Decreased incidence of headache after unintentional dural puncture in patients with cesarean delivery administered with postoperative epidural analgesia

Purpose  To investigate how subsequent placement of a catheter into the epidural space after unintentional dural puncture for postoperative analgesia for 36–72 h affected the incidence of post-dural puncture headache (PDPH). Methods  The records of 52 parturients who had had accidental dural puncture in cesarean delivery were reviewed. The parturients were assigned to two groups. Twenty-eight parturients were assigned to the study group, in whom an epidural catheter was inserted and was used for anesthesia and postoperative analgesia. Twenty-four parturients were assigned to the control group, in whom spinal anesthesia (n = 20) or general anesthesia (n = 4) was applied. For postoperative analgesia in patients with incision pain above visual analog scale (VAS) 3, 3 mg morphine in 15 ml saline was administered through the epidural catheter in the study group, while intramuscular meperidine or tramadol was administered in the control group. Once PDPH was observed, conservative treatment was tried first. If the headache persisted despite conservative treatment, an epidural blood patch was applied through the catheter or a reinserted epidural needle. Results  The study group demonstrated significant reduction of the incidence of PDPH and reduction in the indication for an epidural blood patch compared to the control group (7.1% vs 58% [P = 0.000] and 3.6% vs 37.5% [P = 0.002], respectively). Conclusion  Subsequent catheter placement into the epidural space after unintentional dural puncture in cesarean delivery and leaving the catheter for postoperative analgesia for 36–72 h may reduce the incidence of PDPH.     

Dural puncture epidural versus conventional epidural block for labor analgesia: a systematic review of randomized controlled trials

IntroductionDural puncture epidural (DPE) analgesia is a modification of conventional epidural analgesia that involves the intentional puncture of the dura with a spinal needle through the needle placed in the epidural space, without a medication being injected intrathecally. There have been contradictory findings regarding better analgesia and better block quality.MethodsA systematic literature search was done to identify randomized controlled trials (RCT) comparing DPE with epidural analgesia. The risk of bias was assessed with the Cochrane tool. Risk ratio and 95% confidence intervals were calculated.ResultsFive RCTs including 581 patients were identified. One RCT on caesarean section was excluded. Single studies suggested slightly better analgesia by finding a median time to achieve sufficient analgesia of two minutes less in the DPE group, a higher number of women having a pain score <10/100 at 20 min, a reduction in the number of epidural top-ups and better sacral spread. The studies did not show a difference between DPE and epidural analgesia for catheter replacement or manipulation rates, the incidence of intravascular placement or unilateral block.ConclusionThere is a lack of clear evidence on either the benefits or the risks of the DPE technique, such that a recommendation for or against its routine use is premature. Two of the three studies showing a beneficial effect of DPE came from the same institution and replication of the findings by other groups is warranted.     

A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour

BackgroundAfter accidental dural puncture in labour it is suggested that inserting an intrathecal catheter and converting to spinal analgesia reduces postdural puncture headache and epidural blood patch rates. This treatment has never been tested in a controlled manner.MethodsThirty-four hospitals were randomised to one of two protocols for managing accidental dural puncture during attempted labour epidural analgesia: repeating the epidural procedure or converting to spinal analgesia by inserting the epidural catheter intrathecally. Hospitals changed protocols at six-month intervals for two years.ResultsOne hundred and fifteen women were recruited but 18 were excluded from initial analysis because of practical complications which had the potential to affect the incidence of headache and blood patch rates. Of the remaining 97 women, 47 were assigned to the repeat epidural group and 50 to the spinal analgesia group. Conversion to spinal analgesia did not reduce the incidence of postdural puncture headache (spinal 72% vs. epidural 62%, P = 0.2) or blood patch (spinal 50% vs. epidural 55%, P = 0.6). Binary logistic analysis revealed the relative risk of headache increased with 16-gauge vs. 18-gauge epidural needles (RR = 2.21, 95% CI 1.4–2.6, P = 0.005); anaesthetist inexperience (RR = 1.02 per year difference in experience, 95% CI 1.001–1.05, P = 0.043), and spontaneous vaginal compared to caesarean delivery (RR = 1.58, 95% CI 1.14–1.79, P = 0.02). These same factors also increased the risk of a blood patch: 16-gauge vs. 18-gauge needles (RR = 2.92, 95% CI 1.37–3.87, P = 0.01), anaesthetist inexperience (RR = 1.06 per year difference in experience, 95% CI 1.02–1.09, P = 0.006), spontaneous vaginal versus caesarean delivery (RR = 2.22, 95% CI 1.47–2.63, P = 0.002). When all patients were included for analysis of complications, there was a significantly greater requirement for two or more additional attempts to establish neuraxial analgesia associated with repeating the epidural (41% vs. 12%, P = 0.0004) and a 9% risk of second dural puncture.ConclusionsConverting to spinal analgesia after accidental dural puncture did not reduce the incidence of headache or blood patch, but was associated with easier establishment of neuraxial analgesia for labour. The most significant factor increasing headache and blood patch rates was the use of a 16-gauge compared to an 18-gauge epidural needle.     

