Obstetric Anesthesia

Subcommittee Meeting

September 16, 2026

Agenda

Announcements

June Meeting Recap

Measure Review: ABX-01-OB (Antibiotic Timing for Cesarean Delivery)

Measure Review: BP-04-OB (Hypotension after Neuraxial for CD)

New Measure Discussion: PONV-06-OB (PONV Prophylaxis for CD)

Announcements

2027 Meeting Dates:

–

February 3, 2027, 1-2pm EST

–

June 2, 2027, 1-2pm EST

–

September 15, 2027 1-2pm EST

OB Subcommittee is open to anyone interested.

–

Contact Kate (kjbucrek@med.umich.edu) to be added to invites.

Quantitative Blood Loss (QBL)

•

Situation

o Historically, QBL variable(s) were not included in the data sites uploaded to MPOG. Therefore,

MPOG did not have a concept to capture this data.

•

Background:

o QBL is an objective measure (weighing, measuring, accounting for amniotic fluid/irrigation)

o EBL tends to underestimate blood loss during significant hemorrhage

o QBL provides an earlier, more objective, warning of significant hemorrhage

o Supported by ACOG (#794), AWHONN (#13), and the Alliance for Innovation on Maternal Health

(AIM) Obstetric Hemorrhage Patient Safety Bundle, for which SOAP provided formal feedback

•

Assessment

o Many institutions have transitioned to measuring QBL, which some would say is best practice

Recommendation

o MPOG created 2 new QBL concepts and are asking sites to check for this variable in their MPOG

data and map to the new concept(s).

Obstetric Concepts Available for Variable Mapping!

Quantitative Blood Loss (QBL) Concepts:

Dural Puncture Epidural (DPE) Concept:

Post Dural Puncture Headache (PDPH) Concept:

General Anesthesia Definition Update

•

OB Subcommittee voted in September 2025 to update the GA definition for cesarean

delivery to no longer consider cases with only nitrous oxide administration as general

anesthesia.

•

The Coordinating Center has been working to update the underlying phenotypes to

reflect this change in the general anesthesia for cesarean delivery measures (GA01,

GA-02, GA-03).

•

This change was released to production earlier this month and will soon be reflected in

measure performance scores. Score changes may be significant for some sites – please

reach out to Kate with any questions.

•

12 underlying phenotypes, including Obstetric Anesthesia Type, required revisions to

accommodate updates to the Anesthesia Technique: General phenotype as requested

by the Pediatric and Obstetric Subcommittees.

•

Thanks for your patience!

June Meeting Recap

•

Subcommittee requested updates to the NCR-01-OB (Neuraxial Catheter Replacement)

measure to separate neuraxial replacement during labor from placement of a second

neuraxial block to facilitate cesarean delivery.

•

UDP-01-OB (Unintended Dural Puncture): Subcommittee voted to incorporate sphenopalatine

ganglion (SPG) blocks, caffeine, and Fioricet as additional proxies for identifying potential UDP

events. Group requested the UDP-01-OB measure specification explicitly note that post-dural

puncture headache (PDPH) is being used as a surrogate indicator of potential UDP.

•

2026 priorities outlined as follows:

–

Advance UDP-01-OB measure

–

Revise NCR-01 to limit to replacement labor epidural only

–

Create new NCR-02 measure to assess neuraxial replacement for cesarean delivery

–

Develop pregnancy gestational age phenotype

–

Develop IONV/PONV prophylaxis measure for cesarean delivery

–

Incorporate brief obstetric research presentations into OB Subcommittee agendas

NCR-01-OB Updated!

• New Description/Title: Neuraxial Catheter Replacement for Labor Analgesia

• Denominator Limited to Labor Analgesia: Obstetric Anesthesia Type Value Codes = 1 (Conversion labor

epidural to cesarean delivery), 3 (labor epidural), and 6 (labor epidural portion of conversion).

o For Labor Epidural cases (3), exclude cases when the first neuraxial procedure note occurs after

Patient in Room

o For Conversion Cases (1 & 6), count only replacements that occur before the decision to convert to

cesarean delivery.

• New exclusion: Cases with "No Neuraxial Concepts Found" are now excluded.

• Technique codes expanded: Now assess any case with any neuraxial procedure initially performed

(Anesthesia Technique: Neuraxial) value codes: 1–6 (previously only included 1, 2, 4, and 6).

