Developed By: Committee on Obstetric Anesthesia
Original Approval: October 26, 2022
The Institute of Medicine has defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”1 While quality improvement has always been important to anesthesiologists, it has taken decades for quality metrics to be incorporated into clinical practice. Quality and safety have been at the forefront of medical care in the United States, especially following the Institute of Medicine’s landmark publication, “To Err is Human.” This report highlighted an estimated 100,000 deaths that were attributable to medical error. Of note, the report singled out anesthesiology as the most successful specialty at leading improvements in patient safety and outcomes.2
Anesthesiologists initially focused their quality improvements on mortality reduction.3 As we expanded our focus into perioperative care, the specialty recognized broader measures were needed. The Institute of Medicine outlined six domains of quality to be safety, effectiveness, patient centricity, timeliness, efficiency, and equitability. (Figure 1) These domains should be the framework for measuring our specialty’s overall performance.1 Anesthesiologists as perioperative physicians have been empowered to take more ownership and engagement in perioperative outcomes.
These principles also apply and hold true for obstetric anesthesia care. Anesthesiologists are integral to the safe provision of modern obstetric care, delivery of anesthesia, and perioperative services on labor and delivery. As such, broader quality metrics to guide overall performance are needed. Using the Institute of Medicine’s six domains of quality to develop quality metrics will contribute to an elevation of the quality being provided and hopefully redefine the current quality of clinical care provided.
The following recommendations were developed following input from a broad group of obstetric anesthesiologists and approved by the ASA Committee on Obstetric Anesthesia. These suggested quality metrics were selected to highlight various areas for potential improvement, and to assist in improving the quality of care provided, but this is not a complete list.
This statement outlines six areas for quality improvement based on relevant and quantifiable metrics to measure obstetric anesthesia care.
- Mode of Anesthesia for Cesarean Delivery
- Neuraxial-Induced Hypotension during Cesarean Delivery
- Post Cesarean Opioid Consumption
- Responsiveness to the Request for Labor Analgesia
- Post Dural Puncture Headache Accountability
- Labor Epidural Replacements
These measures reflect the perioperative and peripartum continuum of care being provided by anesthesiologists on labor and delivery (L&D). These suggested metrics are intended to help guide anesthesiologists in various types of practices, varying locations, and varying ACOG Levels of Maternal Care in the development of meaningful clinical improvements for their local environments. The measure should not be viewed as a comprehensive list, rather a starting point for quality metrics to assess obstetric anesthesia care. The following six tables were created to help frame, outline, and explain each of these measures.
Table 1. Mode of Anesthesia for Cesarean Delivery
||There is no national consensus on what an ideal rate of general anesthesia in the obstetric setting should be. Furthermore, there is not widespread reporting of the use of systemic anesthetic adjunct medication. Institutions that report a low rate of general anesthesia for cesarean delivery may have a high unreported use of systemic analgesic/anesthetic adjunct medications such as intravenous ketamine or inhaled nitrous oxide.
|| The Society for Obstetric Anesthesia and Perinatology’s Serious Complication Repository Project study found a pooled general anesthesia rate of 5.6%, while investigators from Brigham and Women’s reported a rate of less than 1%, and investigators from the University of Pennsylvania reported a rate of 12%.4-6 None of these three studies commented on the use of systemic anesthetic adjunct medication administration. Clevenger reported a rate of general anesthesia of 5.6% and 17.8% of those who had regional anesthesia had at least one systemic analgesic/anesthetic adjunct medication administered.7
A high rate of systemic analgesic/anesthetic adjunct medication administration may suggest that general anesthesia is not used when indicated. A high rate of general anesthesia may reflect a high-risk obstetric patient population, low use of neuraxial analgesia, inadequate neuraxial anesthesia, failure to replace inadequately functioning labor epidurals, and/or obstetric/nursing/anesthesiologist communication failures.
|| General anesthesia for cesarean delivery should be avoided when possible but also initiated when indicated.