硬膜穿孔后硬膜外镇痛在分娩镇痛中的应用

目的探讨硬膜穿孔后硬膜外镇痛在分娩镇痛中应用的有效性和安全性。方法接受分娩镇痛的单胎足月初产妇180例,随机均分为自控硬膜外镇痛组(P组)、腰-硬联合镇痛组(S组)和硬膜穿孔复合硬膜外镇痛组(D组)。P组于硬膜外穿刺置管成功后,注入0.125%罗派卡因+0.4μg/ml舒芬太尼的混合药液5ml作为首量,继而已同一混合液行自控硬膜外镇痛,背景量7ml/h,单次2ml,时间锁定15min。S组在腰-硬联合操作成功后,在蛛网膜下腔注入舒芬太尼3μg,继而行自控硬膜外镇痛,配方同P组。D组在穿刺成功后(以发现脑脊液回流为准),作硬膜外置管,注入0.0625%罗派卡因+0.2μg/ml舒芬太尼10ml作为首量,继而已同一混合液行自控硬膜外镇痛,背景量14ml/h、单次4ml、时间锁定15min。于镇痛前(T0)、镇痛后1min(T1)、5min(T2)、10min(T3)、60min(T4)行VAS评分;记录各组镇痛首次PCA时间、PCA次数、舒芬太尼用量、镇痛不良反应、产程及分娩方式。结果与T0时比较,T2～T4时三组VAS评分显著降低(P<0.05)。与D组和S组比较,T2、T3时P组VAS评分明显升高;P组首次PCA时间明显缩短、PCA次数和舒芬太尼用量明显增加(P<0.05)。与D组比较,P组第一产程活跃期明显延长、器械助产、产前发热例数明显增加(P<0.05);S组剖宫产、产前发热、胎心减慢、瘙痒例数明显增加(P<0.05)。结论硬膜穿孔后硬膜外镇痛效果确切、不良反应更少,是一种安全有效的分娩镇痛方法。     

Catheter failure rates and time course with epidural versus combined spinal-epidural analgesia in labor

BackgroundThe combined spinal-epidural technique for labor analgesia has several advantages over the traditional epidural technique, including faster onset, greater maternal satisfaction, and decreased need for physician boluses. Proponents of the epidural technique criticize the combined spinal-epidural technique, arguing that the epidural catheter remains untested and thus may not be reliable if needed for surgical intervention. We compared failure rates and time of failure between techniques in our tertiary-care academic practice.MethodsData regarding failed catheters were collected from October 2012 to September 2014 as part of our Quality Assurance program. Failed catheters were defined as any catheter replaced after it was considered to be properly placed and then determined to be intravascular, one sided or resulting in poor maternal analgesia or anesthesia.ResultsA total of 5487 analgesics were performed (3980 combined spinal-epidural; 1507 epidural). Eighty-five combined spinal-epidural catheters (2.1%) and 59 epidural catheters (3.9%) were replaced during labor (P<0.001). Mean time to replacement was 512 ± 422 min and 354 ± 300 min for the combined spinal-epidural (n=80) and epidural (n=57) groups, respectively (P=0.02). Median time to replacement was 398 [IQR 131–578] min and 281 [IQR 186–767] min for combined spinal-epidural and epidural groups, respectively (P<0.0001).ConclusionWe were able to demonstrate that catheters placed using a combined spinal-epidural technique were less likely to fail during labor and that the time to detection of a failed catheter was significantly longer in the combined spinal-epidural group. Our findings validate the combined spinal-epidural technique as reliable for labor analgesia and tend to refute the theory of the untested catheter.     

