Incidence Of Accidental Dural Puncture Research Articles

A Structured Method of Teaching Epidural Block reduces the incidence of accidental dural puncture in inexperienced trainees.

A Structured Method of Teaching Epidural Block reduces the incidence of accidental dural puncture in inexperienced trainees.

Handheld ultrasound-assisted versus palpation-guided combined spinal-epidural for labor analgesia: a randomized controlled trial

Preprocedural ultrasound assistance can enhance the efficacy of neuraxial anesthesia in obstetrics. We investigated whether the use of handheld ultrasound can shorten the procedural time of labor combined spinal-epidural (CSE) analgesia compared with conventional landmark-guided methods. Eighty-four women requesting labor analgesia were randomly assigned to either handheld ultrasound-assisted or palpation-guided CSE analgesia. Primary outcome was procedure time of the CSE analgesia. Secondary outcomes included identification time, performance time, number of needle manipulations required for epidural/spinal success, first-attempt success rate, periprocedural pain scores, the incidence of accidental dural puncture, and patient satisfaction. Total procedure time did not significantly differ between the ultrasound and palpation groups (median [IQR], 191.5 [167–224] vs. 204.5 [163–358] s; P = 0.442). However, the performance time was significantly shorter in the ultrasound group (134.5 [115–177] vs. 183 [129–296] s; P = 0.011), although identification time was longer in the ultrasound group (53 [41–72] vs. 30.5 [21–45] s; P < 0.001). The epidural success rate at first insertion attempt was higher in the ultrasound group (85.7% vs. 59.5%, P = 0.014). Preprocedural handheld ultrasound assistance resulted in equivalent total procedure times but reduced performance times and higher first-attempt success rates. Therefore, clinicians may consider this technique for labor CSE analgesia.Trial registration: NCT04759547.

P. 68 Neurological complications after epidural catheter insertion for labour analgesia: an observational study including more than 92% of deliveries in Malta

Introduction: Neuraxial techniques are the gold standard for labour analgesia. However, these techniques are not risk-free. Particularly, the incidence of accidental dural puncture (ADP), predisposing to the development of post-dural puncture headache (PDPH), is considered a standard of care in many units. [1] Plaat, F. Regional analgesia during labour. In: Chereshneva M, Johnston C, Calvin JR, Peden CJ, editors. Raising the Standards: RCoA quality improvement compendium. London: Royal College of Anaesthesia;2020.248-9. Google Scholar Our centre caters for over 4000 births annually and has a dedicated obstetric anaesthetist round the clock. All procedures carried out by obstetric anaesthetists are recorded in a paper logbook.

Accidental dural puncture-perioperative management.

Accidental dural puncture-perioperative management.

Accidental dural puncture and post-dural puncture headache: a retrospective review in an Irish maternity hospital.

Accidental dural puncture (ADP) during epidural catheter insertion and the possible consequent post-dural puncture headache (PDPH) remain challenging complications in obstetric anaesthesia. ADP/PDPH can represent a considerable degree of morbidity for the parturient and require immediate diagnosis and appropriate management to ensure recovery and avoid complications. This retrospective audit was carried out to identify the accidental dural puncture and post-dural puncture headache rates at the Coombe Women and Infant University Hospital in Dublin. Cases of ADP and PDPH were identified retrospectively from a register used to record these cases. Demographic and obstetric data was retrieved using the patients' medical records. Analysis was carried using MS Excel. In 1year (June 1, 2018 to June 1, 2019), there were 25 cases of ADP during epidural catheter insertion and this is 0.78% of epidurals done in this period. Seventeen of these (68%) subsequently developed PDPH. In total, there are 32 cases of PDPH: 27 after epidural analgesia using an 18G Touhy needle and 5 after a spinal anaesthetic using a 25G Whitacre needle. All PDPH cases received first-line conservative treatment and 9 (28.1%) required an epidural blood patch (EBP). No-one required a second EBP. The incidence of ADP at our hospital (0.78%) is within the range quoted in the literature (0.1-1.5%) and below the UK standard of 1%. The incidence of PDPH after recognized ADP (68%) is also consistent with other published reports.

