Lower-limb neurologic deficit after vaginal delivery: a prospective observational study

Enhancing functional recovery following postpartum femoral neuropathy: early neurorehabilitation and multidisciplinary obstetric care

Postpartum femoral neuropathy has a reported incidence of less than 1% and its total recovery time extends up to 6 months to a year. A multidisciplinary approach is vital to rule out permanent disability and to assure a correct diagnosis and earlier rehabilitation. We report a case of a 37-year-old puerperal woman with a history of intrapartum epidural analgesia, who presented post-labor unilateral lower-limb motor weakness and sensory loss, with functional compromise on independent gait. A multidisciplinary team consisting of an anesthesiologist, a physiatrist, a neurologist, and an obstetrician was then established. In the initial physiatry and neurology assessment, the patient reported pain (numerical rating scale 7/10) over the inguinal ligament, lower limb hypoesthesia, and muscle weakness. Femoral neuropathy was suspected. Magnetic resonance imaging ruled out potential complications related to the anesthetic procedure. The patient was then enrolled in a supervised rehabilitation program and, 3 weeks later, electrodiagnostic studies confirmed the initial suspicion. Two months later, the patient had regained lower-limb active range of motion and no pain nor paresthesia was reported. Our case report describes how an early multimodal rehabilitation program within a multidisciplinary framework allows for sooner neuromotor function improvement and activities of daily living independence.

Left common peroneal nerve palsy caused by cross-legged sitting during epidural labor analgesia: a case report

BACKGROUND

Nerve injury in epidural labor analgesia can occur with various potential causes. We report a rare case of left common peroneal nerve palsy after delivery caused by a prolonged period of sitting cross-legged during epidural labor.

CASE REPORT

Epidural labor analgesia in a 28-year-old primipara started at 39 weeks of gestation. She sat cross-legged to prompt delivery for approximately 4 h with a break of a few minutes every hour. She had numbness in her left lower limb and difficulty in dorsiflexion of the ankle joint that did not improve until 3 h after delivery. We made a diagnosis of left common peroneal nerve palsy. Most of the symptoms had improved at 2 months postpartum.

CONCLUSION

Epidural labor analgesia prevented recognition of prolonged peroneal head compression caused by sitting cross-legged. When this position is used to facilitate delivery, it should be released frequently owing to the possibility of a neurologic deficit.

Postpartum complications following neuraxial anaesthesia for obstetric physicians

Neuraxial analgesia and anaesthesia are widely accepted and well-tolerated modes of delivery analgesia, being employed in up to 76% of vaginal deliveries and 94% of caesarean deliveries in the United States.1 A cause of considerable concern for postpartum women, their family and caring health professionals is the occurrence of unexplained postpartum complications, not only for management in the index pregnancy, but the uncertain risk of recurrence in future pregnancies. Complications of neuraxial blocks may impact significantly on the ability of mothers to care for and bond with their newborn. The reported incidence of temporary neurological deficit following obstetric neuraxial blocks is 1 in 3900 procedures, and the risk of permanent neurological harm estimated to be between 1 in 80,000 and 1 in 320,425 procedures.2 Obstetric physicians may be asked to review women with postpartum complications following neuraxial blocks. This article reviews complications that may be seen following neuraxial blocks for delivery.

Factors associated with a maternal lower-limb neurological deficit after vaginal delivery

INTRODUCTION

The etiology of lower-limb neurological deficit after vaginal delivery remains poorly understood. The objective herein was to identify factors associated with this maternal nerve injury after vaginal delivery.

MATERIAL AND METHODS

A single-center, case-control (matching 1:4) study. Cases were women with a lower-limb neurological deficit that appeared immediately after vaginal delivery. Controls were randomly selected women who gave birth vaginally during the same period, without any deficit. Finally, to assess the rates of factors associated with these deficits, we studied them using a randomly selected 5% sample of the population with vaginal deliveries.

RESULTS

During the 30-month study period, 31 cases were identified among 10 333 women who gave birth vaginally (0.3%, 95% CI 0.20-0.43); 124 controls were also included. After logistic regression, the presence of a neurological deficit after delivery was associated with second-stage labor duration (per hour odds ratio [OR] 3.67, 95% CI 2.09-6.44; OR per standard deviation increase 2.73, 95% CI 1.75-4.25, p < 0.001) and instrumental delivery (OR = 3.24, 95% CI 1.29-8.14, p = 0.012), with no interaction effect (p = 0.56). Extrapolation of these factors to a 5% sample of the overall population of women with vaginal births showed that the rate of these deficits would be very low for women with second-stage labor lasting up to 90 min without instrumental delivery (0.05%) but increased to 1.52% when these factors were combined (OR 33.1, 95% CI 9.4-116.9).

CONCLUSIONS

Following vaginal delivery, the onset of a neurological deficit is principally associated with the duration of second-stage labor and instrumental delivery.

Integrative Review of Lower Extremity Nerve Injury During Vaginal Birth

OBJECTIVE

To describe the incidence, health effects, risk factors, and practice implications of lower extremity nerve injury (LENI) related to vaginal births.

DATA SOURCES

We searched MEDLINE, CINAHL, and PubMed from 2000 to 2020 for peer-reviewed published case reports and research studies of LENI related to vaginal births.

STUDY SELECTION

We identified 188 potential records, and 20 met inclusion criteria (six research studies and 14 case studies).

DATA EXTRACTION

Three independent reviewers extracted details of injuries and births into an Excel spreadsheet and analyzed data using SPSS.

DATA SYNTHESIS

Using birth data from each case study and from four of the six research articles, we found the incidence of LENI in vaginal births was 0.3% to 1.8%. The description of health effects includes affected nerves and the location, description, and duration of symptoms. Analyses of risk factors were limited by missing birth data (length of second stage, birth weight, etc). Vaginal births with LENI were 76% spontaneous, 77% with neuraxial anesthesia, and 64% first vaginal birth. Practice implications focused on prevention through specific positioning strategies. Despite nurses being the primary caregivers during labor, LENI was reported most often in anesthesia journals with virtually no reports in nursing journals.

CONCLUSION

LENI is a potential complication of vaginal birth, and little published research is available on prevention and prognosis. While obstetric and anesthesia factors can cause or contribute to nerve injury, LENI is usually caused by positioning and is considered preventable. Care recommendations include the following: avoid prolonged hyperflexion of women's thighs and knees; minimize time in lithotomy, squatting, or kneeling positions; prevent hand or other deep pressure on lateral knee and posterior thigh areas; avoid motor-blocking neuraxial (epidural) anesthesia; and implement frequent repositioning. The paucity of literature contributes to the lack of awareness of LENI among clinicians.