Effect of neuraxial technique after inadvertent dural puncture on obstetric outcomes and anesthetic complications

BackgroundThe aim of this study was to evaluate labor and delivery outcomes in parturients with inadvertent dural puncture managed by either insertion of an intrathecal catheter or a resited epidural catheter.MethodsThis was a retrospective cohort review of 235 parturients who had an inadvertent dural puncture during epidural placement over a six-year period. The primary outcome was the proportion of women with a delayed second stage of labor. Secondary outcomes were the proportion of cesarean deliveries, the proportion of cases resulting in post-dural puncture headache, and the incidence of failed labor analgesia.ResultsBaseline characteristics such as age, body mass index and parity were similar between the two groups. Among the 236 cases of inadvertent dural puncture, 173 women (73%) had an intrathecal catheter placed while 63 women (27%) had the epidural catheter resited. Comparing intrathecal with epidural catheters, there was no observed difference in the proportion of cases of prolonged second stage of labor (13% vs. 16%, P=0.57) and the overall rate of cesarean deliveries (17% vs. 16%, P=0.78). However, we observed a lower rate of post-dural puncture headache in women who had cesarean delivery compared to vaginal delivery (53% vs. 74%, P=0.007). A greater proportion of failed labor analgesia was observed in the intrathecal catheter group (14% vs. 2%, P=0.005).ConclusionThe choice of neuraxial technique following inadvertent dural puncture does not appear to alter the course of labor and delivery. Cesarean delivery decreased the incidence of post-dural puncture headache by 35%. Intrathecal catheters were associated with a higher rate of failed analgesia.     

Epidural anesthesia and analgesia are not impaired after dural puncture with or without epidural blood patch.

Previous reports have noted a decrease in the success of subsequent epidural anesthesia and analgesia in patients who have undergone prior dural puncture with or without an epidural blood patch. Our retrospective study evaluated the success of epidural anesthesia and analgesia in all patients at the Mayo Clinic who had received a prior epidural blood patch over a 12-yr period. Each epidural blood patch patient was matched to two patients undergoing epidural anesthesia after previous dural puncture (without epidural blood patch) and to two patients undergoing epidural anesthesia after previous epidural anesthetic (without dural puncture/blood patch). These patients were matched for the duration of time between the initial procedure and subsequent epidural anesthetic and the indication (surgery, labor analgesia, postoperative analgesia) for which the subsequent epidural was performed. Subsequent epidural anesthesia was successful in 28 of 29 (96.6%, exact 95% CI 82.2%-99.9%) patients who had undergone prior blood patch, 55 of 58 (94.8%, 85.6%-98.9%) patients with a history of dural puncture, and 55 of 58 (94.8%, 85.6%-98.9%) patients who had had previous epidural anesthesia. There was no significant difference in the success rate of subsequent epidural anesthesia among groups. We conclude that prior dural puncture, with or without epidural blood patch, does not affect the success rate of subsequent epidural anesthesia. Implications: Patients with postdural puncture headache should not be denied the benefits of an epidural blood patch because of concerns about the impairment of subsequent epidural anesthetics. The success rate of subsequent epidural anesthesia and analgesia in patients who have undergone dural puncture with or without epidural blood patch is similar to that of patients who have undergone two prior epidural anesthetics.     

Sequential higher epidural catheter re-insertion after accidental dural puncture ameliorates the frequency and severity of post-dural puncture headache

