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Integrative Review of Lower Extremity Nerve Injury During Vaginal Birth

Published:October 20, 2020DOI:https://doi.org/10.1016/j.jogn.2020.09.155

      Abstract

      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.

      Keywords

      Neurologic injuries from vaginal births have been reported since at least the 1800s (
      • Chalmers J.A.
      Traumatic neuritis of the puerperium.
      ), and sporadic reports continue to be published. Although accounts vary, modern case studies tend to recount often-uncomplicated births with neuraxial (epidural) analgesia/anesthesia (NAA) in which the second stage of labor was longer than 1 hour (
      • Richard A.
      • Vellieux G.
      • Abbou S.
      • Benifla J.
      • Lozeron P.
      • Kubis N.
      Good prognosis of postpartum lower limb sensorimotor deficit: A combined clinical, electrophysiological, and radiological follow-up.
      ;
      • Tournier A.
      • Doremieux A.C.
      • Drumex E.
      • Labreuche J.
      • Cassim F.
      • Bartolo S.
      • Subtil D.
      Lower-limb neurologic deficit after vaginal delivery: A prospective observational study.
      ). After birth when the epidural wears off, women may experience weakness, numbness, and/or the inability to move parts of one leg or to walk independently, depending on the nerve involved (
      • Haller G.
      • Pichon I.
      • Gay F.O.
      • Savoldelli G.
      Risk factors for peripheral nerve injuries following neuraxial labour analgesia: A nested case-control study.
      ;
      • O'Neal M.A.
      • Chang L.Y.
      • Salajegheh M.K.
      Postpartum spinal cord, root, plexus, and peripheral nerve injuries involving the lower extremities: A practical approach.
      ). Symptom resolution varies, with most impairments resolving by 2 to 6 months after injury and some lasting a year or more (
      • Dar A.
      • Robinson A.
      • Lyons G.
      Postpartum neurological symptoms following regional blockade: A prospective study with case controls.
      ;
      • Haas D.M.
      • Meadows R.S.
      • Cottrell R.
      • Stone W.J.
      Postpartum obturator neurapraxia.
      ;
      • Haller G.
      • Pichon I.
      • Gay F.O.
      • Savoldelli G.
      Risk factors for peripheral nerve injuries following neuraxial labour analgesia: A nested case-control study.
      ;
      • Richard A.
      • Vellieux G.
      • Abbou S.
      • Benifla J.
      • Lozeron P.
      • Kubis N.
      Good prognosis of postpartum lower limb sensorimotor deficit: A combined clinical, electrophysiological, and radiological follow-up.
      ;
      • Tournier A.
      • Doremieux A.C.
      • Drumex E.
      • Labreuche J.
      • Cassim F.
      • Bartolo S.
      • Subtil D.
      Lower-limb neurologic deficit after vaginal delivery: A prospective observational study.
      ;
      • Wong C.A.
      • Scavone B.M.
      • Dugan S.
      • Smith J.C.
      • Prather H.
      • Ganchiff J.N.
      • Mccarthy R.J.
      Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.
      ).
      Lower extremity nerve injury (LENI) is not limited to vaginal births and can occur during cesarean births with and without labor (
      • Cohen S.
      • Zada Y.
      Postpartum femoral neuropathy.
      ;
      • Dar A.
      • Robinson A.
      • Lyons G.
      Postpartum neurological symptoms following regional blockade: A prospective study with case controls.
      ;
      • Wong C.A.
      • Scavone B.M.
      • Dugan S.
      • Smith J.C.
      • Prather H.
      • Ganchiff J.N.
      • Mccarthy R.J.
      Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.
      ), as well as during other types of surgeries (
      • Hewson D.W.
      • Bedforth N.M.
      • Hardman J.G.
      Peripheral nerve injury arising in anaesthesia practice.
      ;
      • Madson T.J.
      Functional lower extremity deficits with sensory changes and quadriceps weakness in a 29-year-old female post labor and delivery: A case reports and literature review of postpartum maternal lower extremity peripheral nerve injuries.
      ); LENI may occur either with or without NAA during vaginal births (
      • Wong C.A.
      Nerve injuries after neuraxial anaesthesia and their medicolegal implications.
      ). In operative births, LENI can occur from forceps, retractors, and other instruments separately or in combination with injury from lithotomy positioning or other positions with hyperflexed thighs or knees that may compromise nerves (
      • Butchart A.G.
      • Mathews M.
      • Surendran A.
      Complex regional pain syndrome following protracted labour.
      ;
      • Haller G.
      • Pichon I.
      • Gay F.O.
      • Savoldelli G.
      Risk factors for peripheral nerve injuries following neuraxial labour analgesia: A nested case-control study.
      ;
      • Park S.
      • Park S.W.
      • Kim K.S.
      Lumbosacral plexus injury following vaginal delivery with epidural analgesia.
      ;
      • Richard A.
      • Vellieux G.
      • Abbou S.
      • Benifla J.
      • Lozeron P.
      • Kubis N.
      Good prognosis of postpartum lower limb sensorimotor deficit: A combined clinical, electrophysiological, and radiological follow-up.
      ). In the surgical literature, factors reported to contribute to nerve injury include small or large body mass index, hypothermia, preexisting neuropathy, diabetes, hypovolemia, hypotension, hypoxia, tobacco use, and anatomic variations. Symptoms of LENI may be transient and mild and last only hours or days; or symptoms may be significant, mobility impairing, and permanent (
      • Haller G.
      • Pichon I.
      • Gay F.O.
      • Savoldelli G.
      Risk factors for peripheral nerve injuries following neuraxial labour analgesia: A nested case-control study.
      ;
      • Richard A.
      • Vellieux G.
      • Abbou S.
      • Benifla J.
      • Lozeron P.
      • Kubis N.
      Good prognosis of postpartum lower limb sensorimotor deficit: A combined clinical, electrophysiological, and radiological follow-up.
      ;
      • Tournier A.
      • Doremieux A.C.
      • Drumex E.
      • Labreuche J.
      • Cassim F.
      • Bartolo S.
      • Subtil D.
      Lower-limb neurologic deficit after vaginal delivery: A prospective observational study.
      ).
      Although obstetric, anesthesia, and anatomic factors can cause or contribute to nerve injury, most often LENI is considered to be caused by positioning (
      • Madson T.J.
      Functional lower extremity deficits with sensory changes and quadriceps weakness in a 29-year-old female post labor and delivery: A case reports and literature review of postpartum maternal lower extremity peripheral nerve injuries.
      ;
      • Peirce C.
      • O'Brien C.
      • O'Herlihy C.
      Postpartum femoral neuropathy following spontaneous vaginal delivery.
      ;
      • Sahai-Srivastava S.
      • Amezcua L.
      Compressive neuropathies complicating normal childbirth: Case report and literature review.
      ;
      • Wong C.A.
      Nerve injuries after neuraxial anaesthesia and their medicolegal implications.
      ;
      • Wong C.A.
      • Scavone B.M.
      • Dugan S.
      • Smith J.C.
      • Prather H.
      • Ganchiff J.N.
      • Mccarthy R.J.
      Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.
      ). NAA is more likely to be an indirect cause of nerve injury by masking sensations of nerve injury that would normally prompt women to change positions (
      • Kim S.H.
      • Kim I.H.
      • Lee S.Y.
      Sciatic neuropathy after normal vaginal delivery: A case report.
      ;
      • Wong C.A.
      Neurologic deficits and labor analgesia.
      ;
      • Wong C.A.
      • Scavone B.M.
      • Dugan S.
      • Smith J.C.
      • Prather H.
      • Ganchiff J.N.
      • Mccarthy R.J.
      Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.
      ). However, use of NAA may also contribute to nerve compromise from hypotension that reduces nerve perfusion and leads to ischemia (
      • Zillioux J.M.
      • Krupski T.L.
      Patient positioning during minimally invasive surgery: What is best practice?.
      ). Nerve tissue is metabolically active and requires an uninterrupted blood supply from its delicate capillary network (
      • Chui J.
      • Murkin J.M.
      • Posner K.L.
      • Domino K.B.
      Perioperative peripheral nerve injury after general anesthesia: A qualitative systematic review.
      ). The risk for nerve injuries increases with longer times in lithotomy or other positions with hyperflexed thighs. These positions can also impair nerve perfusion from elevation above the heart and from stretching and/or compressing the nerve (
      • Hewson D.W.
      • Bedforth N.M.
      • Hardman J.G.
      Peripheral nerve injury arising in anaesthesia practice.
      ;
      • Zillioux J.M.
      • Krupski T.L.
      Patient positioning during minimally invasive surgery: What is best practice?.
      ). Most nerve compression or stretch insults during childbirth cause segmental demyelinating injury while axons remain intact with good prognosis for recovery (
      • Madson T.J.
      Functional lower extremity deficits with sensory changes and quadriceps weakness in a 29-year-old female post labor and delivery: A case reports and literature review of postpartum maternal lower extremity peripheral nerve injuries.
      ;
      • O'Neal M.A.
      • Chang L.Y.
      • Salajegheh M.K.
      Postpartum spinal cord, root, plexus, and peripheral nerve injuries involving the lower extremities: A practical approach.
      ). Prolonged nerve compression can cause axonal damage in peripheral nerves and limited ability to regenerate (
      • O'Neal M.A.
      • Chang L.Y.
      • Salajegheh M.K.
      Postpartum spinal cord, root, plexus, and peripheral nerve injuries involving the lower extremities: A practical approach.
      ).
      In addition to the wide range of specific and often overlapping diagnoses pertaining to individual nerves, there are several terms for the overall phenomenon of LENI. Other common global terms are obstetric neuropraxia, traumatic neuritis of the puerperium, peripheral nerve injury, and various combinations that use the word palsy (obstetric palsy, etc.). We chose the acronym LENI for its clarity and inclusiveness.
      There are significant public health implications of a phenomenon that can cause lasting impairments and impede women’s abilities to care for their newborns and families (
      • Webb J.
      On analgesia and anesthesia in the intrapartum period: Evidence-based clinical practice guideline.
      ). Health implications are further magnified by a lack of awareness in frontline clinicians, whose care may unintentionally increase risks for nerve injury and may delay detection and subsequent management (
      • Sahai-Srivastava S.
      • Amezcua L.
      Compressive neuropathies complicating normal childbirth: Case report and literature review.
      ;
      • Zillioux J.M.
      • Krupski T.L.
      Patient positioning during minimally invasive surgery: What is best practice?.
      ). Although uncommon, LENI is not rare and is considered potentially preventable. Maternity caregivers of all disciplines tend to be unaware of LENI (
      • Peirce C.
      • O'Brien C.
      • O'Herlihy C.
      Postpartum femoral neuropathy following spontaneous vaginal delivery.
      ;
      • Rowland C.
      • Kane D.
      • Eogan M.
      Postpartum femoral neuropathy: Managing the next pregnancy.
      ;
      • Sahai-Srivastava S.
      • Amezcua L.
      Compressive neuropathies complicating normal childbirth: Case report and literature review.
      ).
      Lower extremity nerve injury is uncommon after childbirth and is considered preventable, but care providers tend to be unaware of its incidence, causes, and prevention.
      The purpose of our integrative review was to describe the incidence, health effects, risk factors, and practice implications for LENI related to vaginal births. Synthesis of published research and case reports from the past 20 years may uncover information of the best available evidence for nurses and other providers to use during their care of women during labor and birth. Our goal was to use a transparent and systematic approach to summarize extant evidence and provide practice implications and directions for future research.

