documented at the Brigham — we have a separate

follow-up mechanism and a ﬁeld to check for unintended dural puncture — but a large poron

Daniel Berenson (Mass General Brigham): of those are oen missed. That makes sense. My suggeson would sll

be to call the measure PDPH, since that’s primarily what it’s capturing.

Sharon Reale (Mass General Brigham): Once documentaon improves, we can revisit separang this into UDP01

and UDP02.

Kate Buehler (MPOG): Yeah, or PDPH01.

Daniel Berenson (Mass General Brigham) [chat]: Could also call it "UDP-PDPH-01" since it includes all!

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Brandon Togioka (OHSU): Daniel, I reviewed our OHSU data — I believe I’m the only one who has done a detailed

review of this measure. A few studies show that only about 70% of unintended dural punctures are recognized at

the me of the procedure, and I’m aware of two studies with similar ﬁndings. If you’re looking for unintended

dural puncture, you do need proxies to idenfy cases that weren’t recognized at the me. In my review of

approximately one year of OHSU data, most cases were captured via ICD-10 codes for CSF leak. There were also

some surrogate cases, but at our instuon — and this will vary — over 70% were unintended dural punctures

without evidence of a subsequent post-dural puncture headache.

ABX-01-OB: Anbioc Timing for Cesarean Delivery

Brandon Togioka (OHSU): Let’s move on to the measure review. We conduct these reviews every 3 years. We were

supposed to cover this at the last meeng but ran out of me. I’ll move through this quickly to leave me for what

follows. This measure looks at the percentage of cesarean deliveries in which anbioc prophylaxis is documented

within one hour before surgery start, with a focus on surgical site infecon prevenon.

By way of background: endometris (infecon of the endometrium) and surgical site infecon from the incision are

both fairly common aer cesarean delivery. There is substanal literature supporng mely anbioc prophylaxis

for reducons in maternal fever, urinary tract infecon, surgical site infecon, endometris, and more serious

infecons such as pelvic abscess, sepsis, and necrozing fasciis.

Previously, anbiocs were administered aer umbilical cord clamping due to concerns about fetal exposure.

Subsequent studies found no increased incidence of fetal complicaons, and established that peak plasma

anbioc concentraon should occur at the me of surgical incision to reduce infecon risk.

Prophylacc anbioc administraon before incision is strongly supported by both ACOG and the American

Academy of Pediatrics, which aﬃrms that fetal exposure is acceptable.

To summarize: this measure captures the percentage of cesarean deliveries with documented anbiocs within

one hour, with leniency for vancomycin (consistent with standard OR cases). Inclusion criteria are cesarean

deliveries and cesarean hysterectomy cases, as both require surgical site infecon prophylaxis. Exclusions include

non-obstetric cases, neuroaxial analgesia cases that do not progress to cesarean (related to OB anesthesia

phenotype coding in MPOG), and paents on scheduled anbiocs within approximately 4 hours prior.

The measurement window diﬀers for non-emergent versus emergent cases. For non-emergent cases, anbiocs

must be documented up to the me of incision. For emergent cases, leniency is allowed — anbiocs may be given

at any point during the OR visit, up to anesthesia end. This is a MOCA measure available for provider feedback,

with a success threshold of 90%.

Current performance is strong — the vast majority of instuons are meeng the 90% threshold. Here is how I

structured the review analysis. On clinical appropriateness: yes, this measure is clinically relevant. Postpartum

infecons are a signiﬁcant cause of morbidity, appropriate prophylaxis reduces infecon frequency, and anbiocs

should be given before incision to achieve peak plasma concentraon at the me of incision. I recommend keeping

this measure. On inclusion and exclusion criteria: the current criteria are appropriate — including cesarean

deliveries and cesarean hysterectomies, and excluding paents already on scheduled anbiocs. At our instuon

we sll administer SSI prophylaxis in those cases, but some instuons exclude them, and that’s accounted for. I

recommend no changes to inclusion or exclusion criteria. Regarding success criteria and ﬂagged cases:

I believe the current approach is appropriate. Vancomycin leniency is reasonable, and consistent with prior

decisions, leniency for emergent cases — extending the window to anesthesia end — is also reasonable. A

literature search found no evidence of beneﬁt to administering anbiocs earlier versus later aer incision, so if we

allow a few minutes post-incision, there is no clear reason to restrict it to less than 30 minutes aer.

