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Modeling the effect of stage of labor on cerebral spinal fluid loss after dural puncture
Abstract Number: F3B-1
Abstract Type: Original Research
Background: Dural puncture commonly occurs in the setting of labor and delivery due to utilization of neuraxial anesthesia and analgesia. Spinal anesthesia necessitates dural puncture, whereas a common complication of epidural analgesia is inadvertent dural puncture. The severity of complications is likely dependent upon the rate of cerebral spinal fluid (CSF) loss and degree of resultant intracranial hypotension. Labor has been shown to directly impact central neuraxial pressures given painful contractions in the first stage of labor and maternal expulsive effort in the second stage. The effect such increases have on rate of CSF loss, however, is not known. We hypothesize that the rate of CSF loss through a dural puncture site is directly related not only to needle size and type, but also to transdural pressure gradients generated throughout the course of labor.
Methods: We calculated transdural pressure gradients using previously reported epidural and intrathecal pressure values transduced in term parturients in first stage labor with and without painful contractions, and during the second stage of labor with active pushing. Values were measured in the lateral decubitus and supine flexed positions, respectively. We also calculated the gradient in the sitting position to model patient behavior postpartum. Using saline, with similar viscosity and surface tension to CSF, contained in pressurized plastic (Baxter-Viaflo) with a thickness similar to the lumbar dural membrane, we punctured the container with commonly used needle types and measured volume loss over time under the calculated gradients.
Results: Calculated transdural pressure gradients for first stage of labor without and with painful contractions were 4mmHg and 16mmHg respectively. The gradient in the second stage of labor with pushing was 21mmHg, and in the upright sitting position was 18mmHg. Values for CSF rate of loss (mL/min) are reported in the attached figure.
Discussion: Our data suggest CSF loss through a dural puncture is significantly impacted by the course of labor, especially with defects from larger bore or cutting type needles. Strategies to reduce the rate of CSF loss include ensuring adequate labor analgesia, avoiding a prolonged second stage, and placement of an intrathecal catheter through an epidural needle puncture defect.
Marx et al. Anesthesiology 5 1961, Vol.22, 348-354.
Messih, N.A. Anaesthesia 1981, Vol. 36 775-782.