      Methods

       Search Strategy

      We used the methods outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA;
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      The PRISMA Group
      Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement.
      ;
      • Moher D.
      • Shamseer L.
      • Clarke M.
      • Ghersi D.
      • Liberati A.
      • Pettigrew M.
      The PRISMA Group
      Preferred reporting items for systematic reviews and meta-analyses protocols (PRISMA-P) 2015 Statement.
      ). In consultation with a medical librarian, we searched MEDLINE, CINAHL, and PubMed from 2000 to 2020 for peer-reviewed published reports, case reports, and research studies of LENI related to vaginal births. To identify publications, we searched the electronic databases and examined article reference lists. Initially, searches were iterative, and additional keywords were added to subsequent searches after we identified them in publications. We used Boolean operators, such as AND, OR, and NOT, as we searched titles and abstracts with the following search terms: maternal, obstetric, obstetrical, intrapartum, postpartum, labor, delivery, birth, nerve, neurological, neuropathy, plexopathy, injury, trauma, morbidity, deficit, dysfunction, lithotomy position, palsy, paralysis, meralgia, femoral nerve, electromyography, peroneal nerve, peroneal neuropathies, foot drop, sciatic nerve, and lumbosacral plexus.

       Eligibility Criteria

      We included peer-reviewed case studies and research reports on LENI related to vaginal births that were published in English. We excluded reports of cesarean births and other surgeries (such as gynecologic, orthopedic, neurological, etc.); nerve injuries of newborns, children, or those unrelated to vaginal births; animal studies; and reports that focused primarily on diagnostic techniques or procedural interventions for nerve injuries. We also excluded book chapters, review articles, and editorial letters.

       Study Selection

      We screened retrieved records from each search based on the title and abstract. Two authors (M.S. and B.T.) used a criteria-based retrieval strategy and obtained full-text articles of all potentially relevant publications. Our outcome of interest was any case report or research study of LENI related to vaginal birth. We hand searched citations and reference lists to identify published works not revealed in database searches. To enhance reliability and reduce the risk of bias, three authors (M.S., B.T., and J.W.) determined the eligibility of studies based on our inclusion and exclusion criteria. Our article selection process is depicted in Figure 1.
      Figure thumbnail gr1
      Figure 1The flow diagram for article selection.
      We identified 188 potential records from databases (n = 180) and searches of reference lists (n = 8) and removed 101 duplicates. After screening the remaining 87 abstracts, we excluded 45 based on our eligibility criteria. We assessed 42 full-text articles and removed 22 that did not meet our criteria, which resulted in a final sample of 20 articles. One of the 22 excluded articles (
      • Hayes N.
      • Wheelahan J.
      • Ross A.
      Self-reported post-discharge symptoms following obstetric neuraxial blockade.
      ) included only women who reported late LENI symptoms after hospital discharge. Because their sample excluded women who reported symptoms in the first 1 to 3 days postpartum, we removed that study from consideration.
      The 20 articles contained several borderline cases related to the type of anesthesia/analgesia and birth type. Of the six research studies, two had research questions pertaining to neurological complications related to use of NAA during birth and were considered borderline because samples were restricted to women who received NAA (
      • Dar A.
      • Robinson A.
      • Lyons G.
      Postpartum neurological symptoms following regional blockade: A prospective study with case controls.
      ;
      • Haller G.
      • Pichon I.
      • Gay F.O.
      • Savoldelli G.
      Risk factors for peripheral nerve injuries following neuraxial labour analgesia: A nested case-control study.
      ). All except
      • Tournier A.
      • Doremieux A.C.
      • Drumex E.
      • Labreuche J.
      • Cassim F.
      • Bartolo S.
      • Subtil D.
      Lower-limb neurologic deficit after vaginal delivery: A prospective observational study.
      included vaginal and cesarean births.
      • Haller G.
      • Pichon I.
      • Gay F.O.
      • Savoldelli G.
      Risk factors for peripheral nerve injuries following neuraxial labour analgesia: A nested case-control study.
      excluded elective cesareans but included cesareans after labor. This left only one research study on LENI in a sample of exclusively vaginal births (
      • Tournier A.
      • Doremieux A.C.
      • Drumex E.
      • Labreuche J.
      • Cassim F.
      • Bartolo S.
      • Subtil D.
      Lower-limb neurologic deficit after vaginal delivery: A prospective observational study.
      ). Given the paucity of literature on LENI in childbirth, we decided to keep any studies that included vaginal births regardless of anesthesia type or whether they also included cesarean births.

       Data Extraction and Synthesis

      Four of the research studies and all 14 case studies included sufficient details of individual cases so that it was possible to combine some of the data for further analysis. Our process was to create an Excel spreadsheet in which each case from the research and case study articles was listed. We recorded details about the affected nerve (i.e., duration of symptoms; unilateral or bilateral; and sensory, motor, or both) and the birth (i.e., spontaneous or assisted, newborn weight, duration of second stage of labor, and first vaginal birth or not). Data were exported into SPSS (Version 25) for descriptive analyses.