ObjectivesThis cohort study aimed to evaluate the outcome of a hypothesis to use higher level for epidural catheter insertion and activation when an epidural tap was encountered at a lower level during epidural analgesia for labor pain.MethodsEpidural analgesia for labor pain was conducted using a mixture of 0.125% bupivacaine and fentanyl 5 μg/ml (10–15 ml) in 5-ml increments and maintained using continuous epidural infusion of 0.125% bupivacaine and fentanyl 2 μg/ml at rate of (5–15 ml/h), subsequently adjusted according to the patients needs. All cases had accidental dural puncture (ADP) were managed immediately with re-insertion of the needle at a higher level and completion of the procedure and maintained using continuous epidural infusion of 0.0625% bupivacaine and fentanyl 2 μg/ml at rate of (6–12 ml/h) for 24 h after delivery. Postpartum follow-up was conducted for 30 days to comment on the occurrence and severity of post-dural puncture headache (PDPH). All patients developed PDPH were followed daily until resolution of their headache.ResultsAbout 4800 parturient were enrolled in the study, ADP occurred in 24 patients with a frequency of 0.5%. All cases were immediately managed by re-insertion of the needle at a higher level and the procedure was successfully completed without new dural puncture, with 100% re-insertion success rate, and patients were maintained on continuous epidural infusion for 24 h. Throughout 30-day follow-up; only six of 24 patients developed PDPH with a success rate of re-insertion procedure as a prophylactic modality for PDPH after ADP of 75%. PDPH was relieved with bed rest, liberal fluids and paracetamol for 4 days in four patients, while the 5th patient continued to complain but the patient refused to undergo epidural blood patch (EBP) and headache started to subside and patient stopped to complain by the 10th day, and the last patient agreed to undergo EBP; and headache was relived immediately after 2 h.ConclusionIt could be concluded that re-insertion of epidural catheter at higher level of accidental dural puncture with epidural continuous infusion for 24 h could be considered as an efficient prophylactic modality to safe guard against PDPH with success rate of 75% and minimizes its severity if occurred.     

Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries

A retrospective analysis was performed on 19,259 deliveries that occurred in our institution from January 2000 to December 2002. Anesthesia records and quality assurance data sheets were reviewed for the characteristics and failure rates of neuraxial blocks performed for labor analgesia and anesthesia. The neuraxial labor analgesia rate was 75% and the overall failure rate was 12%. After adequate analgesia from initial placement, 6.8% of patients had subsequent inadequate analgesia during labor that required epidural catheter replacement. Ultimately 98.8% of all patients received adequate analgesia even though 1.5% of patients had multiple replacements. Six percent of epidural catheters had initial intravenous placement but 46% were made functional by simple manipulations without higher subsequent failure. Unintended dural puncture occurred in 1.2% of labor neuraxial analgesia. The incidences of overall failure, intravenous epidural catheter, wet tap, inadequate epidural analgesia and catheter replacement were lower in patients receiving combined spinal-epidural versus epidural analgesia. For cesarean section, 7.1% of pre-existing labor epidural catheters failed and 4.3% of patients required conversion to general anesthesia. Spinal anesthesia for cesarean section had a lower failure rate of 2.7%, with 1.2% of the patients requiring general anesthesia. The overall use of general anesthesia decreased from 8% to 4.3% over the three-year period. Furthermore, regional anesthesia was used in 93.5% of cesarean deliveries with no anesthetic-related mortalities. Future investigations should identify acceptable international standards, risk factors associated with failure and methods to reduce failure before cesarean section.     

Accidental dural puncture,postdural puncture headache,intrathecal catheters,and epidural blood patch: revisiting the old nemesis

One of the controversial management options for accidental dural puncture in pregnant patients is the conversion of labor epidural analgesia to continuous spinal analgesia by threading the epidural catheter intrathecally. No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. To investigate whether the intrathecal placement of an epidural catheter following accidental dural puncture impacts the incidence of postdural puncture headache (PDPH) and the subsequent need for an epidural blood patch in parturients. A retrospective chart review of accidental dural puncture was performed at Hutzel Women’s Hospital in Detroit, MI, USA for the years 2002–2010. Documented cases of accidental dural punctures (N = 238) were distributed into two groups based on their management: an intrathecal catheter (ITC) group in which the epidural catheter was inserted intrathecally and a non-intrathecal catheter (non-ITC) group that received the epidural catheter inserted at different levels of lumbar interspaces. The incidence of PDPH as well as the necessity for epidural blood patch was analyzed using two-tailed Fisher’s exact test. In the non-ITC group, 99 (54 %) parturients developed PDPH in comparison to 20 (37 %) in the ITC [odds ratio (OR), 1.98; 95 % confidence interval (CI), 1.06–3.69; P = 0.03]. Fifty-seven (31 %) of 182 patients in the non-ITC group required an epidural blood patch (EBP) (data for 2 patients of 184 were missing). In contrast, 7 (13 %) of parturients in the ITC group required an EBP. The incidence of EBP was calculated in parturients who actually developed headache to be 57 of 99 (57 %) in the non-ITC group versus 7 of 20 (35 %) in the ITC group (OR, 2.52; 95 % CI, 0.92–6.68; P = 0.07). The insertion of an intrathecal catheter following accidental dural puncture decreases the incidence of PDPH but not the need for epidural blood patch in parturients.     

