A day after I gave birth to my daughter, Beatrice, I suddenly couldn’t get out of bed. It wasn’t exhaustion that was keeping me under the hospital bed’s stiff sheets—I physically couldn’t move without feeling like a metal pot was banging against my head and a freshly sharpened knife was digging into my neck. The only thing that brought relief was lying completely flat, without even so much as a pillow to prop me up. Only then would the ache disappear. But then I was unable to hold my newborn baby girl in my arms.
At first, my OB-GYN thought I had simply pulled a neck muscle during labour. It was only after both topical and oral painkillers failed to bring even a smidgen of relief that we discovered the real issue: I had a post-dural puncture headache (PDPH). During my epidural, the needle had accidentally passed through my dura (the outer membrane that envelopes the spinal cord) and created a tiny hole that was now leaking cerebrospinal fluid, resulting in a pressure headache so intense it made my past migraines feel like a head massage.
Epidurals are meant to relieve the pain of childbirth, but sometimes they go wrong. According to the Canadian Journal of Anesthesia, post-dural puncture headaches occur in one to three out of every 100 women who undergo an epidural. They are considered the most common significant complication of a puncture, says Pamela Angle, director of the obstetrical anesthesia research unit at Sunnybrook Research Institute in Toronto. Women around age 20 to 40 are at a greater risk than those younger or older due to higher levels of cerebrospinal fluid. Previous spinal issues and a lower body mass index are also thought to increase your chances.
Compared to other needles used in spinal procedures, the curved tip of an epidural needle and its larger diameter are often what cause punctures and subsequent leaks, says Angle. She explains that the larger needle is needed in order for a catheter to be inserted, but that size also makes it more likely that spinal fluid will leak if a hole is created in the dura. The fluid-filled sacks that surround the spine also surround the brain, and if too much fluid flows through the hole, the pressure around the brain is reduced, resulting in an intense throbbing headache that sets in within five days post-puncture, with many patients experiencing pain within a day or two. The headache becomes worse when you stand or sit up because the pressure around the brain is reduced even more. In an attempt to maintain the pressure, vessels around the brain dilate to fill with more blood, which causes the headache, says Angle. Other symptons can include nausea, vomiting and stiffness in the neck.
Despite its relatively quick onset, post-dural puncture headaches are difficult to diagnose. Hormonal changes, stress and sleep deprivation can cause tension headaches in 50 percent of women post-delivery, which makes it tricky for doctors to identify and treat headaches caused by epidurals.
The best treatment for a PDPH involves drawing blood from a patient’s arm and injecting it into the epidural space. This blood patch has a success rate of over 70 percent; however, it’s pretty invasive. Most doctors will only perform it if the patient has severe symptoms that last more than 48 hours.
Though conservative treatments include increased hydration or loading up on caffeine, recent studies have found that neither are all that useful. The most effective treatment is time. Most PDPHs resolve themselves without any treatment needed. Angle and her team performed a trial on 1,100 women and found 80 percent of patients’ headaches were gone within 10 days. More extreme cases have lasted six months to even a year.
My headache lasted two weeks. I was determined to try everything my doctors had suggested, from drinking as much as six litres of water a day to choking down extra-strong coffee. I even tried acupuncture with no success. In the end, time was the best treatment. Gradually I was able to get out of bed for short periods, the pain having transitioned to a dull ache. Then one morning, my ears started popping and I could feel the pressure start to balance out. Two days later, I was pushing my daughter’s stroller at the park pain-free.
Sadly, all of that time spent in pain can impact a mother’s ability to bond with her little one in those crucial first days, because sitting up to breastfeed or even just hold the baby can be too difficult. “It is hard to deal with everything that comes along with being a new parent at the same time as being in pain,” says Toronto-based OB-GYN Beth Cruickshank. “It is an emotional time, both high and low, and complications can absolutely impact some patients’ emotional health.”
Cruickshank advises patients to educate themselves as much as possible on epidurals and their side effects. “When my patients are in labour I always counsel them about the various options for pain control, including epidural. If my patients are interested in one, I encourage them to discuss the epidural with the anesthesiologist to learn more about the risks and benefits.” Specialized or larger hospitals, like Humber River Hospital in Toronto where Cruickshank works, often have 24-hour in-house anesthesia teams on the labour floor, which means more opportunities to discuss epidurals in advance of labour.
Despite having attended prenatal classes and reading the brochures from my OB-GYN, I don’t remember PDPH being mentioned (and neither does my husband). And when I first met my anesthesiologist in the delivery room, it wasn’t discussed then either. Should I get pregnant again, I haven’t decided if I would have another epidural. According to Angle, there is no increased risk of having a puncture if you’ve already had one. But considering it took me two weeks until I could hold my baby girl in my arms, I won’t be making the decision lightly.
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