North American survey of the management of dural puncture occurring during labour epidural analgesia

Purpose: To document the range and the most common strategies for the management of the parturient with inadvertent dural puncture (DP) during labour epidural analgesia. Methods: A confidential survey form was mailed to 46 academic units in Canada and USA. The responses were compiled into Canadian, US and joint North American databases. Results: Thirty-six centres (78%) responded, representing 137,250 annual deliveries. The reported incidence of DP was 0.04-6%. The most common initial response to DP was re-siting the catheter at another level. Most centres made little change in routine practice regarding epidural top-ups and infusion rates after DP. Unrestricted mobilisation was advocated by 86% of centres following delivery; enhanced oral hydration was encouraged by 61%. Prophylactic epidural blood patch (PEEP) was recommended by 37% of centres, with twice as many US as Canadian centres doing so. In the presence of PDPH, EBP was offered most commonly at or within 24 hr of diagnosis. Complications were common after EBP: 86% of centres reported patch failures; 44% reported persistent headache after greater than or equal to 2 EBP. Despite this, centres remained optimistic about EBP success, quoting cure rates >90% in 58% of centres. Conclusion: There is little difference between the practices reported by Canadian or US centres. The expressed optimism regarding the efficacy of EBP is not supported by the evidence available and may be unwarranted. More research is needed to define the issue better.