• Other Measure Logic Details: If one or more Neuraxial Procedure Note Concept(s) is documented after

the first, assess the value of the subsequent note(s). If subsequent note indicates spinal, will pass the

case.

UDP-01-OB: Unintended Dural Puncture Measure Released!

•

Based on June subcommittee meeting feedback, the following surrogates for UDP

were added to the measure:

– Acetaminophen/Butalbital/Caffeine 325/50/60 – Concept ID:10009

– Caffeine/Sodium benzoate - Concept ID: 10091

– Butalbital/acetaminophen (Fioricet) – Concept ID: 10766

– Sphenopalatine Ganglion (SPG) Block - CPT: 64505, associated with the case or a subsequent case

within 14 days after initial procedure

•

Postdural Puncture Headache (PDPH) also included as a surrogate for UDP:

– O74.5 Spinal and epidural anesthesia-induced headache during labor and delivery

– O89.4 Spinal and epidural anesthesia-induced headache during the puerperium

– Postdural Puncture Headache (MPOG Concept ID: 90223)

•

All surrogates are listed in the measure specification.

•

Site OB and QI Champions will soon be able to view departmental results within the QI

Reporting Tool (dashboard) – will post to the forum once available.

ABX-01-OB Measure Review

Brandon Togioka, MD – OHSU

First Published 7/14/2020

Last Reviewed 5/24/2023

ABX-01 Rationale

•

Endometritis and SSI are common after CD

•

Timely prophylactic antibiotic administration are associated with reductions in

•

Historically Antibiotics were administered at time of umbilical cord clamp

o Administration prior to incision decreases maternal morbidity without compromising fetal

outcomes

•

Prophylactic antibiotic administration is supported by ACOG and AAP

Fever EndometritisUTI SSI

Serious infection (pelvic abscess, sepsis, necrotizing fasciitis)

ABX-01 Measure Summary

•

Percentage of CD with documentation of antibiotic administration initiated

within one hour (2 hours for vancomycin) before surgery start

•

Inclusion Criteria: CD and C-Hyst cases

•

Exclusion Criteria:

o Non-obstetric cases

o Neuraxial labor analgesia that does not progress to CD

o Patients on scheduled antibiotics for documented infection

•

Measurement Time Period

o Non-emergent: 60 min prior to surgical incision -> Surgical incision

o Emergent: 60 min prior to surgical incision -> Anesthesia End

•

Available for Provider Feedback: Yes

•

ASA MOCA Measure: Yes

•

Threshold for Success: 90%

ABX-01-OB Current Performance

Description: Cesarean delivery cases with antibiotic administration within one hour before

surgical incision

Average collaborative-wide performance: 92%

Range: 0-100%

Median: 95%

ABX-01 Review

•

Appropriateness of Rationale

o It is clinically relevant, recommend keeping it

•

Evaluation of Inclusion/Exclusion Criteria

o It is appropriate to include CD + C-Hyst

o It is appropriate to exclude patients on prior antibiotics

o No changes recommended

•

Evaluation of definition of success or flagged cases

o Classen NEJM 1992: Prophylactic antibiotics are associated

reduced infection compared to administration after incision

o It is appropriate to require administration 1 hour before incision

(2 hr for vancomycin)

o It is appropriate to be more lenient for emergent cases, push

measurement time period back to anesthesia end

o No changes recommended

ABX-01: Cefazolin prophylaxis in obese pregnant patients

Obesity is highly prevalent

on the labor floor

Stitely M. Surg Infect 2013

Maggio L. Obstet Gyn 2015

Young OM Am J Obstet Gyn 2015

Kram JJF Obstet Gynecol Rep Biol 2017.

•

All found MIC appropriately reached

with 2 g dose

•

Redosing may be required in the

setting of obesity with surgical

duration exceeding 2 hours

Recommended MIC > 2 mg/l

for S. aureus and MIC > 4 mg/l

for E. coli.

Insufficient evidence to

support requiring a 3 g dose for

higher weight patients

ABX-01: Cefazolin prophylaxis in obese pregnant patients

ACOG Practice Bulletin 199

-Clindamycin +AG is

reasonable alternative for

women with a history of

significant cephalosporin

allergy

Kawakita T Obstet Gyn 2019

•

Retrospective study of 6,584 women undergoing CD

•

-Primary Outcome: Cellulitis, endometritis, deep

wound infection, abscess, or sepsis

•

Compared to cefazolin:

Clindamycin alone is associated with increased odds (OR

4.4) of primary outcome

Clinda+Gent not associated with increased odd of primary

outcome

Recommended requiring an aminoglycoside

when clindamycin is administered

American Society of Health-

System Pharmacists (ASHP)

-For patients with Beta-lactam

allergies, an alternative

regimen is clindamycin plus

gentamicin.

ABX-01-OB Measure Review – OB Subcommittee Vote

1 vote/ site

Continue as is/ modify/ retire

Need > 50% to retire measure

Coordinating center will review all votes

after meeting to ensure no duplication

BP-04-OB Measure Review

Dr. Teshi Kaushik, MD – University of Alabama

BP-04 Measure Review

September 2026

Teshi Kaushik, MBBS

Assistant Professor

Department of Anesthesiology and Perioperative Medicine

The /university of Alabama at Birmingham

Current measure – success criteria

SBP <90 mmHg for less than or equal to 5 minutes from Neuraxial

placement to Delivery

Introduction

Proposed – success criteria

SBP<100mmhg

for less than or equal to minutes between neuraxial placement and

delivery

Decline in BP post neuraxial closely

related to intraoperative

nausea/vomiting and neonatal

acidemia.

Introduction

Literature Review

Meta analysis/systematic reviews

targeting optimal management of

maternal hypotension defining maternal

hypotension as SBP<100.

Literature Review Maternal and fetal outcomes

Hypotension

definition

Primary outcomeNumber of patientsStudy DesignStudy

SBP<20% baseline or

SBP<100mmHg

Sustained hypotension after

neuraxial independently

associated with neonatal

acidosis

332Retrospective cohort

Scheduled cesarean birth under

spinal for healthy parturient and

healthy fetus

Kazzi et al. 2024

In both study groups

SBP>100 mmHg

Tighter BP control

reduced intraoperative

nausea and vomiting

and incidence of

maternal hypotension

and reduced neonatal

acidemia

1183Multicenter randomized

controlled trial – cesarean birth

under neuraxial anesthesia for

healthy parturient and healthy

fetus.

Chen et al. 2026

Kazzi NG, Chen HY, Lee L, Nazeer SA, Brown K, Sibai BM, Chauhan SP. Spinal Hypotension and Time from Spinal-to-Delivery in Scheduled Cesarean Deliveries: Association with Neonatal Acidosis. Am J

Perinatol. 2024 May;41(S 01):e3091-e3098. doi: 10.1055/a-2196-6660. Epub 2023 Oct 23. PMID: 37871639.

Literature Review Optimal management of

hypotension

Hypotension

definition

Primary outcomeNumber of patientsStudy DesignStudy

SBP<100mmHgNE superior vasopressor for

Preeclamptic

Sample size for studies ranging

from 30-166.

Systematic review 6 RCTs

Preeclamptic patients

undergoing cesarean birth

Gunawan et

al.2025

Gunawan MFB, Soetomo CT, Richard R, Darmayasa PB, Suastika AV. Dissecting Vasopressor Efficacy in the Management of Maternal Hypotension in Preeclamptic Cesarean Delivery: A

Systematic Review of Randomized Controlled Trials. Matern Fetal Med. 2025 Oct;7(4):234-243. doi: 10.1097/FM9.0000000000000314. Epub 2025 Sep 22. PMID: 41158424; PMCID:

PMC12558338..

Garg, H., Narayanan M R., V., Khanna, P., & Yalla, B. (2024). Comparison of Phenylephrine Bolus and Infusion Regimens on Maternal and Fetal Outcomes During Cesarean Delivery:

A Systematic Review and Meta-Analysis. Anesthesia & Analgesia, 139(6), 1144–1155. https://doi.org/10.1213/ANE.0000000000007156.

Literature Review Optimal management of

hypotension

Hypotension definitionPrimary outcomeNumber of patientsStudy DesignStudy

Maternal systolic blood

pressure below 70% to

80% of baseline

recordings, an absolute

value of less than 90

mmHg to 100 mmHg, or

both

Hypotension

management review

9469

Cochrane review from

2020. Included 125

studies.

Cochrane review

SBP<80% or <100mmHg

SAP

Consensus Statement

Collaborators.

International

consensus statement

on the management of

hypotension with

vasopressors during

caesarean section

under spinal

anaesthesia

Kinsella et al.

in 2018

Literature Review Optimal management of

hypotension

Hypotension definitionPrimary outcomeNumber of patientsStudy DesignStudy

The study used a hypotension index

incorporating SBP <80% of baseline or

MAP <80 mmHg over time or

SBP<100

Sustained hypotension

associated with Neonatal

acidosis.

3150Retrospective cohort analysis of

elective cesarean delivery

Knigin et al. 2020

Study limitations and clinical Interpretation

EVIDENCE-TO-DECISION PATHWAY

1 2 2 3

Effect on APGAR

score

remain uncertain

APGAR outcomes were

either not evaluated or no

association was identified.

Evidence on

patients with

maternal or fetal

diseases not there;

data or urgent

/emergent c section

is limited

Most studies included healthy

parturient and healthy

fetuses; only one included

preeclampsia

Clinical

uncertainty

requires caution

Risk may be greater in

patients with compromised

maternal or fetal physiology.

CLINICAL IMPLICATION

Even in healthy dyads, allowing SBP to fall below 100mmHg for prolong duration may be associated with:

Neonatal acidemia Severe maternal hypotension Intraoperative nausea and vomiting

Proposed action: revise the criterion toward a more clinically protective

blood pressure target of SBP>100mmHg.

SCHOOL OF MEDICINE

BP-04 review - Discussion

• What definition best

balances clinical validity

with reliable automated

measurement?

Proposed success criteria - SBP<100mmhg

for <=5 minutes between neuraxial

placement and neonate delivery

BP-04-OB Measure Review – OB Subcommittee Vote

1 vote/ site

Continue as is/ modify/ retire

Need > 50% to retire measure

Coordinating center will review all votes

after meeting to ensure no duplication

References

• Gunawan MFB, Soetomo CT, Richard R, Darmayasa PB, Suastika AV. Dissecting Vasopressor Efficacy in the Management of

Maternal Hypotension in Preeclamptic Cesarean Delivery: A Systematic Review of Randomized Controlled Trials. Matern Fetal

Med. 2025 Oct;7(4):234-243. doi :10.1097/FM9.0000000000000314. Epub 2025 Sep 22. PMID: 41158424; PMCID:

PMC12558338.

• Kazzi NG, Chen HY, Lee L, Nazeer SA, Brown K, Sibai BM, Chauhan SP. Spinal Hypotension and Time from Spinal-to-Delivery in

Scheduled Cesarean Deliveries: Association with Neonatal Acidosis. Am J Perinatol. 2024 May;41(S 01):e3091-e3098. doi:

10.1055/a-2196-6660. Epub 2023 Oct 23. PMID: 37871639.

• Chen Y, Wang M, Yang Z, Ta Z, Liu Y, Kong H, Li H, Song Y, Shi Y, Qin R, Zhou X, Ma S, Ni X. Effect on neonatal outcomes of

maintenance of maternal blood pressure targets with noradrenaline after spinal anaesthesia for caesarean delivery: a multicentre,

randomised, controlled trial. Anaesthesia. 2026 Jul;81(7):952-958. doi: 10.1111/anae.70179. Epub 2026 Feb 26. PMID: 41744137.

• Knigin D, Avidan A, Weiniger CF. The effect of spinal hypotension and anesthesia-to-delivery time interval on neonatal outcomes

in planned cesarean delivery. Am J Obstet Gynecol. 2020 Nov;223(5):747.e1-747.e13. doi: 10.1016/j.ajog.2020.08.005. Epub

2020 Aug 11. PMID: 32791121.

• Chooi C, Cox JJ, Lumb RS, Middleton P, Chemali M, Emmett RS, Simmons SW, Cyna AM. Techniques for preventing

hypotension during spinal anaesthesia for caesarean section. Cochrane Database of Systematic Reviews 2020, Issue 7. Art. No.:

CD002251. DOI: 10.1002/14651858.CD002251.pub4. Accessed 04 September 2026.

• Kinsella SM, Carvalho B, Dyer RA, Fernando R, McDonnell N, Mercier FJ, Palanisamy A, Sia ATH, Van de Velde M, Vercueil A;

Consensus Statement Collaborators. International consensus statement on the management of hypotension with vasopressors

during caesarean section under spinal anaesthesia. Anaesthesia. 2018 Jan;73(1):71-92. doi: 10.1111/anae.14080. Epub 2017 Nov

1. PMID: 29090733.

•

Kazzi et al. 2024

• Study design - Retrospective cohort (n=332 scheduled cesareans, 99.4% receiving prophylactic

vasopressors).

