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

Transcription

1 The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice* R. Baraz 1 and R. E. Collis 2 1 Anaesthetic Specialist Registrar, 2 Consultant in Obstetric Anaesthesia, Department of Anaesthesia, University Hospital of Wales, Cardiff and Vale NHS Trust, Cardiff CF14 4XW, UK 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 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 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%).... Correspondence to: Rafal Baraz baraz@doctors.org.uk *Presented in part at the Obstetric Anaesthetists Association Annual Meeting, Versailles, France; April Accepted: 11 March 2005 Parturients have approximately a 1.5% risk of accidental dural puncture with insertion of an epidural for labour analgesia [1]. However, this rate varies amongst maternity units in the UK, ranging from 0.19% to 3.6% [2]. Accidental dural puncture is the most common major complication of epidural pain relief and the headache following this complication can be very distressing and extremely disabling to the mother who is trying to nurse her newborn in the postnatal period. A survey performed in 1993 reviewed national UK practice following accidental dural puncture and explored various management strategies for the prophylaxis and treatment of postdural puncture headache (PDPH) during labour and the postnatal period [3]. New measures have been reported to reduce the incidence and improve the treatment of PDPH. These include the use of intrathecal catheters [4], caudal epidural blood patch [5], epidural fibrin glue or dextran 40 patch [6 8] and intravenous hydrocortisone [9]. However, the success of these treatments remains controversial. Our survey aimed to examine practice in the UK 10 years on, to identify any changes and evaluate their place in modern obstetric anaesthesia. Methods After obtaining approval from the Obstetric Anaesthetists Association (OAA) Audit Subcommittee, a postal questionnaire was sent to the lead obstetric anaesthetist in all (248) maternity units in the UK during October 2003 Ó 2005 Blackwell Publishing Ltd 673

2 R. Baraz and R. E. Collis Æ Accidental dural puncture during labour anaesthesia Anaesthesia, 2005, 60, pages (Appendix A). The names and addresses of all lead clinicians were supplied by the OAA at the time of sending the questionnaire. Because of an unanticipated and dramatic change in practice regarding intrathecal catheters, a second questionnaire (Appendix B) was sent 5 months later to the 99 units that reported the use of intrathecal catheters in the initial survey to confirm the change and to review the factors that may have created the change. Microsoft EXCEL was used to aid the data analysis of both questionnaires. Results Of the 248 questionnaires sent, 176 were returned, a response rate of 71%. Seven units had either no epidural service or had closed down and were therefore excluded. Full data were available from the remaining 169 units. Of the units surveyed, 148 (88%) now audit the incidence of accidental dural puncture. This audit was conducted either annually in 119 (80%), continuously in 16 (11%) or with a variable pattern in 13 (9%) units. Most units, 144 (85%), had written guidelines for the management of accidental dural puncture and a further 14 (8%) were in the process of writing them at the time of sending the questionnaires. In the 1993 survey, only 58% of units had a written protocol for managing this complication. The management of a recognised accidental dural puncture associated with labour epidural analgesia varied amongst maternity units. In 69 units (41%) the epidural catheter was re-sited at a different level, in 47 (28%) it was inserted intrathecally and used for labour analgesia, and in the remaining 53 units (31%) either option was allowed according to the operator s preference. Prophylactic measures that were commonly employed to reduce the incidence of PDPH following accidental dural puncture and the advice given about the patient s mobility after delivery are summarised in Tables 1 and 2. Although the gold standard for treatment of PDPH remains an epidural blood patch, 120 units (71%) treated the headache conservatively before performing an epidural blood patch (Table 3). Only 44 units (26%) considered the patch as soon as a PDPH was diagnosed and in five units (3%) the management was variable. Complications of the epidural blood patch such as the risk of another dural puncture and back pain were explained