Evaluating hemostatic thresholds for neuraxial anesthesia in adults with hemorrhagic disorders and tendencies: A scoping review.

Neuraxial anesthesia can be complicated by spinal or epidural hematoma and may result in permanent neurologic injury. There is a paucity of literature characterizing this serious complication in patients with congenital and acquired hemorrhagic disorders or tendencies. The objective of this scoping review was to describe the hemostatic laboratory parameters where neuraxial anesthesia has been administered with and without spinal and epidural hematoma in patients with preexisting hemorrhagic disorders and tendencies, including immune thrombocytopenia, gestational thrombocytopenia, thrombocytopenia associated with hypertensive disorders of pregnancy, platelet function disorders, von Willebrand disease, coagulation factor deficiencies, and fibrinogen disorders. A systematic search of Ovid MEDLINE, CINAHL, Embase, Scopus, and Web of Science was performed. Two authors independently reviewed all titles, abstracts, and full texts to determine study eligibility and extract data. Qualitative synthesis of 91 studies revealed significant gaps in our understanding of the risk of spinal and epidural hematoma in patients with hemorrhagic disorders and tendencies, including few studies of males and in nonobstetric settings. Most reviewed articles were small, retrospective studies at high risk for potential bias. With such low-quality data, we were unable to provide any true estimates of the risk of spinal or epidural hematoma for these patients, nor could we attribute any specific hemostatic or laboratory values to increased risk of hematoma. There is a need both for larger and more rigorously designed and reported studies on this subject and for structured, comprehensive recommendations for safe administration and removal of neuraxial anesthesia in patients with hemorrhagic disorders and tendencies.

Village health worker training for complications of labor and delivery in rural Maharashtra, India.

BACKGROUND: By analyzing the perspectives of village health worker/trainers with the Comprehensive Rural Health Project (CRHP), this study aimed to investigate their level of knowledge of treatment, risks, and prevention of complications of labor and delivery and to evaluate current teaching methods. METHODS: Three focus groups of six village health workers/trainers were conducted and divided according to level of experience. The resulting semistructured discussion was analyzed according to grounded theory. RESULTS: Participants displayed strong content retention with respect to clinically relevant knowledge. Village health workers experienced barriers, including lack of education and casteism, which affected their ability to establish trust in the community. Clinical observation was perceived to be the most effective learning method and is recommended for teaching village health workers about the treatment and prevention of the complications of labor and delivery. CONCLUSION: When implementing this training model in comparable global communities, local culture and its impact on establishing trust is an important factor to consider.