      Results

      Of the final group of 20 articles, six were research studies, and 14 were case studies. The 14 case studies, summarized in Table 1, reported various lower extremity nerves affected during 15 vaginal births (one case study described two births). The six research studies were all single-center studies and are summarized in Table 2. Two were retrospective studies of health care records with case controls (
      • Haller G.
      • Pichon I.
      • Gay F.O.
      • Savoldelli G.
      Risk factors for peripheral nerve injuries following neuraxial labour analgesia: A nested case-control study.
      ;
      • Richard A.
      • Vellieux G.
      • Abbou S.
      • Benifla J.
      • Lozeron P.
      • Kubis N.
      Good prognosis of postpartum lower limb sensorimotor deficit: A combined clinical, electrophysiological, and radiological follow-up.
      ). Four were prospective observational studies in which nerve injuries were identified on the basis of patient reports and/or screening after birth (
      • Dar A.
      • Robinson A.
      • Lyons G.
      Postpartum neurological symptoms following regional blockade: A prospective study with case controls.
      ;
      • Richard A.
      • Vellieux G.
      • Abbou S.
      • Benifla J.
      • Lozeron P.
      • Kubis N.
      Good prognosis of postpartum lower limb sensorimotor deficit: A combined clinical, electrophysiological, and radiological follow-up.
      ;
      • Tournier A.
      • Doremieux A.C.
      • Drumex E.
      • Labreuche J.
      • Cassim F.
      • Bartolo S.
      • Subtil D.
      Lower-limb neurologic deficit after vaginal delivery: A prospective observational study.
      ;
      • Wong C.A.
      • Scavone B.M.
      • Dugan S.
      • Smith J.C.
      • Prather H.
      • Ganchiff J.N.
      • Mccarthy R.J.
      Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.
      ).
      Table 1Birth and Injury Information From Lower Extremity Nerve Injury (LENI) Case Studies
      Case

      Study Author(s)
      Affected Nerves and Initial SymptomsLabor and Birth Details

      Discharge Status
      Method of DiagnosisDuration of Symptoms
      • Bellew J.W.
      • Nitz A.J.
      • Schoettelkotte B.
      Postpartum femoral nerve palsy: A case study and the role of electrophysiologic testing and neuromuscular electrical stimulation.
      • Femoral nerve injury
      • After birth, noted
        • o
          Paresthesia in the right anterior medial thigh and lower leg right
        • o
          Quadriceps weakness and knee buckling
        • o
          Limited weight-bearing ∖on right
      • G1P0, vaginal birth with NAA
      • Total labor duration: 18 hr
      • Second stage: 30 min
      Neurology evaluation

      Nerve conduction testing (EMG)
      Returned to normal stepping pattern 5 weeks from when first seen in clinic at 11 days PP or 9 weeks after birth.

      Required handrail support for another 2 weeks.

      Does not report when fully resolved.
      • Butchart A.G.
      • Mathews M.
      • Surendran A.
      Complex regional pain syndrome following protracted labour.
      • Peroneal nerve injury
      • 6 hr after birth, noted weakness and numbness of left foot with weak ankle dorsiflexion
      • 2 weeks: paresthesia, pain, and swelling of left foot progressing to burning pain and allodynia of left foot; diagnosed with regional pain syndrome
      • G1P0, forceps birth at 41 5/7 weeks
      • Newborn weight 4200 g
      • 24 hr of labor, no mention of second stage
      • Positioning: lithotomy
      • Discharged with crutches, physical therapy, and occupational therapy
      • Complex type 2 regional pain syndrome treated with gabapentin
      Neurological examination

      MRI and nerve conduction studies
      6 months: return of motor power and resolution of foot drop

      9 months: persistent burning sensation in big toe
      • Cohen S.
      • Zada Y.
      Postpartum femoral neuropathy.
      • Case 1
      • Left femoral neuropathy
      • 24 hrs after birth noted “residual epidural block of left leg”
      • Case 2
      • Right femoral neuropathy and herniated disc
      • First postpartum morning had right leg weakness and fell to the floor
      • Case 1
      • G4P2 with third VBAC at 38 weeks with NAA.
      • Two previous VBAC births 4 years apart, after first CS birth for FTP
      • Newborn weight: 3,205 g
      • First stage: 200 min
      • Second stage: 71 min
      • Discharged with leg brace
      • Case 2
      • G2P1 at 38 weeks, vaginal birth with NAA
      • Newborn weight: 3635 g
      • First stage: 270 min
      • Second stage: 75 min
      • Discharged with leg brace and wheelchair
      Case 1

      Neurologist diagnosed

      Case 2

      Neurologic exam, postpartum right femoral neuropathy

      MRI: herniated disc
      Case 1

      1 year

      Case # 2

      No report of resolution time
      • Haas D.M.
      • Meadows R.S.
      • Cottrell R.
      • Stone W.J.
      Postpartum obturator neurapraxia.
      • Left obturator nerve injury
      • First postpartum day, reported feeling “like my leg will give out”
      • Unable to adduct left leg
      • Gait difficulty and slowness
      • G2P1, 38 weeks gestation, vaginal birth with NAA
      • Newborn weight 3,726 g
      • First stage: 10 hr 20 min
      • Second stage: 67 min
      Neurologist exam and nerve conduction study3 months: “gait had normalized and there was minimal discomfort…”
      • Hakeem R.
      • Neppe C.
      Intrinsic obstetric palsy: Case report and literature review.
      • Femoral, sciatic, and lumbosacral plexus neuropraxia (and active denervation)
      • PP day 1, noted right leg weakness and decreased sensation
      • G1P0 with vaginal birth at 38 6/7 weeks with NAA
      • Newborn weight 2,840 g
      • Second stage: 58 min
      • Position: lithotomy for second stage
      • Discharged after 31 days with home rehabilitation and assistive mobility devices
      MRI and EMG31 days: “slow progress” with improved mobility
      • Hashim S.S.
      • Addekanmi O.
      Bilateral foot drop following a normal vaginal delivery in a birthing pool.
      • Bilateral peroneal nerve palsies at the head of the fibula
      • Bilateral foot drop
      • Absent ankle dorsiflexion bilaterally
      • Symptoms presented 30 min after birth with high stepping gait, reduced sensation on the dorsal aspect of both feet and shins, and bilateral loss of ankle dorsiflexion
      • G1P0
      • Vaginal birth with no NAA
      • First stage: 8 hr
      • Second stage: 1 hr
      • Positioning description
        • o
          Labored in kneeling position with full knee flexion for 4 hr
        • o
          Squatted with the anterior aspect of her knee resting on the side of the pool for 4 hr
        • o
          Pushed with palm on fibula head, fingers on tibia for 1 hr
      • Fitted with a brace
      Nerve conduction studyFully resolved at 12 weeks
      • Kim S.H.
      • Kim I.H.
      • Lee S.Y.
      Sciatic neuropathy after normal vaginal delivery: A case report.
      • Left sciatic neuropathy
      • Left lower left extremity weakness and tingling sensation from the lower half of the thigh to the sole in the left posterior leg
      • G1P0 vaginal birth at 38 5/7 weeks with NAA
      Nerve conduction study and EMG

      MRI
      Weakness, paresthesia resolved at 3 months

      EMG showed “near complete” recovery
      • Madson T.J.
      Functional lower extremity deficits with sensory changes and quadriceps weakness in a 29-year-old female post labor and delivery: A case reports and literature review of postpartum maternal lower extremity peripheral nerve injuries.
      • Right femoral nerve palsy; diagnosed by anesthesiologist
      • Femoral cutaneous nerve and pudendal nerve palsies; diagnosed by obstetrician
      • After birth, noted
        • o
          Urinary incontinence, numbness in her perineal region
        • o
          Weakness, numbness, and paresthesia of right anterior thigh
        • o
          Knee buckling and difficulty walking
        • o
          Weak quadriceps
      • G1P0, vaginal birth at 38 5/7 weeks with NAA
      • Labor duration: 25 hr
      • Second stage: 4 hr
      • Discharged with a cane
      • Physical therapy evaluation at 3 weeks postpartum
        • o
          Weakness and reduced sensation of right quadriceps.
        • o
          Difficulty rising to stand from chair
      Assessment onlyUrinary incontinence resolved in a few days