to the mother before performing the procedure in the majority of units. In 100 (59%), explanations of both complications were given, 51 (30%) explained one and the remaining 18 (11%) did not mention either complication. In addition, figures regarding the success rate of an epidural blood patch were not given in 11 (6.5%) of the units surveyed. All maternity units obtained consent before a blood patch was performed. In 97 (57%) it was verbal and in 72 (43%) Table 1 Prophylactic measures used in UK units to minimise the risk of postdural puncture headache following accidental dural puncture (n = 169). Values are number (proportion). During delivery None 116 (69%) Limit 2nd stage (generally min) 31 (18%) Avoid pushing 19 (11%) Variable 3 (2%) After delivery Encourage fluid intake 154 (91%) Regular analgesia (paracetamol codeine NSAID) 141 (83%) Leave spinal catheter for h 26 (15%) Crystalloid bolus epidurally before catheter removal 22 (13%) Crystalloid infusion epidurally before catheter removal 9 (5%) Inject blood epidurally before catheter removal 4 (2%) None 3 (2%) Prophylactic blood patch within 24 h of delivery 2 (1%) Table 2 Mobility after delivery in UK units following accidental dural puncture (n = 169). Values are number (proportion). Mobilised as early as possible 127 (75%) Advised bed rest: 6h 9(5%) 12 h 13 (8%) 24 h 20 (12%) Table 3 Non-invasive methods routinely or occasionally used in UK units for the treatment of postdural puncture headache (n = 169). Values are number (proportion). Routinely used Occasionally used Encourage fluid intake 158 (93%) Regular paracetamol codeine NSAID 163 (96%) Caffeine 51 (30%) Sumatriptan 24 (14%) 9 (5%)* Strong opioids 18 (11%) Intramuscular injection of ACTH 7 (4%) 7 (4%)* Theophylline 5 (3%) Caffeine containing drinks 4 (2%) Abdominal binders 1 (0.6%) 1 (0.6%) Intravenous hydrocortisone 2 (1%) *Used if epidural blood patch had failed, or was declined or contraindicated. it was written. Clinicians from 165 units (98%) routinely checked the patient s temperature and 77 (46%) consistently requested a white blood cell count before blood patching. Other investigations such as a coagulation screen and full neurological examination were performed in only 10 (6%) units. The epidural blood patch was performed in the operating theatre in 100 units (59%) and the rest either in the antenatal or labour wards. Blood for culture and sensitivity were taken in 75 units (44%) at the 674 Ó 2005 Blackwell Publishing Ltd

3 R. Baraz and R. E. Collis Æ Accidental dural puncture during labour anaesthesia Table 4 Lead clinician s advice to the mother at discharge following successful blood patch in UK units (n = 169). Values are number (proportion). Table 5 Recommendations of lead obstetric anaesthetists to reduce the incidence of accidental dural puncture (n = 169). Values are number (proportion). Contact ward or anaesthetist return if headache recurs 143 (85%) Avoid straining heavy housework 51 (30%) Contact if any concern 41 (24%) Avoid heavy lifting 31 (18%) Return if develop back pain 20 (12%) Report weakness or numbness 19 (11%) Report fever 16 (9%) Advise taking laxatives 16 (9%) High fluid intake 10 (6%) No response 4 (2%) time of the blood patch. Early mobilisation of the mother after a blood patch was usual. In 159 units (94%), advice regarding bed rest did not exceed 4 h and two units (1%) allowed full mobility immediately afterwards. Most patients were discharged home early following this procedure. In 46 units (27%) women were discharged within a few hours, in 60 (36%) after 6 h and in 51 (30%), the following day. In 11 units (7%) the mother was kept for 24 h for observation. Lead obstetric anaesthetists were asked about the advice given to the mother at discharge following a successful blood patch. The advice was rather inconsistent and lacked details in most units (Table 4). However, in six units (4%) the information given was supported by a leaflet that explained what to do if a headache recurred or another complication arose. Routine follow-up after discharge was carried out in 94 units (56%). Of those, in 44 (47%) the telephone was the sole method, in 29 (31%) the patient was given an outpatient follow-up appointment and in 16 (17%) the community midwives were responsible for follow-up. Respondents from 156 units (92%) would consider investigations if two blood patches were not successful or the headache recurred, to exclude other possible causes for the headache. In 120 units (71%), a neurologist would be involved. In