Frequency of adherence to obstetric anesthesia best practices for cesarean delivery: A multicenter retrospective cohort analysis

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BACKGROUND: Increasingly, protocols have been developed to optimize obstetric anesthesia care. However, there is a paucity of data on adherence to these guidelines. The primary aims of this study were to utilize the Multicenter Perioperative Outcomes Group (MPOG) database to estimate (1) the rate of adherence to best practice guidelines for cesarean delivery (CD) (2) the association of case- and hospital-level factors with adherence, and (3) the percentage of variability in adherence attributable to the patient-, case-, and hospital-level factors. METHODS: We performed a multicenter, observational cohort study utilizing the MPOG database to review all CDs in women aged 15-44. Best practices were defined based on societal guidelines and included timely antibiotic administration, post-spinal SBP maintenance >90 mmHg, general anesthesia (GA) avoidance, prevention of perioperative hypothermia, use of low-dose neuraxial morphine, post-spinal vasopressor infusions, and spinal needles ≥ 25-gauge. Covariates of interest included patient-, case-, and hospital-level factors. RESULTS: We analyzed 289,047 CD cases in the MPOG database from 2015-2022. The following adherence outcomes were observed: timely antibiotic administration, 86.2% (99%CI: 86-86.3%); post-spinal SBP maintenance, 96.7% (99%CI: 96.6-96.8%); avoidance of GA, 97.0% (99%CI: 96.9-97.0%); prevention of perioperative hypothermia, 56.7% (99%CI: 56.5-56.9%); use of low-dose neuraxial morphine, 74.2% (99%CI: 74.0-74.5%); use of post-spinal vasopressor infusion, 55.4% (99%CI: 55.1-55.8%); and use of ≥ 25-gauge needle for spinal anesthesia, 89.0% (99%CI: 88.6-89.4%). Poorer adherence correlated with factors at the patient- (ASA Physical Status ≥ 4), case- (evening or overnight CD), and institution-level (absence of obstetric fellowship or "Center of Excellence" status). CONCLUSIONS: Among our large cohort of CD cases, overall adherence to guideline-supported best practices was variable, with post-spinal vasopressor infusions being the lowest and avoidance of GA being the highest. Targeted interventions addressing these factors may improve quality and promote more optimal care.

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