      2 months: 71% improvement

      6 months: not back to baseline

      1 year: fully recovered
      • Murray D.J.
      • Bhatti W.
      Maternal sacral fracture during delivery causing foot drop.
      • Lumbosacral trunk compression with hematoma
      • Left sacral fracture with foot drop
      • 8 hr into labor, left leg “heaviness”
      • After birth, severe lumbosacral pain, no ability to dorsiflex or plantar flex
      • Knee flexion weakness
      • G2P1, vaginal birth with NAA
      • Newborn weight 3,778 g
      • Labor time 12 hr, no mention of second stage
      • Discharged with crutches, ankle-foot orthosis, nerve stimulation therapy, and physical therapy
      Neurological examination

      Electrophysiology studies

      MRI
      2 weeks: severe back pain and neurological deficit

      8 weeks: symptoms resolved and “full recovery ensued”
      • Park S.
      • Park S.W.
      • Kim K.S.
      Lumbosacral plexus injury following vaginal delivery with epidural analgesia.
      • Lumbosacral plexus injury
      • 11 hr after birth reported
        • o
          Inability to walk and difficulty standing
        • o
          Bilateral decreased sensation, numbness, tingling
        • o
          Bilateral muscle weakness
        • o
          Incontinence of urine and stool
      • 3 weeks: improvement in walking, continued incontinence
      • G1P0, vaginal birth at 41 weeks with NAA
      • Newborn weight 3,030 g
      • Second stage: 78 min
      Neurological consult

      MRI: intervertebral disc protrusion with air bubbles in epidural space

      EMG: right-sided compound muscle action potential was reduced
      At 7 months, patient “had not fully recovered”
      • Peirce C.
      • O'Brien C.
      • O'Herlihy C.
      Postpartum femoral neuropathy following spontaneous vaginal delivery.
      • Right femoral neuropathy
      • 6 hr after birth noted “right lower limb weakness,” reduced hip flexion, loss of sensation to medial aspect of leg
      • G1P0, vaginal birth with NAA
      • Newborn weight: 3,950 g
      • First stage: 300 min
      • Second stage: 29 min
      • Required crutches for 6 weeks
      Neurological examination

      MRI and EMG
      6 weeks of crutches

      “progressive resolution confirmed” at 3 months
      • Radawski M.M.
      • Srakowski J.A.
      • Johnson E.W.
      Acute common peroneal neuropathy due to hand positioning in normal labor and delivery.
      • Common peroneal neuropathy
      • Unilateral foot drop
      • After analgesia wore off, noted
        • o
          Persistent numbness of the right lower limb
        • o
          Inability to dorsiflex right ankle
        • o
          Steppage gait
      • G3P2 at 41 1/7 weeks gestation
      • Vaginal birth with NAA
      • Second stage: 52 min
      • Positioning for second stage
        • o
          Semisitting with hands at distal posterior thighs to flex hips and thighs during pushing.
        • o
          Fingertip indentation and ecchymosis at distal thigh behind knees.
      • Discharged with ankle brace for mediolateral stability and elastic bandage for dorsiflexion support
      EMG and nerve conduction study

      Repeat EMG 10 days later
      10 days later, mild improvement in her strength but persistent sensory deficits

      3 months: relatively normal gait with minimal weakness in ankles and sensory changes limited to tip of great toe
      • Rowland C.
      • Kane D.
      • Eogan M.
      Postpartum femoral neuropathy: Managing the next pregnancy.
      • Right femoral neuropathy
      • After birth, had right lower leg weakness with inability to walk unassisted
      • G1P0 vaginal birth at 41 3/7 weeks with NAA
      • Newborn weight: 3,500 g
      • First stage: 9 hr
      • Second stage: 2 hr, 41 min (1-hr passive descent, 1 hr 41 min of active pushing, with 30 min of lithotomy with legs in stirrups)
      • Discharged home with walker and physiotherapy
      EMGUnable to mobilize at 6 weeks with leg weakness

      Full recovery 5 months
      • Sahai-Srivastava S.
      • Amezcua L.
      Compressive neuropathies complicating normal childbirth: Case report and literature review.
      • Bilateral neuropathy of common peroneal nerves at fibular head
      • Bilateral foot drop
      • After anesthesia cleared, noticed “left knee tenderness”
      • One day postpartum, bilateral foot drop and loss of sensation to the dorsum of the feet and lateral aspects of her legs
      • G1P0 at 40 weeks gestation
      • Vaginal birth with NAA
      • Second stage: 2 hr
      • Positioning description: supine in stirrups for 2 hr with patient and husband holding/applying pressure to lateral knees
      • Physical therapy and assistive devices
      Neurologic examination and electro-diagnostic testing“Almost complete recovery” at 4 months with “improvement” of nerve conduction velocities)
      Note. CS = cesarean; EMG = electromyography; FTP = failure to progress; G = gravida; MRI = magnetic resonance imaging; NAA = neuraxial anesthesia/analgesia; P = parity; PP = postpartum; VBAC = vaginal birth after cesarean.
      Table 2Lower Extremity Nerve Injury (LENI) Research Studies: Samples, Methods, and Results
      Author(s), Method, and SettingPopulation (N)

      Sample (n)
      Method DetailsResults
      • Dar A.
      • Robinson A.
      • Lyons G.
      Postpartum neurological symptoms following regional blockade: A prospective study with case controls.


      Prospective observational with case controls

      Single center
      PP women with VB and CS (N = 3,991) with regional labor anesthesia (n = 2,615)

      Total with symptoms or deficits after 24 hours (n = 29; 8 in women in asymptomatic groups)
      On routine inpatient PP visit, women who had NAA were asked to report numb patches and mobility issues. Each symptomatic patient with regional anesthesia was matched to two asymptomatic patients: (a) similar birth mode and anesthesia and (b) similar birth mode and no regional anesthesia.

      Women with NAA were queried for symptoms by anesthesia. Women without NAA identified by patient report to midwife.

      All three groups (21 in each) had neurological exam/assessment. FU at 6 months by phone.
      Overall incidence LENI 0.6%. Incidence with NAA 0.8%.

      Neurological exam revealed deficits women who had not volunteered symptoms (case control, 10% in one group and 29% in the other). Did not assess for neurological deficits in women without NAA.

      Duration of symptoms: range of 4 days to more than 6 months.

      Strength: standardized neurological assessment but only for PP women who had NAA.

      Limitations: diagnosis based on neurological assessment only. Different screening and assessment for patients with NAA or no NAA.
      • Haller G.
      • Pichon I.
      • Gay F.O.
      • Savoldelli G.
      Risk factors for peripheral nerve injuries following neuraxial labour analgesia: A nested case-control study.


      Retrospective nested case control

      Single center
      PP women with NAA to N = 19,840

      PP women (n = 19) with nerve injuries after NAA for labor (only if confirmed by neurologist and diagnostic testing).

      Excluded preexisting neurological conditions and elective CS without labor.
      PP women interviewed by anesthetist or nurse anesthetist within 48 hours of birth. If neurology complication suspected, specific complication form completed and referred to neurologist IF persisted beyond 24 to 48 hours after birth.

      Retrieved electronic health records of 19,840 women who received NAA; found 19 patients with LENI.

      Each case of LENI matched to 4 non-LENI cases occurring in the same month (no other factors were matched).
      4 of 19 were anesthesia needle injury, leaving 15.

      Overall reported incidence 0.96% (not needle-related incidence 0.76%).

      LS plexus/roots: 13, femoral: 4, obturator: 3, common peroneal: 2. More than one nerve involved in 5 women.

      47% nulliparous.

      Risk factors: forceps, NB weight > 3.5 kg, gestational age ≥ 41 weeks, NAA given after 5 centimeters dilated and repeated NAA procedures.

      Duration of symptoms: 3 days to more than 3 years (unresolved).

      Strength: consistent and systematic neurological assessment and diagnosis.

      Limitations: excluded patients who were transferred from other hospitals or DC within 24 hours. Important birth details (parity, infant weight, etc.) not individually reported in table of each case.
      • Richard A.
      • Vellieux G.
      • Abbou S.
      • Benifla J.
      • Lozeron P.
      • Kubis N.
      Good prognosis of postpartum lower limb sensorimotor deficit: A combined clinical, electrophysiological, and radiological follow-up.


