title: Second stage pushing correlates with headache after unintentional dural puncture in parturients.
abstract: OBJECTIVE
  To determine the association between bearing down, postdural puncture headache (PDPH) and epidural blood patch (EBP) following single 17 gauge unintentional dural puncture (UDP) in parturients.
  
  
  METHODS
  The charts of 60 parturients identified with UDP in our institutional database during epidural placement were independently reviewed. Patients were divided into categories based on the anesthetic record: well-documented single punctures; well-documented multiple punctures; catheter-related puncture; unclear category (not clear if more than one puncture occurred or if dural puncture had occurred at all) and no evidence of dural puncture. Patients with single 17 gauge punctures were divided into those who had pushed (Group 1) and those who had not (Group 2). Group 2 patients had undergone Cesarean section before reaching second stage labour. The incidence of PDPH, EBP, and cumulative duration to delivery after UDP were compared between groups.
  
  
  RESULTS
  Thirty-three patients with well-documented single punctures were identified: 23 had engaged in active pushing as part of second stage labour (Group 1); 10 had not (Group 2). Seventy-four percent of Group1I developed PDPH compared with 10% in Group 2 (P < 0.002). Fifty-seven percent of Group 1 received an EBP compared with 0% in Group 2 (P < 0.002). Increasing the duration of pushing was associated with an increasing incidence of PDPH; the majority of women who pushed > 30 min developed headache.
  
  
  CONCLUSIONS
  An increased incidence of PDPH and EBP after UDP occurs in women bearing down in 2nd stage labour when compared with those who never pushed. There was also an association between the cumulative duration of bearing down and the incidence of PDPH.
authors.affiliation: Department of Anesthesiology, Sunnybrook and Women's College Health Sciences Center (Women's College Hospital Campus), University of Toronto, Ontario, Canada. angle@ftn.net
authors.forename: P
authors.initials: P
authors.lastname: Angle
authors.forename: D
authors.initials: D
authors.lastname: Thompson
authors.forename: S
authors.initials: S
authors.lastname: Halpern
authors.forename: D B
authors.initials: DB
authors.lastname: Wilson
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000009:adverse effects*; D016362:Analgesia, Obstetrical / Q000009:adverse effects*; D017217:Blood Patch, Epidural; D002585:Cesarean Section; D004388:Dura Mater / Q000293:injuries*; D005260:Female; D006261:Headache / Q000209:etiology*; D006801:Humans; D007748:Labor Stage, Second; D011247:Pregnancy; D012189:Retrospective Studies