Percentage of patients who receive general anesthesia for cesarean delivery
Percentage of patients who receive systemic analgesic/anesthetic adjunct for cesarean delivery performed under neuraxial anesthesia
- Potential for more detailed measurements by: Type, route, and incidence of analgesic/anesthetic adjunct medications
Consider stratification of general anesthesia by scheduled cesarean deliveries, unscheduled cesarean deliveries, and cesarean deliveries with the indication and National Institute of Child Health and Human Development, NICHD, fetal tracing categorization.
Consider making this metric a “process” metric and not an “outcome” metric since each institution will have a wide variation of obstetric practice, patient preferences and anesthetic techniques depending on patient population
Table 2. Neuraxial-Induced Hypotension during Cesarean Delivery
||Neuraxial-induced hypotension during cesarean delivery is common and has potential maternal and fetal adverse effects. Variability exists in the prevention and treatment strategies for spinal-induced hypotension in clinical practice.
||Neuraxial anesthesia is the most common anesthetic modality utilized for cesarean delivery in the United States. Spinal and combined-spinal epidural techniques are often selected for their rapid and reliable blockade, potential for avoidance of general anesthesia, and ability to keep the mother awake to experience the birth among other advantages. Despite these benefits, administration of spinal anesthesia to the parturient for cesarean delivery is commonly associated with maternal hypotension secondary to sympathetic blockade, acute decreases in systemic vascular resistance and propensity for aortocaval compression.8,9 The incidence in the literature varies but the overall incidence is high (up to 74.1%) with the potential for maternal and fetal impact requiring prompt recognition and treatment.8
||After the initiation of spinal anesthesia and until delivery, maternal blood pressure should be assessed more frequently than the minimum ASA standard (continual, at least every 5 minutes).10 (e.g. frequency of every 1-2 minutes is suggested.)
Maternal heart rate should be assessed before the initiation of neuraxial (spinal or epidural) anesthesia and continuously monitored, as per ASA Standards for Basic Anesthetic Monitoring.10
It is recommended to have a goal to maintain systolic blood pressure ideally within 10% of the patient’s baseline blood pressure following initiation of spinal anesthesia until delivery.
It is strongly recommended to administer prophylactic support of maternal blood pressure with intravenous infusion of a vasopressor, specifically phenylephrine or norepinephrine, unless contraindicated to address the primary cause of spinal hypotension (i.e. systemic vascular resistance reduction).
Intravenous crystalloid or colloid ‘co-load’ (simultaneous administration during spinal anesthesia) is a recommended additional strategy.
There is no need to delay spinal anesthesia for ‘pre-loading’ intravenous fluid administration.
Left lateral uterine displacement until delivery is also recommended.11
Administration of vasopressor and cardiovascular medications should be individualized in the patient with maternal cardiac disease as each pathology warrants a unique optimization of chronotropy, inotropy, and vasoconstriction.
||Percentage of patients with blood pressure monitored more frequently than every 5 min (optimally at least every 1-2 minutes from initiation of neuraxial anesthesia to fetal delivery).
Percentage of cases where vasopressor infusion(s) are used to maintain maternal systolic blood pressure maintained within ≥ 90% until delivery of fetus
Table 3. Post Cesarean Opioid Consumption
||Reducing in-hospital opioid use and the amount of opioid prescribed after discharge following childbirth is recommended by the Society for Obstetric Anesthesia and Perinatology (SOAP), the American College of Obstetricians and Gynecologists (ACOG) and the Academy of Breastfeeding Medicine (ABM) for both optimal maternal and breastfeeding neonatal care.12-14 Although national societies strongly promote opioid-reducing strategies, institutions are not mandated to report their opioid use after childbirth, and there is no national data to facilitate between institution comparisons. High opioid use after childbirth may indicate inadequate multimodal pain management as well as insufficient education of both providers and patients as regards to optimal opioid prescribing practices.
||Opioid overdose deaths and opioid use disorder have reached epidemic proportions in the United States. Approximately 2% of women are using opioids three months after delivery, and 1:300 opioid naïve women exposed to opioids after childbirth become chronic users.15,16 The incidence of persistent opioid use is correlated to excessive opioid prescribing.16 Reducing in-hospital opioid use and instituting appropriate opioid prescribing practices after both vaginal and cesarean delivery is essential.