      Retrospective

      Single center
      All consecutive patients with postpartum sensory and/or motor deficits referred to neurology clinic (N = 13).

      12 VB (4 forceps or vacuum) and 1 CS

      All had NAA
      13 LENI patients comprised 0.11% of total births

      Detailed criteria for diagnosis of each type of nerve injury and specific diagnostic tests

      FU information in person or by phone.

      Excluded pre-existing nerve injury.

      Interval between birth and evaluation ranged from 6-51 days (median 15, mean 27.5).
      Nerves affected: 11 LS or probable (85%), 2 femoral (15%), 1“non-organic symptoms”; 1 combination LS and femoral.

      Duration of symptoms: 3 days to 6 months, 2 lost to FU.

      Strength: Specific and consistent diagnostic testing; specific definition of criteria for each diagnosis (each nerve). Discussed difficulty of specific nerve diagnoses, even with testing. Description of symptoms by case.

      Limitations: LENI cases that are mild or abate quickly were not likely to be referred. Missing birth data and interval between birth and clinic visit varied. FU duration and criteria for resolution varied.
      • Richard A.
      • Vellieux G.
      • Abbou S.
      • Benifla J.
      • Lozeron P.
      • Kubis N.
      Good prognosis of postpartum lower limb sensorimotor deficit: A combined clinical, electrophysiological, and radiological follow-up.


      Prospective observational

      Single center
      PP women (433 CS and 586 VB) regardless of anesthesia (N = 1,019)

      LENI symptoms (n = 35)

      Entered study (n = 27)
      PP women were asked specific questions about numbness, weakness, mobility, paresthesia, and so forth followed by focused screening neurological assessment. Findings reviewed by anesthetist and neurologist to obtain consensus diagnosis.

      Excluded women whose symptoms resolved before neurological exam.

      35 reported symptoms, 27 entered study and 23 had objective signs of neurological injury. Six-week FU by telephone call.
      3.4% incidence before consent for research and before exclusions.

      2.3% incidence after exclusions, 0.8% with motor deficit.

      No association found with parity, maternal weight, labor duration, mode of birth or NAA.

      Duration of symptoms: days to weeks, 9 of 27 “unknown.”

      Strength: prospective, provided detailed list of labor and birth details for each case.

      Limitations: did not screen patients DC early. Initial screening assessment not by neurologist. Diagnosis based on assessment only with no diagnostic testing.

      Only 14 LENI cases (61%) were able to be followed up after DC.
      • Tournier A.
      • Doremieux A.C.
      • Drumex E.
      • Labreuche J.
      • Cassim F.
      • Bartolo S.
      • Subtil D.
      Lower-limb neurologic deficit after vaginal delivery: A prospective observational study.


      Prospective observational

      Single center
      PP women after singleton vaginal birth (N = 10,569)

      LENI women who reported symptoms after VB (n = 33). Two records missing, final n = 31.

      Of the sample of 31:

      71% (n = 22) were nulliparous,

      90% (n = 28) had NAA
      Midwives recorded any complaint of neurological deficit after vaginal birth.

      FU evaluation by obstetrician and neurologist only “if necessary.”
      Incidence of LENI with VB 0.3%.

      Second stage ranged from 13 to 224 minutes (median 94 minutes).

      Nerve injury description: “nerve territory affected”

      11 (35.5%) right, 14 (45.2%) left, 6 (19.3%) bilateral
      • 26 (83.9%) femoral
      • 4 (4%) obturator
      • 1 (1%) peroneal
      Duration of symptoms: median was 18 days. Recovery < 6 days in 11 (42%), 6 days ≤ 6 weeks in 18 (69.2%), > 1 year in 3 (11.5%).

      Strength: labor data included labor and birth positioning (but not leg or hip flexion information), 4-year follow-up.

      Limitations: symptoms solicited only if patient complained. Neurological evaluation and diagnostic testing varied or inconsistent. Labor variables (length of second stage, etc.) could not be compared to women without LENI.
      • Wong C.A.
      • Scavone B.M.
      • Dugan S.
      • Smith J.C.
      • Prather H.
      • Ganchiff J.N.
      • Mccarthy R.J.
      Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.


      Prospective observational

      Single center
      PP women (N = 6,057)

      VB (n = 5,114)

      CS (n = 943)

      72% regional labor anesthesia (N = 2,615)

      LENI confirmed nerve injury (n = 56)
      At 1 day PP, women were asked about symptoms. If yes or unsure, they received an initial neurological exam, then PT exam within 24 hours. Excluded preexisting or not confirmed by exam.LENI incidence 0.92% with 0.37% motor deficit.

      Women with LENI began pushing at higher station, were more likely to be nulliparas, and have prolonged second stage, and be positioned in lithotomy for longer periods.

      Duration of symptoms: 1 week to > 18 months with median of 2 months.

      Strength: prospective standardized approach and neurological evaluation by PT; analyzed labor and birth factors.

      Limitations: nerve diagnoses based on neurological assessment and not diagnostic tests. Did not provide raw numbers of women with VB or women with VB with or without NAA. 8 women had suspected LENI, but were excluded due to early DC or declined consent. Underreporting possible due to not asking about nerve pain or women not reporting symptoms.
      Note. CS = cesarean; DC = discharge; FU = follow-up; LS = lumbosacral; NAA = neuraxial anesthesia/analgesia; NB = newborn; PP = postpartum; PT = physical therapy; VB = vaginal birth.

       Quality and Potential Bias Within the 20 Articles

      Once the articles were selected, two authors (M.S. and B.T.) independently assessed study quality and risk of bias. We did not use a single tool or scoring instrument because the 20 studies were noninterventional, observational, and retrospective. Instead, we used components from two tools, the AXIS tool (
      • Downes M.J.
      • Brennan M.L.
      • Williams H.C.
      • Dean R.S.
      Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS).
      ) and the relevant bias domains of the ROBINS-I tool (
      • Sterne J.A.
      • Hernan M.A.
      • Reeves B.C.
      • Savovic J.
      • Berkman N.D.
      • Viswanathan M.
      • Higgins J.P.R.
      Robins-I: A tool for assessing risk of bias in non-randomized studies of interventions.
      ), to evaluate the quality and limitations of the articles. We identified three main sources of potential bias within the articles. The limitations of each specific research study are listed in Table 2. The potential sources of bias were as follows:
      In addition to potential sources of bias in all six research studies related to specific methods, it is likely that case studies in general may underreport uncommon phenomena such as LENI. Busy clinicians may not have the interest or time to write and submit such accounts for publication, particularly those in nonacademic centers and with less access to library resources. Despite likely underreporting (
      • Al-Ajmi A.
      • Rousseff R.T.
      • Khuraibet A.J.
      Iatrogenic femoral neuropathy: Two cases and literature update.
      ;
      • Madson T.J.
      Functional lower extremity deficits with sensory changes and quadriceps weakness in a 29-year-old female post labor and delivery: A case reports and literature review of postpartum maternal lower extremity peripheral nerve injuries.
      ;
      • Peirce C.
      • O'Brien C.
      • O'Herlihy C.
      Postpartum femoral neuropathy following spontaneous vaginal delivery.
      ;
      • Richard A.
      • Vellieux G.
      • Abbou S.
      • Benifla J.
      • Lozeron P.
      • Kubis N.
      Good prognosis of postpartum lower limb sensorimotor deficit: A combined clinical, electrophysiological, and radiological follow-up.
      ), we found 14 case studies of 15 births with LENI in the last 20 years.

       Incidence of LENI in All Births and in Vaginal Births Only

      Across studies for all births regardless of mode, LENI incidence ranged from 0.3% to 2.3% (
      • Dar A.
      • Robinson A.
      • Lyons G.
      Postpartum neurological symptoms following regional blockade: A prospective study with case controls.
      ;
      • Haller G.
      • Pichon I.
      • Gay F.O.
      • Savoldelli G.
      Risk factors for peripheral nerve injuries following neuraxial labour analgesia: A nested case-control study.
      ;
      • Richard A.
      • Vellieux G.
      • Abbou S.
      • Benifla J.
      • Lozeron P.
      • Kubis N.
      Good prognosis of postpartum lower limb sensorimotor deficit: A combined clinical, electrophysiological, and radiological follow-up.
      ;
      • Tournier A.
      • Doremieux A.C.
      • Drumex E.
      • Labreuche J.
      • Cassim F.
      • Bartolo S.
      • Subtil D.
      Lower-limb neurologic deficit after vaginal delivery: A prospective observational study.
      ;
      • Wong C.A.
      • Scavone B.M.
      • Dugan S.
      • Smith J.C.
      • Prather H.
      • Ganchiff J.N.
      • Mccarthy R.J.
      Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.
      ). Only one group of researchers,
      • Tournier A.
      • Doremieux A.C.
      • Drumex E.
      • Labreuche J.
      • Cassim F.
      • Bartolo S.
      • Subtil D.
      Lower-limb neurologic deficit after vaginal delivery: A prospective observational study.
      , limited their sample to vaginal births, and they reported an incidence of LENI with vaginal births of 0.3% (N = 1,059). Although
      • Richards A.
      • McLaren T.
      • Paech M.J.
      • Nathan E.A.
      • Beattie E.
      • McConnell N.
      Immediate postpartum neurological deficits in the lower extremity: A prospective observational study.
      reported an incidence of 2% for neurological deficits in 1,019 women after birth (433 cesarean and 586 vaginal births), they also listed details of each LENI case with mode of birth and injury, which allowed us to calculate an LENI incidence of 1.8% in their sample of vaginal births. Thus, the range in incidence for vaginal births (regardless of anesthesia) from these two studies was 0.3% to 1.8%. In both studies, researchers prospectively collected data on women during postpartum hospitalizations who self-reported neurological symptoms.

       Health Effects and Risk Factors

      To analyze the health effects and risk factors, we combined the available data from each case study (n = 15) with similar data related to vaginal births provided in four of the research studies (n = 65). In this sample of 80 births, the majority of nerves affected were femoral (22.5%), lumbosacral (33.8%), and uncertain (17.5%; see Table 3). For 10 of the 80 cases (12.5%), authors reported damage to more than one nerve. Of the 76 births for which further information was recorded, 30 LENI injuries (39.5%) occurred on the right side, 24 (31.6%) on the left side, and 22 (28.9%) were bilateral. In most (52.6%, n = 40) of these 76 cases, there were both sensory and motor impairments; 25 cases (32.9%) were sensory only, and 11 cases (14.5%) were motor only.
      Table 3Nerves Affected in 80 Reported Births
      Nerve or Injury Diagnosedn
      Numbers do not equal 80 because some cases had more than one nerve affected.
      Femoral18
      Lateral femoral cutaneous7
      Lumbosacral27
      Peroneal5
      Sciatic5
      Obturator4
      Cluneal3
      Radiculopathy4
      Possible needle injury2
      Pudendal1
      Uncertain14
      a Numbers do not equal 80 because some cases had more than one nerve affected.
      Information about the duration of symptoms was available for 61 of 80 births (see Table 4). Evaluation of symptom resolution or duration was hampered for several reasons. First, the use of vague terminology did not convey when the women had truly returned to preinjury function. Examples of ambiguous wording included “mostly resolved,” “good recovery at 2 months,” “95% improvement at 6 months,” “able to walk without cane,” and resolution of symptoms in “days” or “weeks.” Second, a lack of consistent follow-up meant that symptoms may have persisted for weeks, months, or years beyond the last report. Complete symptom resolution (return to preinjury level of mobility and/or sensation) was confirmed in only 38 (62.3%) of the 61 births with reported symptom duration. Among the 61 women, symptoms were described as mostly or completely resolved in 35 women (57.4%) by 2 months and in 53 women (86.9%) by 6 months. For this analysis, we used the time of the last report for symptom duration. Thus, our analysis is biased toward earlier resolution of symptoms than probably occurred.
      Table 4The Duration of Symptoms for 80 Reported Births
      Time Duration% (n)
      Less than 1 week20 (16)
      1 week to almost 4 weeks11.3 (9)
      1 month to almost 2 months12.5 (10)
      2–6 months22.5 (18)
      7–9 months5 (4)
      10–12 months2.5 (2)
      1–2 years1.3 (1)
      2–3 years0 (0)
      More than 3 years1.3 (1)
      No information23.8 (19)
      Note. Percentages do not equal 100 because of rounding.
      Because of missing information and a small pooled sample, we could not determine risk factors in the studies but were able to describe birth characteristics of the affected women. In this pooled data set of 80 births, 60 (75.9%) were spontaneous, 19 (24.1%) were vacuum or forceps assisted, and birth type was not identified for one. Seventy-nine of the 80 identified whether NAA was used, and in a majority of births (n = 61, 77.25%), women had NAA. Of the 44 births in which women’s parity was recorded, almost two thirds (n = 28, 63.6%) were women’s first vaginal births (either primiparas or first vaginal birth after cesarean). In the case reports of nerve injuries, data about the length of second-stage labor were reported for only 11 births. Of these 11 births, second-stage labor in four births lasted 60 minutes or less, in five births lasted 61 to 90 minutes, and two births lasted more than 90 minutes but less than 2 hours. Neonatal birth weight was reported for only nine cases, with weights ranging from 2.8 kg (6.2 lb) to 4.2 kg (9.3 lb). In this pooled data set, LENI occurred more often in women’s first births and occurred more often when NAA was used. Although we have described birth characteristics in women affected by LENI, the small sample, lack of information on labor and birth positions, and missing birth details preclude the description and reporting of potential risk factors.

       Practice Implications

      Only 5 of 20 selected articles offered practice suggestions to prevent LENI (
      • Butchart A.G.
      • Mathews M.
      • Surendran A.
      Complex regional pain syndrome following protracted labour.
      ;
      • Hashim S.S.
      • Addekanmi O.
      Bilateral foot drop following a normal vaginal delivery in a birthing pool.
      ;
      • Radawski M.M.
      • Srakowski J.A.
      • Johnson E.W.
      Acute common peroneal neuropathy due to hand positioning in normal labor and delivery.
      ;
      • Sahai-Srivastava S.
      • Amezcua L.
      Compressive neuropathies complicating normal childbirth: Case report and literature review.
      ;
      • Wong C.A.
      • Scavone B.M.
      • Dugan S.
      • Smith J.C.
      • Prather H.
      • Ganchiff J.N.
      • Mccarthy R.J.
      Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.
      ). No clinical studies were available on the outcomes from these practice recommendations, and future intervention studies are unlikely because of the infrequency of LENI and ethical concerns. Thus, clinical recommendations from the five articles are based on the known physiology and pathophysiology regarding the affected nerve(s) and literature on nerve injuries from surgical positioning under anesthesia.
      A broad recommendation was that women in labor should be encouraged to be mobile and frequently change positions (
      • Butchart A.G.
      • Mathews M.
      • Surendran A.
      Complex regional pain syndrome following protracted labour.
      ;
      • Hashim S.S.
      • Addekanmi O.
      Bilateral foot drop following a normal vaginal delivery in a birthing pool.
      ;
      • Wong C.A.
      • Scavone B.M.
      • Dugan S.
      • Smith J.C.
      • Prather H.
      • Ganchiff J.N.
      • Mccarthy R.J.
      Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.
      ). More specifically, maternity care providers should avoid positioning women with prolonged hyperflexion of knees and hips and extreme thigh abduction and external rotation (
      • Sahai-Srivastava S.
      • Amezcua L.
      Compressive neuropathies complicating normal childbirth: Case report and literature review.
      ;
      • Wong C.A.
      • Scavone B.M.
      • Dugan S.
      • Smith J.C.
      • Prather H.
      • Ganchiff J.N.
      • Mccarthy R.J.
      Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.
      ). To prevent peroneal nerve injury, hands should be positioned to prevent deep tissue compression at the posterior thigh (
      • Radawski M.M.
      • Srakowski J.A.
      • Johnson E.W.
      Acute common peroneal neuropathy due to hand positioning in normal labor and delivery.
      ) or lateral knee area (
      • Sahai-Srivastava S.
      • Amezcua L.
      Compressive neuropathies complicating normal childbirth: Case report and literature review.
      ). Care providers should educate women about how to avoid these positions (
      • Sahai-Srivastava S.
      • Amezcua L.
      Compressive neuropathies complicating normal childbirth: Case report and literature review.
      ).
      • Wong C.A.
      • Scavone B.M.
      • Dugan S.
      • Smith J.C.
      • Prather H.
      • Ganchiff J.N.
      • Mccarthy R.J.
      Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.
      advised that active pushing time be shortened by allowing time for passive descent during the second stage of labor. When these injuries occur, women should receive multidisciplinary care and follow-up from neurologists, chronic pain specialists, physiotherapists, anesthetists, and obstetricians until full recovery is achieved. This care should also include psychological support (
      • Butchart A.G.
      • Mathews M.
      • Surendran A.
      Complex regional pain syndrome following protracted labour.
      ). Maternity care providers must be aware of these injuries to prevent them from occurring (
      • Hashim S.S.
      • Addekanmi O.
      Bilateral foot drop following a normal vaginal delivery in a birthing pool.
      ;
      • Radawski M.M.
      • Srakowski J.A.
      • Johnson E.W.
      Acute common peroneal neuropathy due to hand positioning in normal labor and delivery.
      ;
      • Sahai-Srivastava S.
      • Amezcua L.
      Compressive neuropathies complicating normal childbirth: Case report and literature review.
      ).

      Discussion

      The results of our integrative review suggested that the incidence of LENI in vaginal births ranges from 0.3% to 1.8%, whereas the incidence in all births ranges from 0.3% to 2.3%. Although 15 of the 20 articles included only women who had NAA for birth, it is well-known that nerve injury occurs without anesthesia and in nonobstetric circumstances solely related to positioning. For instance, historically in the 1900s, farm workers experienced so-called, “strawberry pickers’ palsy” (
      • Hashim S.S.
      • Addekanmi O.
      Bilateral foot drop following a normal vaginal delivery in a birthing pool.
      ;
      • Koller R.L.
      • Blank N.K.
      Strawberry pickers' palsy.
      ). This compression neuropathy of the common peroneal nerve was also reported in sewer workers from prolonged squatting (
      • Kodaira M.
      • Sekijima Y.
      • Ohashi N.
      • Takahashi Y.
      • Ueno K.
      • Miyazaki D.
      • Ikeda S.
      Squatting-induced bilateral peroneal nerve palsy in a sewer pipe worker.
      ). In his literature review in an era when NAA was not commonly used in childbirth,
      • Chalmers J.A.
      Traumatic neuritis of the puerperium.
      found 142 published cases of LENI in childbirth in the previous 100 years. From 1935 to 1965, the incidence was reported to range from 0.2% to 0.5% (
      • Loo C.
      • Dahlgren G.
      • Irestedt L.
      Neurological complications in obstetric regional anaesthesia.
      ).
      Health effects in reports from this review varied based on the affected nerve and were consistent with reports of nerve injuries from perioperative and other literature. In most instances, NAA was used, and the births were the women’s first vaginal births. Without sufficient birth details and with small samples in the articles reviewed, we were unable to determine risk factors. Findings from our review suggest that LENI related to childbirth is a problem that is not rare but is sufficiently uncommon so that it may not be well-known among clinicians or the public.
      Future research is needed to explore risk factors associated with birth and positioning and women’s experiences with LENI.
      Contemporary case reports and research articles of nerve injury during childbirth tended to be published in anesthesia journals, rather than obstetric or maternity care journals. There were virtually no publications on LENI in the maternity nursing journals even though nurses are the primary caregivers during women’s labor, especially second stage. This paucity of literature exacerbates the lack of knowledge among those who care for women during childbirth and may contribute to the continued occurrence of LENI.

       Limitations of the Review

      Our analyses were hampered by variations among studies in the method of diagnosis and by overlapping and inconsistent terminology. Most nerve diagnoses were based on symptoms in anatomic locations presumed to be innervated by a specific nerve, rather than based on diagnostic neurological tests. We cataloged diagnoses as published regardless of whether authors reported specific neurological testing (such as nerve conduction studies) and despite the likelihood of overlapping terms. Inconsistent terminology challenged our ability to combine results. If authors described leg weakness and an inability to walk, there may have been sensory impairment also, but if this was not noted in the published report, we did not include it. In addition, although publications often contained abundant details about the NAA technique and dosing, they were often missing birth details that limited our analyses. As noted earlier, our analyses of symptom duration probably depict earlier resolution of symptoms than occurred because of short-term rather than long-term follow-up of individual cases and series of cases of women who experienced LENI.
      Single-center, observational, retrospective, and case studies have well-known limitations of selection bias and nonrepresentativeness. These limitations were compounded by the heterogeneity of screening and diagnosis and loss to follow-up. Pooled data from 80 births are still a small sample. The difficulty of performing research on infrequent conditions makes it likely that conclusions may not be representative due to underreporting of this phenomenon.

       Implications for Research

      Future research is needed to provide clarity on the incidence and risk factors. Future publications should provide consistent, specific terminology; detailed reporting of symptoms; and precise duration in days, weeks, months, or years. Research is urgently needed on the effectiveness of preventive measures and optimal strategies to prevent recurrence with subsequent vaginal births. Qualitative research on women’s lived experiences of LENI would be a valuable contribution. Such accounts might help clinicians better understand, anticipate, and address women’s home care needs.

       Recommendations for Practice

      Recommendations from published research and case reports from the past 20 years uncovered few recommendations for practice, and those were listed previously. However, other sources do report specific prevention and care suggestions. Because of the importance of this topic to care providers of all disciplines, we have synthesized and expanded on these recommendations in this section.

