title: Can the incidence of accidental dural puncture in laboring women be reduced? A systematic review and meta-analysis.
abstract: BACKGROUND
  Accidental dural puncture (ADP) after epidural analgesia (EDA) for labor pain may cause severe postdural puncture headache (PDPH) and may prolong hospital stay. We aimed to identify techniques that reduce the incidence of ADP.
  
  
  METHODS
  A systematic literature search was performed. Data on the occurrence of ADP and PDPH were extracted and subjected to meta-analysis. The random effects model was applied. Risk ratios (RR) and 95% confidence intervals (CI) were calculated.
  
  
  RESULTS
  We identified 54 articles, 13 non-randomized controlled trials and 41 randomized controlled trials (RCTs), reporting on a total of 98,869 patients. In non-RCTs, the use of liquid for the identification of the epidural space was associated with a reduced risk of ADP compared to the use of air (RR 0.55, 95% CI 0.39 to 0.79, P=0.001). In our analysis of RCTs this comparison did not produce a significant difference. No effect was found for combined spinal-epidural analgesia, maternal position, type of the catheter, needle size, bevel direction, operator experience, or use of ultrasound.
  
  
  CONCLUSIONS
  A reduction of the risk of ADP was found for liquid use for the loss of resistance, but only in lower quality studies. Based on current evidence, we cannot make a recommendation regarding any of the techniques under study. Therefore, clinicians should focus on measures to prevent or treat PDPH once ADP has occurred.
authors.affiliation: Department of Anesthesiology, Klinikum am Bruderwald, Bamberg, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Heesen
authors.forename: S
authors.initials: S
authors.lastname: Klöhr
authors.forename: R
authors.initials: R
authors.lastname: Rossaint
authors.forename: M
authors.initials: M
authors.lastname: Van De Velde
authors.forename: S
authors.initials: S
authors.lastname: Straube
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000009:adverse effects*; D016362:Analgesia, Obstetrical / Q000009:adverse effects*; D002986:Clinical Trials as Topic; D004388:Dura Mater / Q000293:injuries*; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D051299:Post-Dural Puncture Headache / Q000517:prevention & control; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies