Incidence of Headache Following an Unintentional Dural Puncture

Unintentional dural puncture is a known risk of neuraxial techniques, occurring in roughly 1%
of all epidural catheter placements. The incidence of post dural puncture headaches(PDPH)
after unintentional dural puncture (UDP) is 50-80%. A PDPH is defined as a headache that
occurs following a dural puncture, worsens within 15 minutes after sitting or standing and
improves within 15 minutes after lying, with at least one of the following: neck stiffness,
tinnitus, hypacusia, photophobia, or nausea. The headache develops within 5 days after dural
puncture and resolves either spontaneously within 1 week or within 48 hours after effective
treatment of the spinal fluid leak.

The rates of PDPH following unintentional dural puncture with placement of an intrathecal
catheter will be compared in two groups: intrathecal morphine (treatment) versus intrathecal
saline (control) administered 1-2 hours after delivery, followed by immediate catheter
removal. Patients randomized to the treatment group (morphine) will receive preservative-free
morphine 0.3 mL (150 mcg) intrathecally. Those randomized to the control group will receive
normal saline 0.3 mL intrathecally. After administration of intrathecal morphine, all
patients will have their respirations monitored every hour for a period of 12 hours and then
every two hours for a period of 12 hours. On postpartum days 1-5, all patients will be
visited daily while inpatient and/or contacted by phone after discharge from the hospital.

PDPH can lead to significant morbidity and negatively impact patient satisfaction with
postpartum recovery. Along with headache, patients may develop cranial nerve palsy during the
postpartum period leading to permanent disability. In addition, new mothers are unable to
bond with their babies due to headache and associated symptoms of nausea, vomiting and
limited mobility secondary to pain. Therefore, an effective intervention to decrease the risk
of PDPH after UDP would be useful.

Inclusion Criteria:

- Postpartum patients following vaginal delivery

- Unintentional dural puncture

- Functioning intrathecal catheter

- Patients must be 18 years of age or older

- English speaking.

Exclusion Criteria:

- History of previous PDPH

- Body mass index BMI > 40 kg/m2

- History of obstructive sleep apnea (OSA)

- Morphine allergy

- Patients who receive Cesarean delivery