Other causes of postpartum headache should be excluded (see Table 44.1, p. 115). Two operators are required. Whilst one locates the epidural space in the usual way, the other prepares to draw 20 ml of blood under aseptic conditions. The blood is injected slowly and the patient is asked to report any unpleasant effects. The interspace at or below the level of the original dural puncture is usually recommended, since injected blood has been shown to track mainly upwards after injection. In general, the more blood that is injected the greater the chance of success; most would attempt to inject 15-20 ml if no adverse effects allow. Flushing the epidural needle with saline as it is withdrawn has been suggested, to avoid leaving a plug of blood, which can act as a conduit for infection.
The patient is usually kept lying for 2-4 hours after EBP (reduced efficacy has been suggested if mobilisation is immediate). The success rate of EBP has been reported as 70-100%; typically, there is complete relief of headache, although some degree of headache may return in up to 30-50% of women. Repeat EBP is sometimes required, rarely more than once. The procedure is performed on an outpatient basis in some units.
The mother should be fully informed of the benefits and risks of EBP (including the fact that proper randomised trials are few, as concluded by a recent Cochrane review). A senior anaesthetist should perform the EBP for two reasons: first, the original epidural may have been difficult, and a second dural puncture occurring during EBP would be at best embarrassing; second, the mother has suffered considerable distress and deserves the reassurance of knowing that a senior anaesthetist is handling her case. Since the headache may return after EBP, she should be invited to contact the anaesthetist if this occurs.
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