The next queson is whether to adjust criteria for paents with high BMI or weight. Some studies use thresholds of

110–120 kg or BMI over 40. This is relevant given increasing obesity prevalence on labor ﬂoors. However, based on

my review, I do not recommend a change.

At our instuon, we do give a higher dosage for paents over 110 kg, but this does not appear to be supported in

the literature. For this measure, surgical site infecon primarily refers to skin infecons — endometris is

addressed separately by azithromycin (anbioc measure 06). The primary organisms of concern are MSSA, MRSA,

and gram-negaves such as E. coli and Klebsiella. For these organisms, the 2-gram dosage achieves appropriate

minimum inhibitory concentraons. Mulple studies found that re-dosing within 2 hours is suﬃcient. For cases

extending beyond 2 hours, blood loss of 1,500 mL typically triggers re-dosing anyway, making dose adjustment for

weight a moot point. Recommendaon: no dosage adjustment for higher-weight paents.

The next topic is second-line agents, which we encounter frequently due to documented penicillin allergies —

oen inappropriately documented. The standard recommendaon is clindamycin plus an aminoglycoside,

commonly gentamicin. Currently, clindamycin alone is suﬃcient to pass. My recommendaon is to align with

naonal guidelines and require co-administraon of an aminoglycoside.

The American Society of Health-System Pharmacists and ACOG both recommend clindamycin plus an

aminoglycoside. A large study of approximately 6,500 paents found that clindamycin alone was associated with a

4- to 5-fold higher odds of infecon compared to clindamycin plus gentamicin.

This brings us to a vote. The opons are: (1) connue the measure as-is, or (2) revise the success criteria to require

co-administraon of an aminoglycoside with clindamycin. Please vote now.

Kate Buehler (MPOG): The majority favor revising the success criteria to require an aminoglycoside — not limited

to gentamicin — co-administered with clindamycin. The Coordinang Center will have follow-up quesons. Since

this is an anbioc ming measure: if either agent is started before incision, does that count as a pass, or must

both be administered before incision?

Chris Milliken [chat]: either

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Michael McDonald [chat]: either

Daniel Berenson [chat]: Agree

Cheyenne Booker [chat]: either

David Arnolds [chat]: agree either

Brandon Togioka (OHSU): My vote would be either, since gentamicin is a longer infusion and may be documented

later. It looks like the consensus is either.

Ashraf Habib (Duke University) [chat]: Either ﬁne with me too

Kate Buehler (MPOG): If clindamycin is given alone, it will ﬂag going forward — even if given on me. Correct?

Brandon Togioka (OHSU): Yes.

Aymen Alian (Yale New Haven Health): [chat]: This should be within 1 h

Kate Buehler (MPOG): I’ll take a quick screenshot of these results. Based on that, I’ll launch a second poll to

formally conﬁrm that the group agrees to modify rather than rere this measure. I’m assuming the answer is yes,

but we need a formal vote conﬁrming we will modify rather than rere this measure. A majority voted to modify.

We will move forward with revisions to require gentamicin or an aminoglycoside in addion to

clindamycin. Anything else, Dr. Togioka, before we move to the next measure review?

Wandana Joshi (Baystate Health) [chat]: Interesng that no one studies MAP vs systolic BP

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Teshi Kaushik (UAB): Can everyone hear me? I’m Teshi, faculty at UAB, and I’ll be presenng the BP04 OB measure

review. Next slide. The current measure states that, to be successful, systolic blood pressure should remain below

90 mmHg for no more than 5 minutes, from neuraxial placement to delivery. Based on my literature review, I am

proposing to raise this threshold to less than 100 mmHg. The literature falls into two categories: studies correlang

hypotension with intraoperave nausea, voming, and neonatal acidemia; and studies on opmizing management

of maternal hypotension, which consistently deﬁne hypotension as systolic blood pressure less than 100 mmHg.

