What are some practical recommendations regard-ing neuraxial anesthesia in the parturient who presents with a low platelet count?
If the decision is made to proceed with neuraxial anesthesia, a subarachnoid block using a small-caliber spinal needle is preferable to epidural anesthesia. This is not always possible, especially for women in labor who will require repeated doses of local anesthetic. An epidural anesthetic should be placed using a midline technique. The lowest concentration of local anesthetic necessary to pro-duce analgesia while preserving motor function should be used. The patient should be examined every 1–2 hours to assess the extent of the motor block, and these examina-tions should continue until after the anesthetic has worn off and the catheter has been removed. In this way, if the patient develops a motor block out of proportion to what one would expect, or if the anesthetic has a prolonged duration of action, the patient can be immediately assessed with MRI for the development of an epidural hematoma. Immediate evaluation is necessary because an emergent laminectomy and decompression must be performed within 6–12 hours of diagnosis to preserve neurologic function. If a patient develops a coagulopathy with an epidural catheter already in situ, the catheter should be removed only after the coagulation status is corrected.