Ultrasound decreases the failed labor epidural rate in resident trainees

BackgroundEpidural analgesia is widely used for pain relief during labor. The purpose of this study was to determine if ultrasound measurement of the depth from skin to epidural space before the epidural technique decreases the failure rate of labor analgesia. A secondary objective was to correlate ultrasound depth to the epidural space with actual depth of the needle at placement.MethodsIn this prospective, randomized, non-blinded study, 370 parturients requesting labor epidural analgesia were randomized to receive their epidural technique by first year anesthesia residents with or without prior ultrasound determination of epidural space depth. Outcome variables included the incidence of epidural catheter replacement for failed analgesia and the number of epidural attempts and accidental dural punctures.ResultsThe ultrasound group had fewer epidural catheter replacements (P < 0.02), and epidural placement attempts (P < 0.01) compared to the control group. Pearson’s correlation coefficients comparing the actual versus ultrasound estimated depth to the epidural space in the longitudinal median and transverse planes were 0.914 and 0.909, respectively. Pearson’s correlation coefficient comparing the ultrasound estimated depths to the epidural space in the transverse and longitudinal median planes was 0.940. No significant differences were noted with respect to staff interventions, top-ups, accidental dural punctures, and delivery outcome.ConclusionsUltrasound measurement of the epidural space depth before epidural technique placement decreases the rate of epidural catheter replacements for failed labor analgesia, and reduces the number of epidural attempts when performed by first year residents and compared to attempts without ultrasound guidance.     

Puerperal ventral epidural hematoma after epidural labor analgesia

Serious complications in obstetric anesthesia are a rare occurrence. High neuraxial block, respiratory arrest in labor and delivery, and an unrecognized spinal catheter are among the most frequently reported serious complications. A serious complication occurs in approximately 1:3 000 obstetric patients. Neuraxial hematoma after obstetric epidural analgesia or anesthesia is extremely rare.We present a case of a puerperal spinal epidural hematoma following epidural labor analgesia. The patient presented with foot drop, which resolved after conservative treatment. We reviewed the epidemiology, clinical manifestations and treatment options for this rare complication.     

Nine-year audit of post-dural puncture headache in a tertiary obstetric hospital in Singapore

BackgroundThe KK Women’s and Children’s Hospital is a tertiary obstetric unit with approximately 11 000 deliveries per year. Epidural analgesia is used in about 40% of laboring women. We reviewed the incidence and management of post-dural puncture headache over a nine-year period.MethodsA retrospective audit of labor epidural analgesia database records from 1 June 2005 to 31 May 2014 was conducted, identifying an “event” as an accidental dural puncture, an inadvertent intrathecal catheter insertion and/or development of a post-dural puncture headache.ResultsA total of 43 434 epidural records were reviewed. Sixty-three events were identified (an incidence of 0.15%). Women had median age of 30 years and median body mass index of 27.6 kg/m²; 69.8% (44/63) delivered vaginally. Procedures performed by less experienced anesthesiologists and those performed outside office hours were associated with a higher incidence of accidental dural puncture. An intrathecal catheter was inserted in 52 of 58 women (89.7%). Headache developed in 24 of 38 (63.1%) women in whom there was a witnessed accidental dural puncture. Most women who developed post-dural puncture headache presented during the primary admission (36/39; 92.3%). Paracetamol and non-steroidal anti-inflammatory drugs were the most commonly prescribed medications. Six women (9.5%) received an epidural blood patch which led to resolution of headache.ConclusionA retrospective audit over a nine-year period at a tertiary teaching hospital found the overall incidence of post-dural puncture headache and associated events to be 0.15%, with a decreasing trend coinciding with improvement in the teaching and supervision of trainees in labor epidural procedures.     

Increasing body mass index predicts increasing difficulty,failure rate,and time to discovery of failure of epidural anesthesia in laboring patients

Study objectiveObese parturients both greatly benefit from neuraxial techniques, and may represent a technical challenge to obstetric anesthesiologists. Several studies address the topic of obesity and neuraxial analgesia in general, but few offer well described definitions or rates of “difficulty” and “failure” of labor epidural analgesia. Providing those definitions, we hypothesized that increasing body mass index (BMI) is associated with negative outcomes in both categories and increased time needed for epidural placement.DesignSingle center retrospective chart review.SettingLabor and Delivery Unit of an inner city academic teaching hospital.Patients2485 parturients, ASA status 2 to 4, receiving labor epidural analgesia for anticipated vaginal delivery.InterventionsNone.MeasurementsWe reviewed quality assurance and anesthesia records over a 12-month period. “Failure” was defined as either inadequate analgesia or a positive test dose, requiring replacement, and/or when the anesthesia record stated they failed. “Difficulty” was defined as six or more needle redirections or a note indicating difficulty in the anesthesia record.Main resultsOverall epidural failure and difficulty rates were 4.3% and 3.0%, respectively. Patients with a BMI of 30 kg/m² or higher had a higher chance of both failure and difficulty with two and almost three fold increases, respectively. Regression analysis indicated that failure was best predicted by BMI and less provider training while difficulty was best predicted by BMI. Additionally, increased BMI was associated with increased time of discovery of epidural catheter failure.ConclusionsObesity is associated with increasing technical difficulty and failure of neuraxial analgesia for labor. Practitioners should consider allotting extra time for obese parturients in order to manage potential problems.     

Prophylactic blood patch performed prior to continuous epidural analgesia

Two cases of inadvertent dural puncture in patients at high risk for dural puncture headache are presented. These patients were managed with an immediate epidural blood patch through a catheter placed at another level with placement of this catheter occurring immediately following the dural puncture. Following the blood patch, the patients were anesthetized with the epidural catheter being used for supplementation of the general anesthetic and for postoperative pain management. Neither patient required further management of a dural puncture headache nor did it appear that the blood interfered with the patients receiving adequate postoperative analgesia through the use of this epidural catheter.     

Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials

BackgroundThis systematic review and meta-analysis evaluates evidence for seven risk factors associated with failed conversion of labor epidural analgesia to cesarean delivery anesthesia.MethodsOnline scientific literature databases were searched using a strategy which identified observational trials, published between January 1979 and May 2011, which evaluated risk factors for failed conversion of epidural analgesia to anesthesia or documented a failure rate resulting in general anesthesia.Results1450 trials were screened, and 13 trials were included for review (n = 8628). Three factors increase the risk for failed conversion: an increasing number of clinician-administered boluses during labor (OR = 3.2, 95% CI 1.8–5.5), greater urgency for cesarean delivery (OR = 40.4, 95% CI 8.8–186), and a non-obstetric anesthesiologist providing care (OR = 4.6, 95% CI 1.8–11.5). Insufficient evidence is available to support combined spinal–epidural versus standard epidural techniques, duration of epidural analgesia, cervical dilation at the time of epidural placement, and body mass index or weight as risk factors for failed epidural conversion.ConclusionThe risk of failed conversion of labor epidural analgesia to anesthesia is increased with an increasing number of boluses administered during labor, an enhanced urgency for cesarean delivery, and care being provided by a non-obstetric anesthesiologist. Further high-quality studies are needed to evaluate the many potential risk factors associated with failed conversion of labor epidural analgesia to anesthesia for cesarean delivery.     