The use of multimodal analgesia, and patient-centered opioid prescribing techniques can vastly reduce the amount of opioid used in-hospital and after discharge.17-20
Additionally, pre-surgical patient engagement and education has been shown to be helpful in reducing post-operative opioid useage.21
||Multimodal analgesia should include neuraxial long-acting opioids (e.g. morphine, hydromorphone), scheduled NSAIDs and scheduled acetaminophen. Local anesthetic techniques (e.g. wound infiltration or fascial plane blocks) should be considered when a long-acting neuraxial opioid is not administered. The multimodal approach significantly reduces pain and opioid requirement for breakthrough pain.12,20
All post-cesarean deliveries should receive scheduled multimodal pain management and the amount of opioids prescribed for breakthrough pain both in-hospital and after delivery should meet and not exceed the patient’s needs.
||Percentage of in-hospital patients who receive opioids after cesarean delivery after PACU discharge
Percentage of post cesarean patients who receive IV opioids after PACU discharge
Total dose (milligram morphine equivalents) and average use per day of opioids administered during hospital stay after cesarean delivery after PACU discharge
Total dose (milligram morphine equivalents) of opioid tablets prescribed on discharge after childbirth
Percentage of hospitalized post-cesarean women receiving a form of multimodal analgesia, as recommended in best practices
Percentage of women receiving educational material related to analgesic and opioid administration before surgery and/or at discharge
Table 4. Responsiveness to the Request for Labor Analgesia
||Patient-centered care is essential to high quality obstetric anesthesia care. A pregnant woman’s satisfaction with her overall birth experience and labor analgesia has been shown to be multifactorial22-24. In fact, for women receiving nitrous oxide analgesia, the quality of pain relief was found to not correlate closely with maternal satisfaction25. Among women who receive neuraxial analgesia, delays in initiation of neuraxial analgesia after maternal request for pain relief have been associated with patient dissatisfaction.23,24,26
||Data regarding response time to neuraxial labor analgesia request are limited. In the Listening to Mothers II Survey, an evaluation of women’s open-ended responses regarding their experiences with neuraxial analgesia found that timing of the analgesia was a common topic associated with a negative experience. Delays in receiving pain relief, usually due to either anesthesiologist unavailability or miscommunication with care providers, was the most common factor leading to a woman’s negative experience related to analgesia timing.23 A recent retrospective observational study reported that a delay in epidural placement >15 minutes after patient request was strongly associated with maternal dissatisfaction with anesthesia care.26
||The ASA/SOAP Practice Guidelines for Obstetric Anesthesia do not provide recommendations for reasonable response times for epidural labor analgesia requests. The Royal College of Anaesthetists (RCoA), recommend that anesthesiologists attempt to respond within 30 minutes of maternal request for neuraxial analgesia.
The response time should only be longer under “exceptional circumstances” and should ideally be within one hour for all patients, per RCoA recommendations27.
Each institution should assess the anesthesiology needs and resources for both the labor and delivery unit and the main operating room suite when determining what should be an acceptable response time for a woman’s request for neuraxial labor analgesia.
Women should be made aware of what the institution considers a reasonable response time upon admission or earlier during their prenatal care or childbirth classes.
||Time from patient request for neuraxial analgesia to arrival of anesthesiologist or other anesthesia care team member
Percentage of patients requesting neuraxial analgesia who experienced a delay in placement beyond the institution-determined reasonable response time
Percentage of eligible patients requesting neuraxial analgesia but did not receive it
Reasons for delays in receiving neuraxial labor analgesia
Table 5. Post Dural Puncture Headache Accountability
||Neuraxial analgesia/anesthesia is an effective means of providing pain control in the obstetric population. Unintentional dural puncture (UDP) is a serious complication of this procedure, and could lead to a postdural puncture headache (PDPH).28,29
The ASA Closed Claims Project database notes that 14% of obstetric malpractice claims are related to headache and therefore a common area of litigation in obstetric anesthesia practice.30 A systematic process of identifying and documenting UDP/PDPH as well as treatment and follow-up may lead to reducing the incidence of long-term sequelae
||UDP rates in the obstetric population range from 0.4-6%. Of those with UDP, 50-60% may develop a PDPH. Recent studies have suggested that there is an increased risk of postpartum depression, post-traumatic stress disorder, chronic headache, back pain, subdural hematoma, cerebral vein thrombosis and decreased rate of breastfeeding in parturients who have a PDPH.29,31,32
||Whenever possible, the use of small gauge (e.g. 25G or smaller) pencil point style spinal needle is strongly recommended.