Regarding maternal and fetal outcomes: a 2024 retrospecve study of 332 paents found that sustained

hypotension — deﬁned as systolic blood pressure less than 100 mmHg for a certain duraon — was associated with

neonatal acidemia. A 2026 mul-center RCT of approximately 1,000 paents compared ghter versus less-ght

blood pressure control. Nausea, voming, and maternal hypotension were reported in the less-ght group, but in

both groups systolic blood pressure remained above 100 mmHg throughout.

Turning to management studies: the only study I found on preeclampc paents was a 2025 systemac review of 6

RCTs comparing inotropes and vasopressors for hypotension. Most of the included RCTs deﬁned maternal

hypotension as systolic blood pressure less than 100 mmHg. Addional management studies include the 2020

Cochrane Review of 9,000 paents, which deﬁned maternal hypotension as a decrease from baseline or an

absolute value below 90 or 100 mmHg. A 2018 consensus statement on opmal hypotension management

similarly deﬁned maternal hypotension as systolic blood pressure less than 100 mmHg. A separate 2020 study of

approximately 3,000 paents again associated sustained hypotension with neonatal acidosis, deﬁning hypotension

as systolic blood pressure less than 100 mmHg. This concludes my literature review, covering studies from 2020 to

2026. Two notable limitaons apply across all studies: ﬁrst, no study reported poor APGAR outcomes — neonatal

APGAR scores were either not recorded or showed no associaon with maternal hypotension. Second,

approximately 95% of studies enrolled only healthy paents with healthy fetuses. Only one study included

preeclampsia, and none included paents undergoing urgent or emergent cesarean secons, or those with fetal

anomalies or maternal comorbidies. There remains clinical uncertainty about the impact of maternal hypotension

in higher-risk scenarios such as urgent cesarean secons or cases involving fetal anomalies.

Based on this review, I recommend a more clinically protecve approach: systolic blood pressure should be

maintained above 100 mmHg, and if it falls below 100, treatment should occur within 5 minutes.

That concludes the presentaon. I’m open for discussion.

Daniel Berenson (Mass General Brigham) Thank you. That was a very informave review. An observer asked me

yesterday in the cesarean OR why we focus on systolic blood pressure rather than MAP. I didn’t have a good

answer, and I was curious whether your literature review addressed this. The broader queson for MPOG is

whether we agree that systolic should be the quality measure rather than MAP.

Allison Lee (University of Pennsylvania) [chat]: Tradion, is what I've always heard

Teshi Kaushik (UAB): In most of the literature, the focus is on systolic blood pressure rather than MAP. Only one

study documented that MAP should be maintained within 80% of baseline, but I did not ﬁnd an absolute MAP

threshold in any study. That is a good queson.

Aymen Alian (Yale New Haven Health): [chat]: Even criteria of Diagnosis of PEC is related to SBP

Patrick Henson (Vanderbilt Health): This 5-minute me period comes up frequently across the hypotension

metrics. To clarify:

does a single measurement of hypotension within a 3-minute check interval ﬂag this measure, or does it require

greater than 5 consecuve minutes of hypotension?

Blake Wilson (MyMichigan Health) [chat]: It's total me for OR

Kate Buehler (MPOG): Historically, it’s been consecuve minutes. If the cuﬀ cycles every 3 minutes and a low

reading lasts 3 minutes, that would count as 6 minutes of hypotension — is that what you mean?

Patrick Henson (Vanderbilt Health): If the cuﬀ cycles every 3 minutes, the 2.5 minutes before and aer a low

reading could represent a 5-minute interval. My queson is whether any second low reading would ﬂag the

measure, regardless of whether the hypotension is consecuve.

Kate Buehler (MPOG): I’d need to double-check the code on that.

Patrick Henson (Vanderbilt Health): My challenge is that it’s diﬃcult to explain these measures and then get into

the technical details across all the metrics.