Epidural Space Identification Using Continuous Real-Time Pressure Sensing Technology (CompuFlo&amp;lt;sup&amp;gt;&amp;amp;reg;&amp;lt;/sup&amp;gt;): A Report of 600 Consecutive Cases

Introduction. The aim of this open, prospective, single operator study was to report the clinical experience with the CompuFlo? Epidural Instrument. Method. Epidural block was performed with the CompuFlo? Epidural Instrument in all consecutive patients undergoing an epidural or thoracic block under the author’s care over a two years period. The epidural needle was considered to have reached the epidural space when an increase in pressure (accompanied by an increase of the pitch of the audible tone) was followed by a sudden and sustained drop in pressure of more than 5 seconds accompanied by a sudden decrease of the pitch of the audible tone, resulting in the formation of a low and stable pressure plateau on the instrument’s visual display. The following outcomes were evaluated: incidence of accidental dural puncture, success of anesthesia, procedure time, volume of saline used for the epidural procedure, number of epidural attempts to reach the epidural space, number of needle redirections, and the operator’s agreement with his tactile sensation of loss of resistance and the CompuFlo? pattern. Results. A total of 600 cases were studied. All the epidural blocks were successful and no accidental dural punctures were noted. Epidural space was correctly identified on the first attempt in 91% of cases, in 95% of cases the operator judged as a perfect correlation between his tactile sensations and the CompuFlo? recordings. Conclusion. The major finding of this paper is the very high success rate of the epidural blocks, no matter in what clinical setting (obstetrical, surgical or blood patch intervention) or at which vertebral level (thoracic or epidural) were done. Most importantly, the reporting of zero incidence of any accidental dural puncture.

Postdural Puncture Headache and Epidural Blood Patch in a Large Obstetric Anaesthesia Population.

Postdural puncture headache (PDPH) is the most common serious complication in obstetric anesthesia. We show the incidence of accidental dural puncture (ADP), PDPH, epidural blood patch (EBP) and associated morbidity following a protocol established in an obstetric anesthesia department. An observational, prospective, analytical study performed in 66,540 epidural labor analgesia procedures. The objective is to describe the incidence of ADP, PDPH and EBP in a large obstetric anesthesia population, as well as morbidity associated with ADP and EBP. Incidence of ADP and PDPH was 0.76% and 59%, respectively, and the global incidence of EBP was 0.2%. Experience of the anesthetist performing the epidural (1st or 2nd year resident) and night shift were correlated with ADP. Low back pain was more frequent in patients undergoing EBP. We found an incidence of ADP and PDPH of 0.76% and 59%, respectively. Experience of the anesthetist performing the epidural (1st or 2nd year resident) and night shift were correlated with ADP. EBP is a safe, easy and acceptable treatment for PDPH, despite a higher risk of low back pain.

Incidence and management of post-dural puncture headache following spinal anaesthesia and accidental dural puncture from a non-obstetric hospital: A retrospective analysis.

Background and Aims:Post-dural puncture headache (PDPH) is one of the complications following spinal anaesthesia (SA) and accidental dural puncture (ADP). In our institute, we routinely practice epidural analgesia (EA) for supra-major surgeries. Our previous audit on EA revealed 4% incidence of ADP. This lead us to a clinical initiative to follow-up patients with dural puncture (DP) to note the incidence, presentation, associated symptoms and treatment of PDPH. Herewith, we present the retrospective analysis over a 2-year period.Methods:Following institutional review board approval, the follow-up notes of patients who had DP from May 2011 to April 2013 were analysed retrospectively (using SPSS 20 version) with respect to the needle size, level of DP, reinsertion of epidural catheter, details of ongoing analgesics, incidence and severity of PDPH and treatment received.Results:In 2 years, we found that the incidence of PDPH in the patients who received SA was 3.9% and 25% in the ADP group. There was a positive association between needle size, type and PDPH, and it was seen more in the 20–40 age group. The commonest presentation of PDPH was occipital/frontal headache within 96 h and lasted for a mean of 3 days. All patients received pharmacological treatment. Seventy-one per cent of patients (25) were either on coffee or caffeine tablets. One case of intractable PDPH responded well to oral pregabalin 75 mg.Conclusion:PDPH severity and incidence following ADP in our centre is lower than the reported incidence from obstetric centres and can be effectively controlled with drug treatment only.