addition, computed tomography and magnetic resonance imaging would be requested in 77 (46%) and 55 (33%) units, respectively, and in six units (4%), a lumbar puncture would be performed. Finally, respondents were asked whether they recommend any measures to reduce the incidence of accidental dural puncture in their units. These recommendations are summarised in Table 5. Of the 99 follow-up questionnaires mailed, 93 were returned (94%). The two most common indications given for the use of intrathecal catheters were to avoid another dural puncture and to allow immediate analgesia for labour (Table 6). Although 54 respondents (58%) believed that intrathecal catheters completely or partially reduced the incidence and or severity of PDPH, many Saline for loss of resistance 116 (69%) Regular audit 90 (53%) No obstetric anaesthetic cover by SHOs with less than 65 (38%) 18 months of experience Obtain senior help after two failed attempts when 62 (37%) performing epidural Others* 22 (13%) Encourage the use of 18-G Tuohy needle 21 (12%) No recommendation 7 (4%) *The first 5 10 epidurals must be supervised; constant saline technique; senior help after three attempts; encourage lateral position. Table 6 Possible reasons for insertion of an intrathecal catheter following accidental dural puncture in UK units (n = 93). Values are number (proportion). Avoid another dural puncture 71 (76%) Allow immediate analgesia for labour 70 (75%) Reduce the incidence and severity of PDPH 38 (41%) Only in difficult cases (e.g. obesity, multiple attempts) 22 (24%) Others (reduce risk of high block, operative delivery is 17 (18%) likely or imminent) Reduce the incidence of PDPH 10 (11%) Reduce the severity of PDPH 6 (6%) were uncertain about this issue and did not feel that at the present time this was the main reason for their change in practice. Intrathecal catheters were removed early (i.e. when labour or the operative procedure had ended) in 67 units (72%). The main reasons given were the potential dangers of catheter misuse (63 units, or 68%) and the risk of infection (56 units, or 60%). Fifteen units (16%) removed the catheter early since they did not believe leaving it in for longer had any advantage. The remaining 26 (28%) kept the catheter in for h since they felt this would minimise the risk of PDPH. Discussion Comparing the findings of our survey in 2003 to those of the 1993 survey we have shown considerable changes in UK practice with regards to the management of accidental dural puncture and PDPH in the obstetric patient. Owing to the increased importance given to written guidelines in general, more units in the UK now have such guidelines for the management of the above complication (85% compared to 58% in 1993). Management of the second stage of labour following accidental dural puncture has changed. Despite conflicting evidence regarding pushing in the second stage and its effect on the incidence and severity of PDPH [10, 11], Ó 2005 Blackwell Publishing Ltd 675

4 R. Baraz and R. E. Collis Æ Accidental dural puncture during labour anaesthesia Anaesthesia, 2005, 60, pages more units now allow labour to proceed without any restrictions. Only 11% of respondents avoid pushing and perform an instrumental delivery electively compared to 47% in The use of a crystalloid infusion into the epidural space is no longer a common prophylactic measure. Only 5% of units surveyed were in favour of this compared to 70% in This is perhaps due to the lack of evidence regarding its long-term effect [12]. Another interesting change in practice is that the majority of respondents (75%) now advise early mobility following accidental dural puncture compared to 30% in This is probably due to the lack of evidence for the effectiveness of bed rest on the development of PDPH [13 15]. Although an epidural blood patch remains the definitive treatment for PDPH, it was performed in only 26% of units as soon as the headache was diagnosed, whereas in 71% of units, it was performed after the failure of conservative measures. Similarly, figures from the summary report of the National Obstetric Anaesthetic Database (1999) have shown that epidural blood patch was performed within 2 days of delivery in only 42% of women [16]. In our survey, delayed blood patch may be explained by concerns about potential complications associated with the procedure and uncertainty among the respondents about its effectiveness [17, 18]. Furthermore, fewer units are currently in favour of a prophylactic blood patch following