Patrick Henson (Vanderbilt Health): No, I mean, the hypotension ones speciﬁcally are really tough, right?

Kate Buehler (MPOG): I’ll need to go back to the code and verify.

Patrick Henson (Vanderbilt Health): The 5-minute window is important but technically challenging to arculate

clearly. I’d like to be able to explain it beer to my clinicians.

Kate Buehler (MPOG): We’ll make sure to specify that clearly in the measure speciﬁcaon.

Aymen Alian (Yale New Haven Health): To build on Dr. Henson’s point: if the cuﬀ cycles every 3 minutes and you

treat aer the ﬁrst low reading, the next reading will come approximately 2.5 minutes later. If that reading is also

below 90 or 100, it will ﬂag — because 5 minutes have elapsed since the ﬁrst low reading. To stay ahead of this

window, you would need to cycle every 2 to 2.5 minutes.

Patrick Henson (Vanderbilt Health): There are some technical quesons here. If a pressure of 90 is recorded, does

the 5-minute clock start at that reading, or at the last normal reading — which could be 3 minutes earlier?

And if you wait 3 minutes to recheck, have you already ﬂagged the measure even if you treated and minimized the

hypotension window?

Kate Buehler (MPOG): The current speciﬁcaon states that each episode of hypotension accounts for a maximum

of 5 minutes if there is a gap in blood pressure measurement. So we carry it out 5 minutes for this measure.

Patrick Henson (Vanderbilt Health): And 5 minutes is the ﬂag threshold, correct?

Kate Buehler (MPOG): Correct.

Patrick Henson (Vanderbilt Health): So in theory, a single low blood pressure reading could ﬂag this measure by

default.

Kate Buehler (MPOG): Correct — less than or equal to 5 minutes passes, and greater than 5 minutes fails.

Brandon Togioka (OHSU): The measure stops at the me of neonatal delivery — so it covers neuraxial placement to

delivery, not the enre cesarean. Part of the intent is to encourage more frequent blood pressure monitoring,

which is an indicator of higher quality care. We know that checking every 5 minutes aer block placement will miss

hypotension. When the cuﬀ fails to cycle, it may indicate very low blood pressure, though paent movement is also

possible. Overall, instuons are performing fairly well. Kate, can you pull up the performance slide?

Kate Buehler (MPOG): I think it's at the end here, let me just keep going. This one?

Brandon Togioka (OHSU): Instuons have generally found a way to perform well on this measure. This reﬂects a

threshold of 90. Dr. Kaushik is proposing 100 — I don’t know what the numbers will look like at that threshold.

What does the group think about requiring more frequent blood pressure measurements — every 3 minutes, for

example?

Patrick Henson (Vanderbilt Health): Do we have guidance beyond ASA standards on this? I’d be curious to hear the

group’s thoughts on the best frequency at this point in the case. I’d like to bring that back to my clinicians.

Kate Buehler (MPOG): It is cumulave, Dr. Henson.

Patrick Henson (Vanderbilt Health): Right.

Kate Buehler (MPOG): That clariﬁes the consecuve versus cumulave queson.

Patrick Henson (Vanderbilt Health): Yes.

Kate Buehler (MPOG): It's cumulave, and they each last 5 minutes.

Patrick Henson (Vanderbilt Health): So a second low reading is a ﬂag?

Kate Buehler (MPOG): Correct. If you’re checking every 5 minutes, yes.

Patrick Henson (Vanderbilt Health): Any second low reading within that window would ﬂag. Thank you for

clarifying.

Teshi Kaushik (UAB): The ASA guidelines are more stringent — they recommend blood pressure monitoring

approximately every minute aer neuraxial placement and maintaining blood pressure at 90% of the mother’s

baseline. This was part of their 2022 quality matrix.

Brandon Togioka (OHSU): For the SOAP Center of Excellence, the recommendaon is every 1 to 2 minutes aer

spinal placement.

Ashraf Habib (Duke University):: Aer spinal placement, every 1 to 2 minutes is appropriate. In our pracce, we

run it every minute.