Postdural Puncture Headache and Epidural Blood Patch in a Large Obstetric Anaesthesia Population

Background: Postdural puncture headache (PDPH) is the most common serious complication in obstetric anesthesia. We show the incidence of accidental dural puncture (ADP), PDPH, epidural blood patch (EBP) and the associated morbidity following an Obstetric Anesthesia Department´s protocol. Methods: An observational, prospective, analytical study was performed in 66.540 labor epidural analgesia. The objective is to describe the incidence of accidental dural puncture, postdural puncture headache and epidural blood patch in a large obstetric anesthesia practice population, as well as the associated morbidity of ADP and EBP. Results: The incidence of accidental dural puncture obtained was 0.76%, of postdural puncture headache 59%, and the global incidence of epidural blood patch 0.2%. Experience of the anesthetist performing the epidural (1st or 2nd year resident) and night time were associated with ADP. Low back pain rate was more frequent in those patients who received an epidural blood patch. Conclusion: We found an incidence of ADP and PDPH of 0.76% and 59% respectively. Experience of the anesthetist performing the epidural (1st or 2nd year resident) and nighttime were associated with ADP. EBP is a safe, easy and acceptable option as treatment for PDPH even with a higher risk of low back pain.

Nine-year audit of post-dural puncture headache in a tertiary obstetric hospital in Singapore

BackgroundThe KK Women’s and Children’s Hospital is a tertiary obstetric unit with approximately 11000 deliveries per year. Epidural analgesia is used in about 40% of laboring women. We reviewed the incidence and management of post-dural puncture headache over a nine-year period. MethodsA retrospective audit of labor epidural analgesia database records from 1 June 2005 to 31 May 2014 was conducted, identifying an “event” as an accidental dural puncture, an inadvertent intrathecal catheter insertion and/or development of a post-dural puncture headache. ResultsA total of 43434 epidural records were reviewed. Sixty-three events were identified (an incidence of 0.15%). Women had median age of 30years and median body mass index of 27.6kg/m2; 69.8% (44/63) delivered vaginally. Procedures performed by less experienced anesthesiologists and those performed outside office hours were associated with a higher incidence of accidental dural puncture. An intrathecal catheter was inserted in 52 of 58 women (89.7%). Headache developed in 24 of 38 (63.1%) women in whom there was a witnessed accidental dural puncture. Most women who developed post-dural puncture headache presented during the primary admission (36/39; 92.3%). Paracetamol and non-steroidal anti-inflammatory drugs were the most commonly prescribed medications. Six women (9.5%) received an epidural blood patch which led to resolution of headache. ConclusionA retrospective audit over a nine-year period at a tertiary teaching hospital found the overall incidence of post-dural puncture headache and associated events to be 0.15%, with a decreasing trend coinciding with improvement in the teaching and supervision of trainees in labor epidural procedures.

Punção Acidental da Dura e Cefaleia Pós-punção da Dura na População Obstétrica: Oito Anos de Experiência

Accidental dural puncture is an important complication of regional anesthesia and post-dural puncture headache remains a disable outcome in obstetric population. The aim of our study was to calculate the incidence of accidental puncture and post-puncture headache and evaluate its management among obstetric anesthesiologists. We conducted a retrospective audit, between January 2007 and December 2014. We reviewed the record sheets of patients who experienced either accidental puncture or post-puncture headache. We excluded the patients undergoing spinal block. We use the SPSS 22.0 for statistical analyses. We obtained 18497 neuro-axial blocks and 58 accidental dural punctures (0.3%). After detected puncture, in 71.4% epidural catheter was re-positioned and 21.4% had intra-thecal catheters. Forty-five (77.6%) developed headache and the prophylactic measures were established in 76.1%. Conservative treatment was performed in all patients. The epidural blood patch was performed in 32.8% with a 84.2% of success. The incidence of post-dural puncture headache is unrelated to the type of delivery or insertion of intrathecal catheter. The re-placement of the epidural catheter remains the main approach after puncture. The institution of prophylactic measures is a common practice, despite the low level of evidence. We performed epidural blood patch after failure of conservative treatment. The incidence of accidental dural puncture and post-dural puncture headache was similar to the literature. Despite being a common complication, there remains lack of consensus on its approach.

No rent is small for migration of epidural catheter into sub-arachnoid space.