       Positioning: stretch + compression + time = injury

      Changing women’s positions frequently during all stages of labor, both with and without NAA, is not only a basic strategy to enhance labor progress (
      Association of Women’s Health, Obstetric and Neonatal Nursing
      Nursing care and management of the second stage of labor: Evidence-based clinical practice guideline.
      ) but can also prevent LENI that arises from nerve pressure and stretch related to positioning (
      • Bellew J.W.
      • Nitz A.J.
      • Schoettelkotte B.
      Postpartum femoral nerve palsy: A case study and the role of electrophysiologic testing and neuromuscular electrical stimulation.
      ;
      • Cohen S.
      • Zada Y.
      Postpartum femoral neuropathy.
      ;
      • Hakeem R.
      • Neppe C.
      Intrinsic obstetric palsy: Case report and literature review.
      ;
      • Richard A.
      • Vellieux G.
      • Abbou S.
      • Benifla J.
      • Lozeron P.
      • Kubis N.
      Good prognosis of postpartum lower limb sensorimotor deficit: A combined clinical, electrophysiological, and radiological follow-up.
      ;
      • Sahai-Srivastava S.
      • Amezcua L.
      Compressive neuropathies complicating normal childbirth: Case report and literature review.
      ). Nurses and other care providers should know the simple formula of stretch + compression + time = injury (
      • True B.A.
      • Sleutel M.
      On analgesia and anesthesia in the intrapartum period: Evidence-based clinical practice guideline.
      ) that underlies recommendations for women to adjust positions often, particularly during second-stage labor (Association of Women’s Health, Obstetric and Neonatal
      Association of Women’s Health, Obstetric and Neonatal Nursing
      Nursing care and management of the second stage of labor: Evidence-based clinical practice guideline.
      ;
      • Bunch K.
      • Hope E.
      An uncommon case of bilateral peroneal nerve palsy following delivery: A case report and review of literature.
      ) and to ambulate (
      • Madson T.J.
      Functional lower extremity deficits with sensory changes and quadriceps weakness in a 29-year-old female post labor and delivery: A case reports and literature review of postpartum maternal lower extremity peripheral nerve injuries.
      ). Nurses should particularly avoid positioning women with extreme thigh flexion, abduction, and external rotation (
      • Wong C.A.
      • Scavone B.M.
      • Dugan S.
      • Smith J.C.
      • Prather H.
      • Ganchiff J.N.
      • Mccarthy R.J.
      Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.
      ), barring acute situations such as the McRoberts maneuver for shoulder dystocia. These emergent situations should be limited in time, and care providers should reposition mothers’ legs into more neutral or physiologic positions as soon as feasible. Hyperflexion of the knees (bending at greater than 90° angles) should also be avoided. The findings of a recent study (
      • Gupta A.
      • Meriwether K.
      • Tuller M.
      • Sekula M.
      • Gaskins J.
      • Stewart J.R.
      • Francis S.
      Candy cane compared with boot stirrups in vaginal surgery: A randomized controlled trial.
      ) with measurements of the angles of hip flexion and abduction during gynecologic surgery suggest that greater hip abduction (frog-leg position) may contribute to worse physical outcomes. During labor, nurses must explain to women the importance of why they need to reposition often. It would be beneficial if this education began during the prenatal period.
      During pushing, hand positions (of women in labor or birth attendants) can lead to injury from compression of the common peroneal nerve in two distinct and different locations. The peroneal nerve exits laterally just below the knees as well as along the posterior thigh behind and below the knee. Nurses should help women avoid deep tissue compression from fingertips in these areas (
      • Hashim S.S.
      • Addekanmi O.
      Bilateral foot drop following a normal vaginal delivery in a birthing pool.
      ;
      • Mabie W.C.
      Peripheral neuropathies during pregnancy.
      ;
      • Sahai-Srivastava S.
      • Amezcua L.
      Compressive neuropathies complicating normal childbirth: Case report and literature review.
      ).
      • Radawski M.M.
      • Srakowski J.A.
      • Johnson E.W.
      Acute common peroneal neuropathy due to hand positioning in normal labor and delivery.
      recommended that hands be placed flat, rather than pressed inward with the fingertips, while holding legs back to prevent deep tissue pressure in either location, especially in instances in which NAA is used.
      Throughout all stages of labor, when laboring down before pushing and between contractions during pushing, women (particularly those with whom NAA has been used) should not rest their legs in stirrups or lean against bed rails. They should reposition with their legs flat or supported by pillows. This recommendation is similar to the strategies suggested to prevent perioperative nerve injuries by avoiding hip abduction (
      • Fleisch M.C.
      • Bremerich D.
      • Schulte-Mattler W.
      • Tannen A.
      • Teichmann A.T.
      • Bader W.
      • Zarras K.
      The prevention of positioning injuries during gynecologic operations. Guideline of DGGG (S1-Level, AWMF Registry No. 015/077).
      ), setting timers when stirrups or the lithotomy position is used, and having rest periods in neutral positions (
      • Hewson D.W.
      • Bedforth N.M.
      • Hardman J.G.
      Peripheral nerve injury arising in anaesthesia practice.
      ). Anatomic differences and individual variations mean that approaches to positioning may have varied effectiveness and must be tailored to each laboring woman.
      Recommendations about anesthesia were consistent that NAA should be dosed to allow women to have lower extremity motor function while providing acceptable analgesia. Risks for LENI increase when women’s legs are numb from NAA and they do not feel warning sensations and/or cannot reposition themselves (
      • Hakeem R.
      • Neppe C.
      Intrinsic obstetric palsy: Case report and literature review.
      ;
      • Madson T.J.
      Functional lower extremity deficits with sensory changes and quadriceps weakness in a 29-year-old female post labor and delivery: A case reports and literature review of postpartum maternal lower extremity peripheral nerve injuries.
      ). Hypotension from NAA can contribute to hypoperfusion of nerves and increases nerve susceptibility to damage (
      • Chui J.
      • Murkin J.M.
      • Posner K.L.
      • Domino K.B.
      Perioperative peripheral nerve injury after general anesthesia: A qualitative systematic review.
      ). Nurses must be vigilant with positioning all women, especially those who have NAA. Anesthesia providers should avoid dense anesthesia that blocks women’s ability to move (
      • Wong C.A.
      Neurologic deficits and labor analgesia.
      ).

       Education and documentation

      According to Zillioux and Krupski (2017, p. 74), “prevention begins with awareness.” Birth facilities can take specific actions to help prevent LENI. First and foremost, birth facilities should require education for all maternity caregivers (nurses, midwives, physicians, and anesthesiologists) about LENI, how to prevent it, what to document, and what to do for women after childbirth who do experience LENI. Physicians and anesthesia personnel are often blamed for LENI (
      • O'Neal M.A.
      • Chang L.Y.
      • Salajegheh M.K.
      Postpartum spinal cord, root, plexus, and peripheral nerve injuries involving the lower extremities: A practical approach.
      ) and thus should have the most to gain from required education for themselves and nurses.
      Caregivers can help prevent nerve injury and improve outcomes through increased awareness and early recognition and intervention.
      Common sense indicates that electronic health records (EHRs) should be designed for quick and succinct documentation of women’s positions, especially during the second stage of labor. Busy nurses and other caregivers should not be burdened with expectations of extensive narrative charting. Instead, we suggest that EHRs have images for nurses, anesthesia staff, and obstetric staff to select depicting women’s positions during the second stage of labor. Images should show specifics about hip angle, or hip flexion, and hand positions, including the location of partners’ or others’ hands while helping hold women’s legs. The duration of time in different positions should be quick and easy to document. Regardless of the current EHR limitations, nurses and other caregivers need to better document and describe specific positioning and duration of each position during the second stage of labor.

       After the injury/postpartum care

      Women who report leg or foot weakness or sensory alterations after childbirth must be believed, and caregivers must respond with compassion and concern. As frontline care providers, nurses should immediately notify the physician or nurse-midwife and, if NAA was used, also notify the anesthesia personnel. In addition to the provision of appropriate patient care and symptom treatment, when LENI is suspected, members of the birth team should meet to debrief; review the medical record and patient’s clinical presentation; and determine what, if any, measures might have helped prevent the injury.
      Women with LENI are at very high risk for falls. Nurses should not encourage these women to ambulate or be out of bed “to help the numbness go away.” Women with LENI symptoms should be discouraged from getting out of bed without assistance (
      • Webb J.
      On analgesia and anesthesia in the intrapartum period: Evidence-based clinical practice guideline.
      ). When assisting women out of bed, nurses should be extremely cautious and vigilant and hold onto women’s arms or a gait belt at all times. In some cases, a walker, cane, or other assistive device may be needed.
      Women who experience unexpected mobility impairments or sensory concerns will have questions. Care providers should “support, reassure, and inform the patient” (
      • Hewson D.W.
      • Bedforth N.M.
      • Hardman J.G.
      Peripheral nerve injury arising in anaesthesia practice.
      , p. 52). Results from our analyses provide some basis to explain the possible duration of symptoms, and nurses should provide as much information as possible. Nurses must advocate for neurology consults, physical therapy consults, and mobility assistive devices. Before discharge, the health care team, the woman, and her family should develop a follow-up plan of home and medical care (
      • Webb J.
      On analgesia and anesthesia in the intrapartum period: Evidence-based clinical practice guideline.
      ). If a woman has leg or foot weakness at the time of discharge, she should be sent home with a cane, walker, leg brace, wheelchair, and/or shower chair, as appropriate (
      • Webb J.
      On analgesia and anesthesia in the intrapartum period: Evidence-based clinical practice guideline.
      ). After discharge to home, providers in clinics should be responsive, supportive, and proactive in to ensure appropriate referrals and specialty care.

       Conclusions

      The current literature on LENI is limited and includes conflicting reports of incidence and a dearth of findings about prevention and prognosis. Nurses are the primary managers of women’s labor in the hospital setting during the first and second stages of labor and can help prevent LENI related to positioning. Intrapartum nurses can encourage greater levels of mobility, change women’s positions frequently in labor, avoid or minimize the use of stirrups, and assist with proper hand placement. Nurses can partner with anesthesia caregivers and advocate for the use of non–motor-blocking (low-dose) NAA. Postpartum nurses can help ease women’s confusion and ensure safety by advocating for appropriate evaluation, treatments, information, and resources. In summary, nurses are in a pivotal position to improve outcomes for women.

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      Biography

      Martha Rider Sleutel, PhD, RN, CNS, C-EFM, is a nurse scientist, Nursing Research & Clinical Excellence, Texas Health Resources, Arlington, TX.
      Barbara True, MN, CNS, RNC-OB, C-EFM, is a clinical nursing instructor, College of Nursing and Health Innovation, University of Texas Arlington, Arlington, TX.
      Jennifer Webb, BSN, RN, CCRN, is a staff nurse, Texas Health Heart and Vascular Hospital Arlington, Arlington, TX.
      Ericka Valdez, BSN, RN, RNC-OB, is a staff nurse in labor and delivery, Texas Health Presbyterian Hospital Denton, Denton, TX.
      Mary Van Thi Tran, BSN, RNC-OB, C-EFM, is a staff nurse in labor and delivery, Texas Health Arlington Memorial Hospital, Arlington, TX.