Second stage pushing correlates with headache after unintentional dural puncture in parturients

Abstract

Purpose: To determine the association between bearing down, postdural puncture headache (PDPH) and epidural blood patch (EBP) following single 17 gauge unintentional dural puncture (UDP) in parturients. Methods: The charts of 60 parturients identified with UDP in our institutional database during epidural placement were independently reviewed. Patients were divided into categories based on the anesthetic record: well-documented single punctures; well-documented multiple punctures; catheter-related puncture; unclear category (not clear if more than one puncture occurred or if dural puncture had occurred at all) and no evidence of dural puncture. Patients with single 17 gauge punctures were divided into those who had pushed (Group I) and those who had not (Group 2). Group 2 patients had undergone Cesarean section before reaching second stage labour. The incidence of PDPH, EBP, and cumulative duration to delivery after UDP were compared between groups. Results: Thirty-three patients with well-documented single punctures were identified: 23 had engaged in active pushing as part of second stage labour(Group I); I 0 had not (Group 2). Seventy-four percent of Group I developed PDPH compared with 10% in Group 2 ~P < 0.002). Fifty-seven percent of Group I received an EBP compared with 0% in Group 2 (P < 0.002). Increasing the duration of pushing was associated with an increasing incidence of PDPI-I; the majority of women who pushed > 30 rain developed headache. Conclusious: An increased incidence of PDPH and EBP after UDP occurs in women bearing down in 2nd stage labour when compared with those who never pushed. There was also an association between the cumulative duration of bearing down and the incidence of PDPH.Objectif : D&erminer l'association qui existe entre les efforts expulsifs, les c~phal~es postponction durale (CPPD) et le colmatage sanguin Epidural (CSE) ~ la suite d'une seule brEche durale accidentelle (BDA) au moyen d'un aiguille de calibre 17 chez des parturientes. M&hode : On a r~vis~ sEpar~ment 60 dossiers qui pr&entaient des BDA pendant la raise en place de l'aiguille Epidurale. On a r~parti les parturientes selon le protocole anesth&ique : des ponctions uniques v&ifi&s; des ponctions multiples v&ifi~es; des ponctions avec cath&ers; une cat~gorie impr&ise, si plus d'une ponction a ~t~ r~alis~e ou si la ponction durale s'est produite ~ chaque essai; aucune preuve de ponction durale. Les patientes qui n'ont eu qu'une ponction avec une aiguille de calibre 17 ont Et~ r~parties en deux groupes : celles qui ont poussE (Groupe I) et celles qui front pas poussE (Groupe 2), ayant subi une c~sarienne avant que le travail n'en soit ~ la p&iode d'expulsion, l'incidence de CPPD et de CSE et le temps entre la naissance et la BDA ont fait robjet de comparaisons intergroupes. Ba~sultats : Trente-trois patientes n'avaient re~su qu'une seule ponction : 23 s'~taient engag~es ~ pousser activement pendant la phase d'expulsion du travail (Groupe I); I0 ne poussaient pas (Groupe 2). Soixante-quatorze pour cent des patientes d...

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

“…Compared with spontaneous vaginal delivery, previous studies have observed reduced PDPH and EBP rates with either instrumental vaginal 20 or caesarean delivery; 21 bearing-down during the active part of the second stage of labour is generally accepted as the reason. Ravindran et al, 22 however, observed no association between bearing-down and PDPH or EBP rates, and current practice does not preclude bearing-down nor does it advise instrumental delivery to minimise headache rates.…”

The management of accidental dural puncture and postdural puncture headache: a North American survey

“…Respondents infrequently altered management of the second stage of delivery. Older reports examining the efficacy of this practice involved low numbers and reported conflicting results [28,29]. Abdominal binder use has been reported as low in all surveys, as no study has demonstrated its efficacy.…”

Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature

“…[50][51][52][53] The increased incidence of post-dural puncture headache in parturients may be attributed to numerous factors including peripartum dehydration, which could reduce the production of CSF, postpartum diuresis, abrupt release of intra-abdominal pressure and venacaval compression at delivery, which reduces epidural venous pressures. Maternal bearing-down efforts that could increase CSF leakage through the dural hole could also be a factor, as well as early ambulation, anxiety about delivery and hormonally-induced ligamentous changes.…”