Sir, Epidural analgesia forms the mainstay of pain relief in abdominal surgeries.[1,2] Epidural needle placement and catheter insertion are preferably performed under local anaesthesia, before induction of general anaesthesia.[3] Dural puncture by the epidural needle is a known complication, and the reported incidence of accidental dural puncture varies from 0.4% to as high as 6%.[4] Dural puncture precludes the catheter placement in the same inter-vertebral space because rent created in the dura mater may allow intra-thecal migration of the epidural catheter. We report a case of inadvertent intra-thecal migration of the epidural catheter through a dural puncture by a 26 gauge needle. A 38-year-old male patient, height 167 cm and weight 63 kg. was posted for hepato-jejunostomy for the benign stricture of the common bile duct. After a written informed consent, patient was taken up for the surgery. As part of perioperative anaesthesia care, epidural catheter placement was planned in the sitting position. With all sterile precautions, inter-vertebral space between 8th and 9th thoracic vertebra was marked and was punctured with a 26 gauge 1½ inch long needle, for infiltration of local anaesthesia. An aspiration check before injecting the local anaesthetic revealed that probably dura mater had been punctured, and fluid, possibly cerebro-spinal fluid (CSF) was getting aspirated. A note of the depth at which dura mater was punctured was made. Because the dura mater was punctured with a 26 gauge needle, too small to be of concern, it was decided to use the same inter-vertebral space for epidural catheter placement. Epidural space was identified by the loss of resistance technique with a 16 Gauge 12 cm long Tuohy epidural needle (with catheter stabiliser). Skin to epidural space distance was 4 cm. There was no CSF leakage at the hub of the epidural needle. The epidural catheter was easily inserted through the needle but just as the catheter had crossed the mark of 14 cm at needle hub, fluid was seen flowing into the catheter. Fluid was aspirated into a syringe, and it was confirmed as CSF (temperature and sugar content of the aspirated fluid). Epidural catheter was then withdrawn and was placed in an inter-vertebral space higher up. Rest of the course of the hospital stay of the patient was uneventful. Dural puncture by epidural catheter on its own is not possible, though arachnoid puncture by the epidural catheter has been shown in an experimental study.[5] In our patient since dura mater and the arachnoid mater were punctured with a 26 G needle, it would have created a weak point through which subsequently the epidural catheter would have travelled into the intra-thecal space. Robbins et al. had also reported a similar case where accidental intra-thecal insertion of an extradural catheter happened during combined spinal-extradural anaesthesia.[6] They used a 26 gauge Whitacre spinal needle through 16 gauge Tuohy extradural needle. Physical characteristics like height and weight can be used to predict the depth of the epidural space to guide epidural needle placement. Ravi et al. in their study had concluded that the mean depth of epidural space in patients of body mass index (BMI) <30 is 41.60 ± 5.80 mm on the basis of a formula (Depth [mm] = a + b [BMI]. where a = 17.7966 and b = 0.9777).[7] Our patient with a calculated BMI of 22.6, the predicted depth of the epidural space was 39.89 mm. Whereas skin to sub-arachnoid space depth (SSD) in Indian males is reported to be 4.81 ± 0.68 cm,[8] the formula derived for determining SSD in the Indian population, 2.71 + 0.09 × BMI, predicts SSD of 4.74 cm for our patient.[8] We located the epidural space at 4 cm depth from the skin that was well within the predicted depth for epidural space, and was short of the predicted SSD. This also supports our observation that the epidural needle was indeed in the extradural space. In our case, that the epidural catheter migrated into the sub-arachnoid space in the absence of any undue force warrants caution. We suggest that caution should be exercised even while puncturing inter-vertebral space for infiltration for local anaesthesia and in case dural puncture happens, epidural puncture should not be attempted in the same inter-vertebral space.

Lower incidence of post-dural puncture headache with spinal catheterization after accidental dural puncture in obstetric patients.

Accidental dural puncture (ADP) and post-dural puncture headache (PDPH) are important complications of obstetric regional anesthesia. Inserting the catheter intrathecally after ADP to prevent PDPH has gained popularity. Nonetheless, data on the effect of an intrathecal catheter on PDPH and epidural blood patch (EBP) rates are mixed. Our primary objective was to examine if spinal catheterization reduces the incidence of PDPH after ADP in obstetric patients. Anesthetic records of 29,749 regional blocks performed between January 1997 and July 2013 were analyzed retrospectively. In all blocks containing an epidural component, 18-gauge epidural needles were used. All patients who experienced a witnessed ADP or PDPH without ADP were identified. Data from patients with or without a prolonged spinal catheter were compared. There were 128 events of witnessed ADP (0.43%). Following known ADP, 39 women had an epidural catheter placed at a different level and 89 had an intrathecal catheter (20-gauge) for at least 24 h. Sixty-one patients developed PDPH after observed ADP (48%). Prolonged intrathecal catheter placement significantly reduced the incidence of PDPH after ADP to 42% compared with 62% in those who have the catheter re-sited epidurally [odds ratio = 2.3 (95% confidence interval 1.04-4.86); P = 0.04]. The incidence of ADP, PDPH and blood patching is similar with previously published studies. After witnessed ADP, inserting the epidural catheter intrathecally significantly reduced the incidence of PDPH.