Treatment of accidental dural puncture during obstetric epidural analgesia

OBJECTIVE: To assess the effectiveness of continuous intrathecal analgesia as prophylaxis for postdural puncture headache (PDPH) and for analgesia during labor in 12 patients who suffered accidental dural puncture. PATIENTS AND METHODS: A total of 920 patients who received spinal analgesia during labor were enrolled. Group A (no accidental dural puncture) received a single dose of 10 mL of 0.2% ropivacaine, and 5 minutes later continuous epidural infusion of 0.125% ropivacaine and 3 micromg mL(-1) was started at a rate of a 5 mL h(-1); a 5 mL bolus dose was allowed every 20 minutes if needed. In patients who suffered accidental dural puncture (Group B) we inserted an intrathecal catheter to administer an initial dose of 3 mL of 0.2% ropivacaine and the same analgesic mixture at the same dose as was administered in Group A. Patient characteristics, analgesic efficacy, duration of labor and delivery, motor blockade, analgesic volume, and incidence of PDPH were recorded. The Student t test was used for statistical comparisons. RESULTS: No significant differences in duration of labor and delivery, analgesic efficacy, or motor blockade were observed. The incidence of PDPH was 16.6% in Group B and 0.33% in Group A. The patients in Group B required more additional bolus doses: 10 (SD, 2) in Group B and 3 (1.25) in Group A (P<0.01). CONCLUSIONS: Continuous intrathecal analgesia after accidental dural puncture was a safe way to provide analgesia during labor and to reduce the expected incidence of PDPH.     

Permanent hearing loss and tinnitus following epidural analgesia complicated by accidental dural puncture

We report a case of permanent high-frequency hearing loss and tinnitus in a 38-year-old woman following an unrecognised dural puncture during epidural placement. The patient reported subjective unilateral hearing loss and tinnitus, along with a post-dural puncture headache, four hours post-delivery. The patient’s headache resolved following two epidural blood patches, however, hearing loss and tinnitus persisted longer than two years. Long-term auditory symptoms following epidural analgesia in labour are very unusual findings.     

Post partum headache after epidural analgesia without dural puncture

In order to improve our knowledge of post partum headache, during a two-year period we studied a large population of pregnant patients of our institution using a four-stage process including two questionnaires (the first at 12-15 weeks' gestation and the second in the first week after delivery), a pre-anesthetic visit at 36 +/- 2 weeks' gestation and a computer printout obtained at delivery. Of 1058 patients for whom records were complete and who had epidural analgesia during labor not complicated by dural puncture, 128 (12.1%) complained of post partum headache. In patients who did not receive epidural analgesia, the incidence of post partum headache tended to be higher (15.2%). However, because of the low response rate (27.1%) and the low absolute number of patients with headache (27) in the non-epidural group, statistical comparison was not possible. Data from the medical history or from the current pregnancy as well as data obtained during delivery (maternal and fetal-neonatal) were not significantly different between those patients free of pain and those presenting with headache, except for a history of migraine and pregnancy-induced hypertension which were both associated with an increased risk of post partum headache. These risk factors should be considered in both clinical studies and obstetric malpractice claims.     

Accidental dural puncture during labor analgesia and obstetric outcomes in nulliparous women

BackgroundThe effect of accidental dural puncture during labor epidural analgesia on obstetric outcomes remains unexplored. In this retrospective cohort study, we tested the hypothesis that accidental dural puncture is associated with prolonged second stage of labor.MethodsAnesthetic and obstetric data from nulliparous parturients who suffered an accidental dural puncture at term labor (n=89) during the years 2006–2012 were compared with randomly selected parturients with uncomplicated epidural analgesia (n=232). The primary outcome was the proportion of parturients with prolonged second stage of labor: secondary outcomes were the proportion of instrumented and cesarean deliveries. Statistical analysis included student t-test for continuous variables, chi-square test for binary variables, and logistic regressions for associations between accidental dural puncture and outcomes.ResultsDemographic and obstetric characteristics of parturients were comparable except for a non-significant increase in prolonged second stage of labor in the accidental dural puncture group (27% vs. 17%, P=0.06). After adjusting for known potential confounders, multivariate logistic regression analyses revealed a significant association between accidental dural puncture and prolonged second stage of labor (adjusted risk ratio [aRR] 1.99, 95% CI 1.04 to 3.82; P=0.037). This was not accompanied by an increase in instrumented (aRR 0.57, 95% CI 0.27 to 1.21; P=0.15) or cesarean delivery (aRR 1.83, 95% CI 0.89 to 3.77; P=0.10).ConclusionAccidental dural puncture during labor analgesia was associated with prolonged second stage of labor in nulliparous parturients. Prospective studies are needed to assess the relationship between the quality of neuraxial block after accidental dural puncture and obstetric outcomes.