• Patient population - Singleton, term, non anomalous pregnancies, with scheduled CD under spinal

anesthesia.

• Aim - Study the effect of sustained hypotension after spinal on neonatal acidosis and adverse outcomes

in those undergoing scheduled cesarean delivery (CD) with universal prophylactic vasopressor exposure

and to examine differences in spinal-to-delivery time by neonatal acidosis status.

• Outcome - Sustained hypotension after spinal (occurring in 12.3%) was independently associated with

neonatal acidosis .

• Hypotension was defined as SBP<20% of baseline or SBP<100mmHg. Built a hypotension index

from magnitude and duration, using the 90th percentile (for SYS-BP20) and 95th percentile (for SYS-

BP100) to define sustained hypotension.

Kazzi NG, Chen HY, Lee L, Nazeer SA, Brown K, Sibai BM, Chauhan SP. Spinal Hypotension and Time from Spinal-to-Delivery in Scheduled Cesarean Deliveries: Association with Neonatal Acidosis. Am J

Perinatol. 2024 May;41(S 01):e3091-e3098. doi: 10.1055/a-2196-6660. Epub 2023 Oct 23. PMID: 37871639.

Multicenter randomized controlled trial • n = 1,183, using NE boluses.

Target SBP ≥90% of

baseline

Vs.

Target SBP ≥80% of

baseline

• Umbilical artery pH <7.2:

0.5% vs 2.2% (P=0.020).

• Maternal hypotension

(<80% baseline): 36.1%

vs 70.5%.

• Severe hypotension

(<60% baseline): 3.9%

vs 7.8% (P=0.006).

• Nausea/vomiting: 9.8%

vs 18.4% (P<0.001).

• No difference in Apgar

scores.

Interpretation

Tighter BP control (within 90%

of baseline) improved

maternal hemodynamics and

reduced neonatal acidemia.

Chen et al. 2026

Gunawan et al. 2025

• Study Design : Systematic review of 6 RCTs

• Patient population : Preeclamptic patients undergoing cesarean birth with neuraxial anesthesia.

• Study Aim : assess vasopressor strategy to prevent maternal hypotension.

• Result : Intermittent bolus administration of norepinephrine offers superior maternal cardiac output and

neonatal safety, making it optimal for preeclamptic cesarean deliveries. Phenylephrine is effective for

blood pressure control but may induce bradycardia, while the use of ephedrine is limited by its

association with neonatal acidosis

• Hypotension was defined as a decrease in systolic blood pressure of ≥ 20% from baseline or an

absolute systolic pressure < 100 mmHg.

Gunawan MFB, Soetomo CT, Richard R, Darmayasa PB, Suastika AV. Dissecting Vasopressor Efficacy in the Management of Maternal Hypotension in Preeclamptic Cesarean Delivery: A Systematic Review of

Randomized Controlled Trials. Matern Fetal Med. 2025 Oct;7(4):234-243. doi: 10.1097/FM9.0000000000000314. Epub 2025 Sep 22. PMID: 41158424; PMCID: PMC12558338..

BP-04-OB Current Performance

Description: Percentage of cesarean delivery cases with systolic blood pressure <90mmHg for

less than or equal to 5 cumulative minutes.

Average collaborative-wide performance: 97%

Range: 63-100%

Median: 98%

2027 Measure Review Schedule

ReviewerMeeting DateMeasure

Daniel Berenson, MD -

Brigham & Women’s

February 2027GA-01-OB: General anesthesia for

cesarean delivery

Daniel Berenson, MD -

Brigham & Women’s

February 2027GA-02-OB: General anesthesia after

neuraxial for cesarean delivery

Daniel Berenson, MD –

Brigham & Women’s

February 2027GA-03-OB: General anesthesia after

epidural for cesarean delivery

Johanna Cobb, MD -

Dartmouth

June 2027TEMP-05-OB: Hypothermia during

cesarean delivery

THANK YOU!

Kate Buehler, MS, RN

MPOG Clinical Program Manager

kjbucrek@med.umich.edu

Brandon Togioka, MD

MPOG Obstetric Anesthesia

Subcommittee Chair

togioka@ohsu.edu

Sharon Reale, MD

MPOG Obstetric Anesthesia

Subcommittee Vice Chair

screale@bwh.harvard.edu