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Prevention of the postpartum, postspinal headache
Prevention of the postpartum, postspinal headache WARREN M. JACOBS, M.D. Houston, Texas
Materials and method
S AD D L E block anesthesia is well established as an effective and safe method for obstetric delivery. The only important deterrent to the more widespread use of saddle block is the fairly frequent occurrence of -postspinal headache. Most investigators feel that the headache is the result of leakage of spinal fluid through the puncture site, resulting in a reduction in voltLme of cerebrospinal fluid with dilatation of the intracranial vessels. When the patient is in the standing position, traction is exerted on the supporting structures of the brain and headache results. Dehydration is the most important factor in the development of headache and since the onset of the headache usually coincides with the appearance of maximum postpartum diuresis (second or third postpartum day), this is even more apparent. Another factor is the size of the needle used for the puncture1 ; the smaller the needle bore, the smaller the puncture wound and the less likelihood of leakage.
Since dehydration seems to be the major factor, the problem was attacked from this angle. Two hundred and fifty patients comprise this study. All of these patients were delivered vaginally without any undue complications. Of this group, labor was electively induced in 120 either by amniotomy alone or amniotomy in combination with intravenous oxytocin. All of these patients received 1,000 c.c. of 5 per cent glucose in normal saline which was initiated immediately after delivery. If the patient was receiving intravenous oxytocin at the time of delivery, the saline infusion followed the completion of the oxytocin. If a patient showed any signs of toxemia, she was not included in this series. Results
This study embraced the calendar year of 1960. A total of 1,238 patients received saddle block anesthesia for delivery during this period. One hundred and sixty-nine patients of 988 who did not receive the saline infusion developed headache. This represents an incidence of 16.1 per cent. Only 17 of the 250 patients in the group receiving saline developed headache, an incidence of 6.7 per cent, which is slightly less than half the incidence in the nontreated group. There were no untoward effects from the saline
Incidence
The reported incidence of postpartum postspinal headache in the literature varies from 5 to 25 per cent. In the past few years, the incidence at Methodist Hospital has been in the neighborhood of 15 to 16 per cent.
• r • IniUSlOnS.
Comment
From the Department of Obstetrics and Gynecology, Baylor University College of Medicine and Methodist Hospital, Texas Medical Center.
Prevention of postspinal headache is the hest treatment. It would appear that the 320
Volume 83 Number3
prophylactic use of intravenous saline is rather effective and merits further trial. Zuspan, in a similar study, but using 500 c.c. instead of 1,000 c.c., got equally good results. In addition, Zuspan 2 used intramuscular vasopressin to treat the headaches after they had developed, also with good results. The rationale of prophylactic intravenous saline and therapeutic vasopressin as well, is based on hydration and antidiuresis. When intravenous saline is administered, it has the twofold action of supplying fluid as well as causing some temporary antidiuresis. In addition, the saline produces thirst, hence the patient will add to her hydration by the oral route. Summary
1. During the one year period of study,
1,238 patients 'vere given saddle block
Prevention of postpartum, postspinal headache 321
anesthetics. Two hundred and fifty of these received 1,000 c. c. of 5 per cent glucose in normal saline just after delivery with a 6. 7 per cent incidence of headache. The incidence of headache in the group not receiving intravenous therapy was 16.1 per cent. 2. The results obtained from the study indicate that intravenous therapy as described offers protection against the development of a postspinal, postpartum headache and should be considered for routine use in all parturients delivered under saddle block anesthesia except patients exhibiting signs of toxemia of pregnancy. 3. No adverse reaction to the described regimen was encountered. REFERENCES
1. Bumgardner, H. D., and Burns, F. D.: AM.
J. 0BST. & GYNEC. 69: 135, 1955. 2. Zuspan, F. P.: Obst. & Gynec. 16: 21, 1960.
Materials and method
S AD D L E block anesthesia is well established as an effective and safe method for obstetric delivery. The only important deterrent to the more widespread use of saddle block is the fairly frequent occurrence of -postspinal headache. Most investigators feel that the headache is the result of leakage of spinal fluid through the puncture site, resulting in a reduction in voltLme of cerebrospinal fluid with dilatation of the intracranial vessels. When the patient is in the standing position, traction is exerted on the supporting structures of the brain and headache results. Dehydration is the most important factor in the development of headache and since the onset of the headache usually coincides with the appearance of maximum postpartum diuresis (second or third postpartum day), this is even more apparent. Another factor is the size of the needle used for the puncture1 ; the smaller the needle bore, the smaller the puncture wound and the less likelihood of leakage.
Since dehydration seems to be the major factor, the problem was attacked from this angle. Two hundred and fifty patients comprise this study. All of these patients were delivered vaginally without any undue complications. Of this group, labor was electively induced in 120 either by amniotomy alone or amniotomy in combination with intravenous oxytocin. All of these patients received 1,000 c.c. of 5 per cent glucose in normal saline which was initiated immediately after delivery. If the patient was receiving intravenous oxytocin at the time of delivery, the saline infusion followed the completion of the oxytocin. If a patient showed any signs of toxemia, she was not included in this series. Results
This study embraced the calendar year of 1960. A total of 1,238 patients received saddle block anesthesia for delivery during this period. One hundred and sixty-nine patients of 988 who did not receive the saline infusion developed headache. This represents an incidence of 16.1 per cent. Only 17 of the 250 patients in the group receiving saline developed headache, an incidence of 6.7 per cent, which is slightly less than half the incidence in the nontreated group. There were no untoward effects from the saline
Incidence
The reported incidence of postpartum postspinal headache in the literature varies from 5 to 25 per cent. In the past few years, the incidence at Methodist Hospital has been in the neighborhood of 15 to 16 per cent.
• r • IniUSlOnS.
Comment
From the Department of Obstetrics and Gynecology, Baylor University College of Medicine and Methodist Hospital, Texas Medical Center.
Prevention of postspinal headache is the hest treatment. It would appear that the 320
Volume 83 Number3
prophylactic use of intravenous saline is rather effective and merits further trial. Zuspan, in a similar study, but using 500 c.c. instead of 1,000 c.c., got equally good results. In addition, Zuspan 2 used intramuscular vasopressin to treat the headaches after they had developed, also with good results. The rationale of prophylactic intravenous saline and therapeutic vasopressin as well, is based on hydration and antidiuresis. When intravenous saline is administered, it has the twofold action of supplying fluid as well as causing some temporary antidiuresis. In addition, the saline produces thirst, hence the patient will add to her hydration by the oral route. Summary
1. During the one year period of study,
1,238 patients 'vere given saddle block
Prevention of postpartum, postspinal headache 321
anesthetics. Two hundred and fifty of these received 1,000 c. c. of 5 per cent glucose in normal saline just after delivery with a 6. 7 per cent incidence of headache. The incidence of headache in the group not receiving intravenous therapy was 16.1 per cent. 2. The results obtained from the study indicate that intravenous therapy as described offers protection against the development of a postspinal, postpartum headache and should be considered for routine use in all parturients delivered under saddle block anesthesia except patients exhibiting signs of toxemia of pregnancy. 3. No adverse reaction to the described regimen was encountered. REFERENCES
1. Bumgardner, H. D., and Burns, F. D.: AM.
J. 0BST. & GYNEC. 69: 135, 1955. 2. Zuspan, F. P.: Obst. & Gynec. 16: 21, 1960.