For patients receiving neuraxial analgesia/anesthesia, a post procedure visit should occur within 24-48 hours of delivery.
Visits should include documentation of UDP/PDPH and, if present, a treatment plan outlined. Plan for conservative management versus an epidural blood patch (EBP) is required, and communication with the primary care team is important.
Written discharge instructions including contact persons/details for questions and emergent situations should be provided by the anesthesia care team.
Daily follow up with documentation by the anesthesia team should occur until symptoms resolve or discharge. If symptoms are not resolved at discharge, additional out-patient follow-up should be performed.
If discharged and needing an EBP, these may be performed in the location that meets capability and timeliness e.g. the obstetric unit, emergency department or radiology, or outpatient center.
Optimally, outpatient PDPH should be evaluated and treated on the obstetric unit and not in the emergency department33
Quality metrics including rate of UDP, PDPH and EBP should be maintained as well as documentation of an institutional protocol for management of these patients.32, 34
||UDP rate of epidurals for labor or cesarean
PDPH rate and the procedure performed: spinal, CSE, DPE, LEP
Rate of PDPH patients that received an Epidural Blood Patch
Response time from patient presentation to PDPH evaluation by anesthesiologist
Gauge and type of spinal needle used for spinal, CSE, DPE
Table 6. Labor Epidural Replacements
||There is no universal consensus regarding how to define inadequate labor analgesia. Proposed definitions include: inability to achieve adequate analgesia within a pre-defined period of time from commencing placement, requirement for re-siting or abandoning the procedure and/or maternal dissatisfaction with analgesia.35
||Inadequate analgesia in the obstetric patient can be due to the use of lower concentrations of local anesthetics to optimize delivery outcomes, anatomical differences in pregnant patients, and effects of fetal positioning on quality of analgesia achieved.36, 37
The RCoA have recommended a 30–60-minute window to ascertain the efficacy of a labor epidural.27
Replacing a labor epidural that does not provide adequate analgesia is an important quality metric since a dysfunctional epidural catheter is associated with higher pain scores, lower maternal satisfaction, and greater use of general anesthesia for cesarean delivery.
As labor is a dynamic process, routine and regular assessment of labor epidural analgesia should be undertaken.
Routine assessment not only optimizes labor analgesia, it also helps to identify labor epidurals that will likely fail to convert to surgical anesthesia if a cesarean delivery is required.
||The adequacy of labor epidural analgesia should ideally be assessed every 2-4 hours or more frequently if indicated.
When indicated, evaluation should also include the degree of motor function, examination of the epidural catheter site, and sensory distribution of blockade.
A standardized approach for management of the laboring patient with inadequate analgesia is recommended.
||Time from epidural placement to achieving adequate analgesia
Frequency of assessment for adequate analgesia during labor
Proportion of labor epidurals that require re-siting during labor
Percentage of labor epidurals that attempted conversion to surgical anesthesia and failed
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- Institute of Medicine Committee on Quality of Health Care in A. In: Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. National Academies Press (US) Copyright 2000 by the National Academy of Sciences. All rights reserved.; 2000.