Incidence of accidental dural puncture and post-dural puncture headache as markers of quality in anesthesiology in HCPB. Results 2011-Sep/2013

Incidence of accidental dural puncture and post-dural puncture headache as markers of quality in anesthesiology in HCPB. Results 2011-Sep/2013

The incidence and management of inability to advance Arrow FlexTip Plus® epidural catheters in obstetric patients

BackgroundDifficulty advancing epidural catheters is troublesome to obstetric anesthesiologists. Flexible epidural catheters have been shown to reduce paresthesiae and intravascular catheter placement in parturients, but the cause of inability to advance these catheters past the epidural needle tip remains undefined. Specifically, its incidence and effective management strategies have not been described. MethodsAll labor epidural catheters were recorded for a 22-week period. Difficulty advancing the epidural catheter was defined as an inability to advance the catheter beyond the needle tip after obtaining loss of resistance. Anesthesiologists completed a survey when difficulty advancing a catheter occurred. ResultsA total of 2148 epidural catheter placements were performed. There were 97 cases of an inability to advance the epidural catheter (4.5%, 95% CI 3.7 to 5.5%). This occurred in 4.2% of combined spinal-epidural and 4.6% of epidural placements (OR 0.92, 95% CI 0.53 to 1.62). On a 0 to 10scale, the median [IQR] provider confidence in loss of resistance was 9 [8, 10]. A total of 230 corrective maneuvers were performed, using nine distinct approaches. The incidence of accidental dural puncture was 3.1% if an inability to advance occurred (n=97) compared to 1.2% for other placements (n=2051, P=0.12). DiscussionInability to advance Arrow FlexTip Plus® epidural catheters was relatively common (4.5%) and occurred despite confidence in obtaining loss of resistance. Injecting saline may be corrective and appears to have little disadvantage. However, removing the needle and performing a new placement was the most successful corrective maneuver.

Ten years of experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department

Accidental dural puncture (ADP) and post-dural puncture headache (PDPH) are important complications of obstetric regional anaesthesia. Between January 1997 and October 2006 in our tertiary obstetric referral centre 17 198 neuraxial blocks were recorded; 965 epidural, 16193 combined spinal-epidural and 40 spinal. Records of all parturients who experienced either ADP or PDPH were reviewed. There were 89 ADPs (0.5%), 55 observed and 34 in which PDPH followed unrecognised dural puncture. Following known ADP, 28 women had epidural catheters re-sited at a different lumbar interspace and 27 had intrathecal catheters for at least 24 h. Thirty-one women developed PDPH after observed ADP; the incidence of PDPH was similar after puncture with needle and catheter, after epidural and CSE techniques, after 27- and 29-gauge pencil-point spinal needles and after spinal and epidural catheter insertion (61% vs 52%; P>0.05). All headaches presented within 72 h. A blood patch was needed in 26/55 women after known ADP and 27/34 unrecognised ADP. A repeat blood patch was needed in 8 (15%). The incidence of ADP, PDPH, blood patching and repeat blood patching is similar to previous studies. Many ADPs are unrecognised during epidural insertion. CSE does not appear to increase the risk of ADP or PDPH; 29-gauge rather than 27-gauge pencil-point spinal needles conferred no benefit. Inserting the epidural catheter intrathecally did not significantly reduce the incidence of PDPH and blood patching in our series.

