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Second Stage Pushing and the Risk of Post-dural Puncture Headache
Abstract Number: S-03
Abstract Type: Original Research
Post-dural puncture headache (PDPH) can be a debilitating complication of neuraxial anesthesia in obstetric patients. Previous reports have attempted to evaluate the effect of bearing down during labor on the incidence of PDPH, but results are conflicting (1, 2). The goal of our study was to determine if pushing during labor increased the risk of PDPH in parturients noted to have obvious dural punctures during placement of neuraxial anesthesia using 17 or 18 gauge Tuohy needles.
We reviewed our PDPH database from 1999 to 2014 to identify patients who had obvious dural punctures, as defined by return of cerebrospinal fluid through the Tuohy needle and/or catheter during placement of epidurals, combined spinal-epidurals, and/or continuous spinals with 17 or 18 gauge Tuohy needles. Patients were divided into two groups: those who pushed before delivery (including women who pushed before cesarean section), and those who did not. The primary outcome was the presence of headache. Secondary outcomes included number of days of headache, maximum headache score (0-10), and epidural blood patch placement. Data was analyzed using Wilcoxon rank sum test and chi-square test as appropriate. Multivariate analysis was performed to control for potential confounders.
190 women were included in our analysis. Results are summarized in the table. Compared to women who did not push, women who pushed during labor had significantly increased risk of PDPH (p=0.02), significantly increased number of days of headache (p=0.02), and significantly increased epidural blood patch placement (p=0.02). Women who pushed also had significantly lower BMIs, fewer spinal catheters placed after dural puncture, and fewer cesarean deliveries than those who did not push. In a multivariate analysis controlling for BMI and spinal catheter placement, pushing was no longer associated with increased risk of headache (p=0.12).
Pushing before delivery was associated with an increased risk of PDPH in our analysis, but the effect was no longer statistically significant after adjusting for potential confounders. A larger study is needed to investigate these factors.
1. Can J Anesth 1999; 46(9): 861-866.
2. Anaesthesia 1993; 48: 247-255.