- Beecher HK, Todd DP. A study of deaths associated with anesthesia and surgery. 1954. Int Anesthesiol Clin. Fall 2007;45(4):1-6. doi:10.1097/AIA.0b013e3181559221
- D'Angelo R, Smiley RM, Riley ET, Segal S. Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. Anesthesiology. Jun 2014;120(6):1505-12. doi:10.1097/aln.0000000000000253
- Palanisamy A, Mitani AA, Tsen LC. General anesthesia for cesarean delivery at a tertiary care hospital from 2000 to 2005: a retrospective analysis and 10-year update. Int J Obstet Anesth. Jan 2011;20(1):10-6. doi:10.1016/j.ijoa.2010.07.002
- Cobb BT, Lane-Fall MB, Month RC, Onuoha OC, Srinivas SK, Neuman MD. Anesthesiologist Specialization and Use of General Anesthesia for Cesarean Delivery. Anesthesiology. Feb 2019;130(2):237-246. doi:10.1097/aln.0000000000002534
- Clevenger K, Maresh B, Graham H, Hammonds K, Hofkamp MP. The use of adjunct anesthetic medication with regional anesthesia and rates of general anesthesia for 1867 cesarean deliveries from 2014 to 2018 in a community hospital. Proc (Bayl Univ Med Cent). Jul 22 2020;33(4):536-540. doi:10.1080/08998280.2020.1790277
- Klöhr S, Roth R, Hofmann T, Rossaint R, Heesen M. Definitions of hypotension after spinal anaesthesia for caesarean section: literature search and application to parturients. Acta Anaesthesiol Scand. Sep 2010;54(8):909-21. doi:10.1111/j.1399-6576.2010.02239.x
- Kinsella SM, Carvalho B, Dyer RA, et al. International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia. Anaesthesia. Jan 2018;73(1):71-92. doi:10.1111/anae.14080
- (CSPP) CoSaPP. Standards for Basic Anesthetic Monitoring. American Society of Anesthesiologists. Updated 2020. https://www.asahq.org/standards-and-guidelines/standards-for-basic-anesthetic-monitoring?&ct=ce1224a7dda3b837fd20cf7336f94eaafbed9affe9b6abf32c710ba2456cecaa78817a405b0b224d551c76ef873b572cef5992990c3cad1045df089a1fe80e78
- Crawford JS, Burton M, Davies P. Time and lateral tilt at Caesarean section. British journal of anaesthesia. May 1972;44(5):477-84. doi:10.1093/bja/44.5.477
- Bollag L, Lim G, Sultan P, et al. Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean. Anesth Analg. May 1 2021;132(5):1362-1377. doi:10.1213/ane.0000000000005257
- Martin E, Vickers B, Landau R, Reece-Stremtan S. ABM Clinical Protocol #28, Peripartum Analgesia and Anesthesia for the Breastfeeding Mother. Breastfeed Med. Apr 2018;13(3):164-171. doi:10.1089/bfm.2018.29087.ejm
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- Bateman BT, Franklin JM, Bykov K, et al. Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naïve women. Am J Obstet Gynecol. Sep 2016;215(3):353.e1-353.e18. doi:10.1016/j.ajog.2016.03.016
- Peahl AF, Dalton VK, Montgomery JR, Lai Y-L, Hu HM, Waljee JF. Rates of New Persistent Opioid Use After Vaginal or Cesarean Birth Among US Women. JAMA Network Open. 2019;2(7):e197863-e197863. doi:10.1001/jamanetworkopen.2019.7863
- Nanji JA, Guo N, Riley ET, Faulkner B, Do C, Carvalho B. Evaluation of Opioid Use With Split Doses of Oral Opioids in a Postcesarean Delivery Analgesia Order Set. Obstet Gynecol. Jul 2019;134(1):120-127. doi:10.1097/aog.0000000000003305
- Holland E, Bateman BT, Cole N, et al. Evaluation of a Quality Improvement Intervention That Eliminated Routine Use of Opioids After Cesarean Delivery. Obstet Gynecol. Jan 2019;133(1):91-97. doi:10.1097/aog.0000000000003010
- Osmundson SS, Raymond BL, Kook BT, et al. Individualized Compared With Standard Postdischarge Oxycodone Prescribing After Cesarean Birth: A Randomized Controlled Trial. Obstet Gynecol. Sep 2018;132(3):624-630. doi:10.1097/aog.0000000000002782
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