The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice*

Abstract

Summary The management of accidental dural puncture and postdural puncture headache in obstetric practice continues to be of great interest. This survey aims to explore the current management of this complication in the United Kingdom and compares the findings to a similar survey undertaken in 1993. A postal questionnaire was sent to all maternity units (n = 248). The return rate was 71%. Of these, 144 units (85%) now have written guidelines for the management of accidental dural puncture compared to 58% in 1993. In 47 units (28%), the epidural catheter is now routinely placed intrathecally following accidental dural puncture; in 69 units (41%) the catheter is re‐sited and in the remaining 53 units (31%) either option is allowed. This is in contrast to the previous survey, which found that catheters were re‐sited in 99% of units. Only 31 units (18%) now limit the second stage of labour and 19 (11%) avoid pushing and deliver by ventouse or forceps, whilst 116 units (69%) allow labour to take place without any intervention. Only 44 units (26%) now treat postdural puncture headache with an epidural blood patch as soon as it is diagnosed, whereas in 120 units (71%) the blood patch is performed only after failure of conservative measures. Due to the large increase in the use of the intrathecal catheter following this complication, a follow‐up questionnaire was posted 5 months later to those units (n = 99) that reported this practice in the initial survey, with a 94% response rate. The two most commonly cited reasons for intrathecal catheterisation were to avoid further dural puncture (76%) and to allow immediate analgesia for labour (75%).

The CobraPLA

“…The first reference cited by Patel and Chatterjee [1] was cited in our reply because it was used by Cook et al to 'support the overall safety of the laryngeal mask airway' [2]. We are in full agreement with Patel and Chatterjee that the laryngeal mask airway has had a remarkable record of safe use since its introduction.…”

“…We read with interest Drs Christie and Ball's report concerning a problem with adhesive surgical drapes during ENT surgery [1], resulting in inadvertent premature extubation.…”

“…If the adhesive portion of a surgical drape has been applied over a cannula's dressing, its subsequent removal will then only result in the removal of this layer of backing, leaving the cannula and its dressing in situ (Fig. 1) We read with interest the response from Quinn [1] to a paper by Cook and Lowe [2]. We wish to correct the inaccurate references made by him to the two papers by Verghese and Brimacombe [3] and Bapat and Verghese [4], in his response.…”

The effect of serial in vitro haemodilution with maternal cerebrospinal fluid and crystalloid on thromboelastographic (TEG®) blood coagulation parameters, and the implications for epidural blood patching

“…Although autologous epidural blood patch is the definitive treatment for PDPH and the failure of this procedure is relatively rare, it may not be effective in a significant proportion of patients [6,[10][11][12]. Baraz et al undertook a postal questionnaire of UK obstetric units, and found that only 26% treated PDPH with an epidural blood patch as soon as it was diagnosed, whereas in 71% of units, the blood patch was only performed once conservative measures had failed [13]. There are two widely held theories, which are somewhat competing, to account for the onset of the headache.…”

Intrathecal catheterization after unintentional dural puncture during orthopedic surgery

“…However, placement of an autologous epidural blood patch may result in both a potential blood infection of the central nervous system [4,5] and a second unintentional dural puncture during attempts to reposition the epidural needle. That concern has compelled anesthesiologists to search for therapeutic modalities that involve less risk [2,[6][7][8][9].…”