accidental dural puncture (4% vs 9% in 1993). Prophylactic blood patch may be difficult to justify when the headache is not present; also, the lack of evidence for its effectiveness may have contributed to its decline [19]. Alternative injections such as dextran 40 or fibrin glue were not given in any of the units surveyed and this is probably due to the lack of strong evidence of an effect with the former and the potential for neurotoxicity with the latter [20]. The most significant change in practice that our survey showed was the insertion of the epidural catheter intrathecally when accidental dural puncture was diagnosed. A procedure that had gained acceptance in only two units (1%) in 1993 is now a common practice in up to 100 units (59%). In the early 1990s the use of any intrathecal injection for labour analgesia was practically unheard of, with descriptions of low dose combined spinal epidurals for labour analgesia being published at around this time [21 23]. There have now been many publications on intrathecal analgesia for labour with safe doses and side-effect profiles [24 26]. It can probably be assumed that the obstetric anaesthetist today is comfortable with the concept of intrathecal analgesia and able to recognise the benefits of placing the catheter intrathecally following accidental dural puncture, such as the provision of rapid analgesia and the prevention of another dural puncture. However, there have been conflicting results as to the role of intrathecal catheters in reducing the risk or severity of PDPH [4, 27 30]. Although some respondents believed that intrathecal catheters might have a role in reducing the headache rate, many were not at all certain and gave other reasons for their change in practice. The length of time recommended for an intrathecal catheter to remain in situ to reduce the headache rate was also variable, with only 28% feeling that the potential benefit of leaving the catheter into the post partum period outweighed the hazards of catheter misuse or infection. It is clear that the role of intrathecal catheters in reducing the headache needs to be researched further. Acknowledgements The authors would like to thank all the OAA members who kindly completed the survey questionnaires. References 1 Choi PT, Galinski SE, Takeuchi L, Lucas S, Tamayo C, Jadad AR. PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies. Canadian Journal of Anesthesia 2003; 50: Gleeson CM, Reynolds F. Accidental dural puncture rates in UK obstetric practice. International Journal of Obstetric Anesthesia 1998; 7: Sajjad T, Ryan TD. Current management of inadvertent dural taps occurring during the siting of epidurals for pain relief in labour. A survey of maternity units in the United Kingdom. Anaesthesia 1995; 50: Dennehy KC, Rosaeg OP. Intrathecal catheter insertion during labour reduces the risk of post-dural puncture headache. Canadian Journal of Anesthesia 1998; 45: Gerancher JC, D Angelo R, Carpenter R. Caudal epidural blood patch for the treatment of postdural puncture headache. Anesthesia and Analgesia 1998; 87: Barrios-Alarcon J, Aldrete JA, Paragas-Tapia D. Relief of post-lumbar puncture headache with epidural dextran 40: a preliminary report. Regional Anesthesia 1989; 14: Crul BJ, Gerritse BM, van Dongen RT, Schoonderwaldt HC. Epidural fibrin glue injection stops persistent postdural puncture headache. Anesthesiology 1999; 91: Reynvoet ME, Cosaert PA, Desmet MF, Plasschaert SM. Epidural dextran 40 patch for postdural puncture headache. Anaesthesia 1997; 52: Moral Turiel M, Rodriguez Simon MO, Sahagun de la Lastra J, Yuste Pascual JA. Treatment of post-dural-puncture headache with intravenous cortisone. Revista Espanola de Anestesiologia y Reanimacion 2002; 49: Ravindran RS, Viegas OJ, Tasch MD, Cline PJ, Deaton RL, Brown TR. Bearing down at the time of delivery and the incidence of spinal headache in parturients. Anesthesia and Analgesia 1981; 60: Angle P, Thompson D, Halpern S, Wilson DB. Second stage pushing correlates with headache after unintentional 676 Ó 2005 Blackwell Publishing Ltd

