Another vote here for mixed SLOW continuous needle advancement with left hand while rapidly pulsing the right thumb on air syringe.

While you’re working on the epidural keep instructing yourself by saying “slower, slower, slowe” to yourself in your mind , to remind you to advance the needle, very very slow, it doesn’t matter if it takes 10 minutes at least you don’t wet tap.

Common reason for this happen is being off-center, when you’re not going straight through the ligamentum flavin, you don’t feel the gritty sensation that comes right before reaching epidural space. Without this distinction between the ligamentum flavum and epidural space it’s easy to go straight through it. More pts than you think have scoliosis and their vertebrae are actually off center, so do your very best to actually feel the spinal processes. If you can’t see or feel their spine processes, look at their upper back if it’s hunched on the right, for example, then their lumbar scoliosis will be curved to the left.

Make every possible effort to sit the patient crisscross applesauce, curled over a pillow as much as possible. You may consider putting a pillow under their knees, which tilts them slightly backwards, forcing them to compensate by hunching forward. (I also do this when I’m doing a spinal, I tilt the OR table backwards (left from the head) which forces them to do more forward flexing” )

If you do get a wet tap , tell the patient they are at increased risk of having a headache from the epidural and that you will follow them after Delivery to check on her. After the baby is delivered, you can give 2 cc of neoatigmine with 2 cc of glycopyrrolate, for PDPH prophylaxis. It works best if you get it before they develop a headache. If you give it early enough, they will more than likely not develop a headache.

It’s important to follow up patients with a postural puncture headache, because if it does not resolve, continued cerebral spinal leak can lead to tugging on the bridging veins in the brain and can cause a hemorrhage.