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Management of Accidental Dural Puncture during Labor: Effect of Technique Choice on Obstetric Outcomes.
Abstract Number: F 21
Abstract Type: Original Research
Introduction: When an accidental dural puncture (ADP) occurs during the placement of an epidural technique, some practitioners place a spinal catheter, whereas others will re-site an epidural catheter. Both approaches during labor have been observed to result in a similar incidence of post dural puncture headache (PDPH) and epidural blood patch (EBP).(1) However, whether these approaches could affect obstetric outcomes is unknown. Based on prior studies on labor analgesia and institutional experience,(2,3) we hypothesized that placement of a spinal catheter, when compared to an epidural catheter, would decrease the duration of second stage of labor and the rate of instrumented vaginal delivery.
Methods: The medical records of term parturients who experienced an ADP from 2008 to 2012 were reviewed. Data on the age, body mass index, parity, the duration of first stage of labor after neuraxial technique, duration of second stage of labor, and the mode of delivery were collected. The total duration of catheter presence, catheter replacement rates due to suboptimal analgesia, presence of PDPH, use of EBP, and neurologic symptoms were documented. Unclear or doubtful ADP and emergent cesarean delivery for fetal indications were excluded. Numerical and categorical data were analyzed with 1-way analysis of variance and chi-square tests, respectively, with significance at P ≤ 0.05; data expressed as Mean ± S.D.
Results: Comparisons between the spinal (N = 124) and the repeat epidural (N = 45) groups indicated similar baseline demographics. A significant decrease in the duration of second stage of labor was observed in the spinal catheter group compared to the epidural group (61.1 ± 71.4 min vs. 89.8 ± 90.4; P = 0.05*). However, this was not associated with a decrease in instrumented (8% vs. 10%, P = 0.74%) or cesarean delivery rates (14% vs. 16%, P = 0.69). Despite earlier onset of analgesia, the spinal group had a significantly higher incidence of catheter replacement (22/124) compared to the repeat epidural group (1/45; P = 0.009**). There were no differences in the rates of PDPH, EBP, or neurologic symptoms between groups.
Conclusions: In this retrospective study, we observed that a spinal catheter following an ADP is associated with a decreased duration of second stage of labor, but without altering delivery outcomes. Of interest, spinal catheters required more frequent replacement when compared to a re-sited epidural catheter. Although prospective confirmation will be needed, these findings may assist decision making for labor analgesia in a parturient with an ADP.
1. Russell IF, Int J Obstet Anesth 2012 Jan; 21(1): 7-16.
2. COMET Study, Lancet 2001:358:19-23.
3. Tsen LC, et al. Anesthesiology 1999; 91:920-5.