Postpartum neurological symptoms following regional blockade: a prospective study with case controls

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.

Foot drop after spinal anesthesia for cesarean section: a case report

Objective

Spinal anesthesia is the preferred anesthetic technique for cesarean section. Neurological complications are very rare and often transient after spinal anesthesia.

Case report

In the present case, a 37-year-old woman was considered eligible for cesarean section due to fetal distress. She underwent spinal anesthesia with a 25-gauge pencil-point spinal needle. In the sitting position, 3 mL of 0.5% bupivacaine was injected following free flow of cerebrospinal fluid. The cesarean delivery was uneventful without severe and significant hemodynamic changes. After recovery, the patient complained of tingling and stiffness in the left leg, accompanied with movement disorders and foot drop. Lumbar magnetic resonance imaging was normal. After receiving 500 mg intravenous methylprednisolone daily for 72 hours, she was discharged from the hospital with no particular problems.

Conclusion

Foot drop is a neurological disorder, which occurs following natural childbirth and spinal anesthesia due to direct needle trauma or local anesthetic toxicity. This complication is transient and usually resolves within a few days. In our patient, the neurological complication appeared after labor and anesthesia recovery, which was treated by corticosteroids and anti-inflammatory drugs, with no particular side effects.

Bilateral Heel Numbness due to External Compression during Obstetric Epidural Analgesia

We describe the case of a 32-year-old woman who developed bilateral heel numbness after obstetric epidural analgesia. We diagnosed her with bilateral neuropathy of the medial calcaneal nerve, most likely due to longstanding pressure on both heels. Risk factors for the development of this neuropathy were prolonged labour with spinal analgesia and a continuation of analgesia during episiotomy. Padded footrests decrease pressure and can possibly prevent this neuropathy.

Extracts from rabbit skin inflamed by the vaccinia virus attenuate bupivacaine-induced spinal neurotoxicity in pregnant rats

Extracts from rabbit skin inflamed by the vaccinia virus can relieve pain and promote repair of nerve injury. The present study intraperitoneally injected extracts from rabbit skin inflamed by the vaccinia virus for 3 and 4 days prior to and following intrathecal injection of bupivacaine into pregnant rats. The pain threshold test after bupivacaine injection showed that the maximum possible effect of tail-flick latency peaked 1 day after intrathecal injection of bupivacaine in the extract-pretreatment group, and gradually decreased, while the maximum possible effect in the bupivacaine group continued to increase after intrathecal injection of bupivacaine. Histological observation showed that after 4 days of intrathecal injection of bupivacaine, the number of shrunken, vacuolated, apoptotic and caspase-9-positive cells in the dorsal root ganglion in the extract-pretreatment group was significantly reduced compared with the bupivacaine group. These findings indicate that extracts from rabbit skin inflamed by the vaccinia virus can attenuate neurotoxicity induced by intrathecal injection of bupivacaine in pregnant rats, possibly by inhibiting caspase-9 protein expression and suppressing nerve cell apoptosis.

Postpartum neurologic symptoms following single-shot spinal block for labour analgesia

BACKGROUND

As part of a quality assurance program, we investigated the incidence of postpartum neurologic symptoms in multiparous parturients receiving spinal block for labour analgesia, now in routine use in our labour ward.

METHODS

Two hundred and twenty-nine consecutive multiparous parturients presenting for vaginal delivery and requesting spinal analgesia were asked to participate in this prospective study. All parturients received our standard intrathecal analgesia (ITA): 2.5 mg bupivacaine (1 ml) + 25 microg fentanyl (0.5 ml) using a 27-gauge Quincke-type needle. The patients filled in a questionnaire on the first day after delivery and again upon discharge. Complaints typical of neurologic sequelae were noted and a neurologic examination was performed, if necessary. All patients with postdural puncture headache (PDPH) and transient neurologic symptoms (TNSs) were interviewed by telephone 2 weeks after discharge to determine the course of the symptoms.

RESULTS

Two hundred and twelve parturients were included in the study. Eighteen (8.5%) parturients complained of PDPH, the severity of which was mild in eight (4%), moderate in seven (3%), and severe in three (1%) patients, respectively. Fifteen (7%) mothers were treated with analgesics or bedrest only. Three (1%) patients were given an epidural blood patch. The paramedian approach was associated with the development of PDPH (P = 0.04). Transient neurologic symptoms were experienced by nine (4.2%) mothers, lasting 1-3 days, mostly presenting as bilateral pain in the buttocks or thighs. One parturient suffered from paraesthesia of the left foot lasting for 3 days. Forty (19%) mothers complained of non-postural headache and 28 (13%) of new-onset back pain. Three mothers (1%) would not want to receive a further spinal block.

CONCLUSION

Transient neurologic symptoms (TNSs) after spinal block occurred infrequently. The incidence of PDPH was higher than in the obstetric population in general and calls for re-evaluation of our spinal block methods. Despite the occurrence of neurologic sequelae, patient acceptability was high.