Brandon Togioka (OHSU) [chat]: us too

Patrick Henson (Vanderbilt Health): ASA recommends every 2 minutes for the ﬁrst 10 minutes, so there is some

ﬂexibility, but more frequent monitoring is the standard recommendaon and I think we all agree on that.

Arthur Calimaran (Cleveland Clinic) [chat]: When I looked into this in the past: SBP compared to MAP can reﬂect

earlier hemodynamic changes - placental perfusion.

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Aymen Alian (Yale New Haven Health): Every 2 minutes aer spinal is appropriate, but the paent record — as

printed from the chart — typically averages readings every 5 minutes for the ﬁrst 15 minutes. MPOG cannot see

every 2-minute reading, correct?

Chris Milliken (University of Michigan) [chat]: 1-2 minutes depending on baseline for 10 minutes

Brandon Togioka (OHSU): Can you clarify that?

Aymen Alian (Yale New Haven Health): Epic can detect readings every 1 minute, so cycling every 2 minutes from

spinal placement to delivery should be suﬃcient to capture any blood pressure drop. My queson is: in the review

data, without specifying minute-by-minute readings, is MPOG working from the 5-minute average printout from

Epic?

Cedar Fowler (Stanford Health) [chat]: We do Q1min unl delivery

Wandana Joshi (Baystate Health) : Most of us probably don’t go to 1 minute in pracce due to paent discomfort

— the repeated cuﬀ inﬂaons are uncomfortable, even though the monitor adjusts to the range. I check every 2

minutes unl the spinal is set, then may space out to every 3, or even every 5 as the case progresses.

Shobana Bharadwaj (University of Maryland) [chat]: we do q1 unl delivery

Brandon Togioka (OHSU): Thank you. Great discussion. Dr. Kaushik, did you have a few more slides you wanted to

run through?

Teshi Kaushik (UAB): Those remaining slides are study details, available if anyone has quesons.

Brandon Togioka (OHSU): Can you summarize your recommendaon, and then we’ll vote?

Melinda Mitchell (Henry Ford Health) [chat]: We use phenyl g so q2 min is suﬃcient

Teshi Kaushik (UAB): I am proposing that the systolic blood pressure threshold be increased to 100 mmHg. Cases

where systolic blood pressure falls below 100 mmHg for more than 5 minutes — from neuraxial placement to

delivery — would be ﬂagged. Cases maintaining systolic blood pressure at or above 100 mmHg throughout that

window would meet the success criteria. Treatment must occur within 5 minutes of the blood pressure falling

below threshold.

Brandon Togioka (OHSU): Thank you — that was an excellent presentaon. Please take a moment to complete the

poll.

Kate Buehler (MPOG): The majority voted to modify in agreement with Dr. Kaushik’s proposal. Thank you so much

for this thorough review. We have 5 minutes remaining.

Brandon Togioka (OHSU): I’ll run through one more slide, then we’ll save the PONV discussion for next me. As a

reminder, per MPOG policies and procedures, measures are reviewed every 3 years. There has also been a focus on

rering measures that are no longer appropriate. The website includes a secon on rered measures — this is

something we acvely consider, and it’s worth keeping in mind going forward. Our next meeng will be led by Dr.

Berenson, who has done extensive research on neuroaxial failure and general anesthesia for cesarean delivery, and

I believe has more experse in this area than anyone else in the country. We are very fortunate to have him lead

that discussion. In June 2027, Dr. Cobb has graciously agreed to lead the TEMP-05 review. Thank you, Dr. Burns, Dr.

Cobb, and Dr. Kaushik for your excellent contribuons today. We’ve made tremendous progress over the past year

or two, and that is enrely because of this group. Thank you all. If you’re aending the MPOG retreat, please stop

by and say hello.

Brandon Togioka (OHSU): It’s the Friday before ASA — October 16th. Please stop by.

Megan Charee (MPOG) [chat]: 10/16

Brandon Togioka (OHSU): We’ll have a secon highlighng the work this group has been doing. Have a great day,

everyone — see you next me.

Kate Buehler (MPOG): Thank you!