Intrathecal catheterization by epidural catheter: management of accidental dural puncture and prophylaxis of PDPH

Accidental or inadvertent dural puncture during epidural anaesthesia results in high incidence of post dural puncture headache (PDPH). Spinal or intrathecal catheter in such a situation, provides a conduit for administration of appropriate local anaesthetic for rapid onset of intraoperative surgical anaesthesia and postoperative pain relief. This procedure prevents PDPH if catheter left in situ for > 24 hrs and also avoids the associated risks with a repeat attempts at epidural analgesia. Primary aim of this study was to observe the effect of spinal catheter on incidence of PDPH, and to assess early and delayed complications of spinal catheterization by epidural catheter. In prospective clinical study 34 patients who had accidental dural puncture during epidural anaesthesia were included. The catheter meant for epidural use was inserted in spinal space and used for spinal anaesthesia and postoperative analgesia. Catheter was removed between 24-36hrs after surgery. The incidence of accidental dural puncture was 4%(34/846). Two patients 5.88% (2/34) had transient paresthesia during spinal catheter insertion. Post dural puncture headache occurred in 11.76% (4/34) patients. Two patients required epidural blood patch and two patients were managed with conservative treatment. No patient had any serious intraoperative or postoperative side effects. Epidural catheter can be used as spinal catheter to manage accidental dural puncture without serious complications, and it also prevents PDPH.

Comparison of epidural analgesia with combined spinal-epidural analgesia for labor: a retrospective study of 6497 cases

Combined spinal-epidural analgesia provides rapid-onset analgesia with minimal motor block, but it is a more invasive technique than epidural analgesia and the risk of complications may be increased. This study compared the safety and effect on delivery of combined spinal-epidural and epidural analgesia in labor. A retrospective observational study was performed. Data were collected from 6497 women who received regional analgesia in our tertiary hospital in 2005. The incidence of complications during labor and the day after delivery was compared. The effect on labor outcome with both techniques was also assessed. 1964 received combined spinal-epidural (30.2%) and 4533 epidural analgesia (69.8%). Quality of analgesia was better in the combined spinal-epidural group. Labor outcome was similar in the two groups. Pruritus, paresthesia and back pain were more frequent in the combined spinal-epidural group. No differences were observed in the incidence of accidental dural puncture or post dural puncture headache. We found that epidural and combined spinal-epidural analgesia were comparable in terms of safety, and had a similar effect on delivery type.

The effect of epidural needle type on postdural puncture headache: a randomized trial

A prospective, randomized trial in labouring parturients was undertaken to assess whether the 18G Special Sprotte epidural needle is associated with a lower incidence of accidental dural puncture (ADP) in comparison with the 17G Tuohy needle. A secondary purpose was to determine if the incidence of postdural puncture headache (PDPH ) differed between groups when ADP occurred. Following Institutional Review Board approval 1,077 parturients requesting epidural analgesia at three tertiary obstetrical units were randomized to epidural catheter insertion with a 17G Tuohy or 18G Special Sprotte needle. Patients were followed for seven days by a blinded assessor to determine the occurrence of PDPH using standardized criteria. If postural headache or neck ache presented, an ADP was diagnosed even if cerebrospinal fluid (CSF) was not observed at insertion. This subgroup was followed daily to assess headache characteristics and response to blood patch. Six Tuohy group patients, and two patients in the Sprotte group were excluded. One of the six excluded in the Tuohy group had an ADP. Twenty-eight ADPs occurred, nine unrecognized by CSF visualization (1.8% Tuohy, 3.4% Sprotte, P = 0.12). The incidence of unrecognized ADPs was higher in the Sprotte group (40% Sprotte vs 20% Tuohy, P < 0.05). If ADP occurred, the incidence of PDPH was lower in the Sprotte group (100% Tuohy vs 55% Sprotte, P = 0.025). The ease of use, and user satisfaction were higher in the Tuohy group (84 +/- 17.3% Tuohy vs 68.2 +/- 25.3% Sprotte, P < 0.001). The incidence of ADP was not reduced with the Special Sprotte epidural needle in comparison with the Tuohy needle, but PDPH after ADP occurred less frequently in the Sprotte group.

Post-dural headache in obstetrics: a complication of epidurals and spinals

Post-dural puncture headache (PDPH) is a well-known complication of spinal or epidural anaesthesia and diagnostic lumbar puncture. It represents the most common potentially serious complication of obstetric regional analgesia and anaesthesia. The reported incidence of accidental dural puncture during epidural analgesia is around 1%, although with considerable variation between units. This contribution covers the aetiology of and contributory factors to PDPH, presentation and diagnosis, management – including drug treatment and epidural blood patch – and prevention.