5 R. Baraz and R. E. Collis Æ Accidental dural puncture during labour anaesthesia dural puncture in parturients. Canadian Journal of Anesthesia 1999; 46: Duffy PJ, Crosby ET. The epidural blood patch: resolving the controversies. Canadian Journal of Anesthesia 1999; 46: Thoennissen J, Herkner H, Lang W, Domanovits H, Laggner AN, Mullner M. Does bed rest after cervical or lumbar puncture prevent headache? A systematic review and meta-analysis. Canadian Medical Association Journal 2001; 165: Spriggs DA, Burn DJ, French J, Cartlidge NE, Bates D. Is bed rest useful after diagnostic lumbar puncture? Postgraduate Medical Journal 1992; 68: Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 1999; 354: Chan TM, Ahmed E, Yentis SM, Holdcroft A. Postpartum headaches: summary report of the National Obstetric Anaesthetic Database (NOAD) International Journal of Obstetric Anesthesia 2003; 12: Williams EJ, Beaulieu P, Fawcett WJ, Jenkins JG. Efficacy of epidural blood patch in the obstetric population. International Journal of Obstetric Anesthesia 1999; 8: Eustace N, Hennessy A, Gardiner J. The management of dural puncture in obstetrics and the efficacy of epidural blood patches. Irish Medical Journal 2004; 97: Scavone BM, Wong CA, Sullivan JT, Yaghmour E, Sherwani SS, McCarthy RJ. Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture. Anesthesiology 2004; 101: Schlenker M, Ringelstein EB. Epidural fibrin clot for the prevention of post-lumbar puncture headache: a new method with risks. Journal of Neurology, Neurosurgery and Psychiatry 1987; 50: Honet JE, Arkoosh VA, Norris MC, Huffnagle HJ, Silverman NS, Leighton BL. Comparison among intrathecal fentanyl, meperidine and sufentanil for labour analgesia. Anesthesia and Analgesia 1992; 75: Stacey RG, Watt S, Kadim MY, Morgan BM. Single space combined spinal-extradural technique for analgesia in labour. British Journal of Anaesthesia 1993; 71: Collis RE, Baxandall ML, Srikantharajah ID, Edge G, Kadim MY, Morgan BM. Combined spinal epidural analgesia. technique, management and outcome of 300 mothers. International Journal of Obstetric Anesthesia 1994; 3: Norris MC, Grieco WM, Borkowski M, et al. Complications of labor analgesia: epidural versus combined spinal epidural techniques. Anesthesia and Analgesia 1994; 79: Vercauteren M, Bettens K, Van Springel G, Schols G, Van Zundert J. Intrathecal labor analgesia: can we use the same mixture as is used epidurally? International Journal of Obstetric Anesthesia 1997; 6: Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK. Effects of low dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial. Lancet 2001; 358: Cohen S, Amar D, Pantuck EJ, Singer N, Divon M. Decreased incidence of headache after accidental dural puncture in caesarean delivery patients receiving continuous postoperative intrathecal analgesia. Acta Anaesthesiologica Scandinavica 1994; 38: Ayad S, Demian Y, Narouze SN, Tetzlaff JE. Subarachnoid catheter placement after wet tap for analgesia in labor: influence on the risk of headache in obstetric patients. Regional Anesthesia and Pain Medicine 2003; 28: Liu N, Montefiore A, Kermarec N, Rauss A, Bonnet F. Prolonged placement of spinal catheters does not prevent postdural puncture headache. Regional Anesthesia 1993; 18: Blaise GA, Cournoyer S, Perrault C, Bedard MJ, Petit F, Landry D. Spinal catheter does not reduce post-dural puncture headache after caesarean section. Canadian Journal of Anesthesia 1992; 39: Appendix A Initial survey sent to lead obstetric anaesthetists This survey has the OAA Seal of Approval Survey No. 40, approved on July 21st There is an on-going nationwide multicentre clinical trial that is looking at the management of accidental dural puncture. If your unit is involved in this trial please complete this questionnaire in a way that matches your departmental protocol prior to the trial starting. 1. Does your unit audit the incidence of inadvertent dural puncture during the insertion of an epidural catheter for pain relief in labour? If yes, how often? h Annually h Once every 2 years h Other, please specify Do you have written guidelines for the management of accidental dural puncture in your unit? h In the process of writing them 3. How is a recognised accidental dural puncture managed in your unit? a) At insertion, what action is followed when a dural tap is recognised? Please choose one or more of the following according to your guidelines h Feed the catheter and use it as spinal h Re-site at a different site h Other, please specify... b) After delivery, is the patient: h Mobilised as early as possible (no restriction) h Advised bed rest 6 h 12 h 24 h (please encircle) Ó 2005 Blackwell Publishing Ltd 677

6 R. Baraz and R. E. Collis Æ Accidental dural puncture during labour anaesthesia Anaesthesia, 2005, 60, pages c) What prophylactic measures are recommended to avoid postdural puncture headache (PDPH) following an accidental dural tap? r Prophylactic measures during delivery (please tick fill appropriately): h Do not treat any different during labour h Limit second stage to minutes h Avoid pushing in 2nd stage of labour h Leave spinal catheter for 24 h (if chose to feed the catheter spinally) h Other measures, please specify... r Prophylactic measures post delivery: h Encourage fluid intake h Regular paracetamol codeine NSAID h Inject blood through existing epidural catheter before removal h Crystalloid bolus through existing epidural catheter before removal h Prophylactic blood patch within 24 h of delivery h Other measures, please specify... d) How is post dural puncture headache treated in your unit? h Drugs (see below) h Perform epidural blood patch as soon as PDPH is diagnosed h Perform epidural blood patch after failure of conservative treatment h Other treatment, please specify... e) Please specify the non-invasive methods of treatment that are routinely used to treat PDPH in your unit (please tick appropriately): h Encourage fluid intake h Regular paracetamol codeine NSAID h Strong opioids h Sumatriptan h Ergometrine h Theophylline h Caffeine (i.v. or oral) h i.m. injection of ACTH h i.v. hydrocortisone h Other treatment, please specify What information would you give the mother regarding the success of epidural blood patch? n Complete relief % n Partial relief % n No relief % n Another blood patch % n Complications: I. Another dural puncture ( II. Backache ( 5. What type of informed consent do you obtain prior to epidural blood patch? h Verbal consent h Written consent 6. What parameters are routinely checked before performing epidural blood patch in your unit? h White cell count h Patient s temperature h Others, please specify Are routine blood cultures taken when performing blood patch? 8. Where are epidural blood patches done in your unit? h In theatre h In labour ward 9. After performing blood patch, what would you advise the patient? h Lie flat for 2 h and then mobilise h Lie flat for 4 h and then mobilise h Other If the blood patch is successful, when is the patient discharged home (provided that the patient is no longer requiring care from the midwives/ obstetricians)? h Within a few hours h After 6 hours h Other What advice would you give the mother at discharge? If two blood patches were not successful or the headache recurs, would you consider any investigations to exclude other possible reasons? If yes, please tick appropriately: h CT scan h MRI h Lumbar puncture h Neurologist opinion h Others please specify Do you routinely follow up women with PDPH after discharge? h Via telephone h Via midwives h Out patient follow up h Advise to contact labour ward if headache recurs 678 Ó 2005 Blackwell Publishing Ltd

7 R. Baraz and R. E. Collis Æ Accidental dural puncture during labour anaesthesia 14. Do you recommend any measures to reduce the incidence of accidental dural puncture in your unit? h Obtain senior help after two failed attempts when performing epidural obstetric anaesthetic cover by SHOs with less than 18 months of experience h Saline for loss of resistance h Encourage use of 18 g Tuohy needle h Regular audit h Others Comments Your details please: Name... Hospital Trust... Address Telephone number... Appendix B Follow-up questionnaire sent to those units that reported the use of intrathecal catheters in the initial survey. 1. During the insertion of an epidural catheter for labour analgesia, please state why you would choose to feed the catheter spinally following accidental dural puncture? Please tick (one or more) appropriately indicating the most important one first: h To allow immediate analgesia for labour h To avoid another dural puncture h Reduce the incidence of PDPH h Reduce the severity of PDPH h Reduce the incidence and severity of PDPH h Only in difficult cases (e.g. obesity, multiple attempts) h Others, please specify: When is the spinal catheter removed? Please note that this applies only to epidural catheters inserted spinally following accidental dural puncture, please encircle either aorb. a) Remove as soon as the catheter is not required (please indicate the reason(s)) h To avoid the risk of catheter misuse h To avoid the risk of infection h Leaving spinal catheter in does not prevent PDPH h Others, please specify... b) Leave the catheter for some time (although not required) following inadvertent dural puncture to minimise risk of headache (please tick the appropriate time period which starts from time of insertion) h 12 h h 18 h h 24 h h 36 h Ó 2005 Blackwell Publishing Ltd 679