Shower hydrotherapy is generally considered benign during labor. We report a case of extensive scalds in a primigravida who used shower hydrotherapy to treat severe back labor pain from fetal malposition. Interestingly, her back pain was so severe that she felt no pain as her scald developed, describing the hot water from the showerhead as the only measure which “soothed” her pain. Her scald was diagnosed presumptively during assessment for epidural analgesia. The nature of her back labor pain, associated with occiput posterior fetal head position and her management are described. Severe pain from persistent fetal malposition may alter somatic pain perception during labor, increasing burn risks during shower hydrotherapy. These women are also at increased risk of operative delivery and infection risks from inadvertent neuraxial blockade after burns. Improved prevention strategies and vigilance for scalds are warranted in women with severe back labor undergoing shower hydrotherapy, including by anesthesiologists assessing them for neuraxial blockade.

BACKGROUND:Factors contributing to subarachnoid catheter passage after epidural placement are not well understood. This study explored mechanisms that might explain its occurrence.METHODS:Human cadaveric dura was mounted on a model and pressurized to physiologic levels. In a standardized fashion, a 20-gauge Portex three-port, closed end (nonflexible) tip catheter was passed through an epidural needle mounted on a micromanipulator at a 90 degree angle, attempting to penetrate dura with the catheter. Attempts then followed with a 19-gauge Arrow Flex Tip Plus single-port catheter. Subarachnoid catheter passage was compared in (1) intact dura, (2) clinically occult versus obvious epidural needle punctures, and (3) single 25-gauge Whitacre spinal needle punctures after combined spinal-epidural placement.RESULTS:Neither catheter penetrated intact dura: Portex, 0 of 300 attempts (0.0000; 95% confidence interval [CI]: 0.0000, 0.0158); Arrow, 0 of 300 attempts (0.0000; 95% CI: 0.0000, 0.0158). In clinically occult epidural needle punctures, the 20-gauge Portex catheter penetrated 1 of 3 specimens in 1 of 14 attempts (0.0714; 95% CI: 0.0021, 0.3583). The 19-gauge Arrow did not pass (0 of 15 attempts, 0.0000; 95% CI: 0.0000, 0.2535). In clinically obvious epidural needle punctures, the Portex passed in 6 of 33 attempts (0.1818; 95% CI: 0.0760, 0.3608) and the Arrow passed in 1 of 35 attempts (0.0286; 95% CI: 0.0012, 0.1662). Neither catheter passed through a single 25-gauge spinal needle puncture after an uncomplicated combined spinal-epidural: Portex, 0 of 90 attempts (0.0000; 95% CI: 0.0000, 0.0510); Arrow, 0 of 90 attempts (0.0000; 95% CI: 0.0000, 0.0510).CONCLUSIONS:Catheter passage is unlikely in the presence of intact dura or after an uncomplicated combined spinal-epidural. Unintentional subarachnoid passage suggests dural damage with the epidural needle.

BACKGROUND:The effects of epidural needle design, angle, and bevel orientation on cerebrospinal fluid leak after puncture have not been reported. The impact of these factors on leak rate was examined using a dural sac model. Dural trauma was examined using scanning electron microscopy.METHODS:Human cadaveric dura, mounted on a cylindrical model, was punctured with epidural needles using a micromanipulator. Tissue was punctured at 15 cm H2O (left lateral decubitus) system pressure, and leak was measured at 25 cm H2O (semisitting) pressure. Leak rates and trauma were compared for the following: (1) six different epidural needles at 90 degrees, bevel parallel to the dural long axis; (2) 18-gauge Tuohy and 18-gauge Special Sprotte epidural needles, 30 degrees versus 90 degrees; (3) 18-gauge Tuohy, bevel perpendicular versus parallel to the dural long axis.RESULTS:With the 90 degrees puncture, bevel parallel, the greatest leak occurred with a 17-gauge Hustead (516 +/- 319 ml/15 min), and the smallest leak occurred with a 20-gauge Tuohy (100 +/- 112 ml/15 min; P = 0.0018). A 20-gauge Tuohy puncture led to statistically significant reductions in leak (P value range, 0.0001-0.0024) compared with all needles except the Special Sprotte. With the 30 degrees versus 90 degrees angle, 30 degrees punctures with an 18-gauge Tuohy produced nonstatistically significant leak reductions compared with the 18-gauge Tuohy at 90 degrees. The puncture angle made no difference for the Special Sprotte. Nonsignificant reductions were found for the Special Sprotte compared with the Tuohy. With the 18-gauge Tuohy bevel orientation, perpendicular orientation produced nonstatistically significant reductions in leak compared with parallel orientation.CONCLUSIONS:Cerebrospinal fluid leak after puncture was influenced most by epidural needle gauge. Leak rate was significantly less for the 20-gauge Tuohy needle.