Integrative Review of Lower Extremity Nerve Injury During Vaginal Birth

Published:October 20, 2020DOI:



      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.


      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.


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        • Al-Ajmi A.
        • Rousseff R.T.
        • Khuraibet A.J.
        Iatrogenic femoral neuropathy: Two cases and literature update.
        Clinical Neuromuscular Disease. 2010; 12: 66-75
        • Association of Women’s Health, Obstetric and Neonatal Nursing
        Nursing care and management of the second stage of labor: Evidence-based clinical practice guideline.
        3rd ed. Author, Washington, DC2019
        • 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.
        Journal of Women's Health Physical Therapy. 2015; 39: 109-114
        • Bunch K.
        • Hope E.
        An uncommon case of bilateral peroneal nerve palsy following delivery: A case report and review of literature.
        Case Reports in Obstetrics and Gynecology. 2014; 2014: 1-4
        • Butchart A.G.
        • Mathews M.
        • Surendran A.
        Complex regional pain syndrome following protracted labour.
        Anaesthesia. 2012; 67: 1272-1274
        • Chalmers J.A.
        Traumatic neuritis of the puerperium.
        The Journal of Obstetrics and Gynaecology of the British Empire. 1949; 56: 205-216
        • Chui J.
        • Murkin J.M.
        • Posner K.L.
        • Domino K.B.
        Perioperative peripheral nerve injury after general anesthesia: A qualitative systematic review.
        Anesthesia & Analgesia. 2018; 127: 134-143
        • Cohen S.
        • Zada Y.
        Postpartum femoral neuropathy.
        Anaesthesia. 2001; 56: 500-501
        • Dar A.
        • Robinson A.
        • Lyons G.
        Postpartum neurological symptoms following regional blockade: A prospective study with case controls.
        International Journal of Obstetric Anesthesia. 2002; 11: 85-90
        • 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).
        British Medical Journal Open. 2016; 6e011458
        • 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).
        Geburtshilfe und Frauenheilkunde. 2015; 75: 792-807
        • 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.
        Obstetrics and Gynecology. 2020; 136: 333-342
        • Haas D.M.
        • Meadows R.S.
        • Cottrell R.
        • Stone W.J.
        Postpartum obturator neurapraxia.
        The Journal of Reproductive Medicine. 2003; 48: 469-470
        • Hakeem R.
        • Neppe C.
        Intrinsic obstetric palsy: Case report and literature review.
        Journal of Clinical and Diagnostic Research. 2016; 10: 6-7
        • Haller G.
        • Pichon I.
        • Gay F.O.
        • Savoldelli G.
        Risk factors for peripheral nerve injuries following neuraxial labour analgesia: A nested case-control study.
        Acta Anaesthesiologica Scandinavica. 2017; 61: 1203-1214
        • Hashim S.S.
        • Addekanmi O.
        Bilateral foot drop following a normal vaginal delivery in a birthing pool.
        Journal of Obstetrics and Gynaecology. 2007; 27: 623-624
        • Hayes N.
        • Wheelahan J.
        • Ross A.
        Self-reported post-discharge symptoms following obstetric neuraxial blockade.
        International Journal of Obstetrics Anesthesia. 2010; 19: 405-409
        • Hewson D.W.
        • Bedforth N.M.
        • Hardman J.G.
        Peripheral nerve injury arising in anaesthesia practice.
        Aneaesthesia. 2018; 73: 51-60
        • Kim S.H.
        • Kim I.H.
        • Lee S.Y.
        Sciatic neuropathy after normal vaginal delivery: A case report.
        Journal of Clinical Neuroscience. 2020; 72: 480-482
        • 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.
        Occupational Medicine. 2017; 67: 75-77
        • Koller R.L.
        • Blank N.K.
        Strawberry pickers' palsy.
        Archives of Neurology. 1980; 37 (320–320)
        • Loo C.
        • Dahlgren G.
        • Irestedt L.
        Neurological complications in obstetric regional anaesthesia.
        International Journal of Obstetric Anesthesia. 2000; 9: 99-124
        • Mabie W.C.
        Peripheral neuropathies during pregnancy.
        Clinical Obstetrics and Gynecology. 2005; 48: 57-66
        • 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.
        Journal of Women's Health Physical Therapy. 2014; 38: 11-18
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • The PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement.
        PLoS Medicine. 2009; 6: 1-6
        • 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.
        Systematic Review. 2015; 4: 1
        • Murray D.J.
        • Bhatti W.
        Maternal sacral fracture during delivery causing foot drop.
        International Journal of Gynecology and Obstetrics. 2011; 115: 289-297
        • 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.
        Anesthesia & Analgesia. 2015; 120: 141-148
        • Park S.
        • Park S.W.
        • Kim K.S.
        Lumbosacral plexus injury following vaginal delivery with epidural analgesia.
        Korean Journal of Anesthesiology. 2013; 64: 175-179
        • Peirce C.
        • O'Brien C.
        • O'Herlihy C.
        Postpartum femoral neuropathy following spontaneous vaginal delivery.
        The Journal of Obstetrics and Gynaecology. 2010; 30: 203-204
        • Radawski M.M.
        • Srakowski J.A.
        • Johnson E.W.
        Acute common peroneal neuropathy due to hand positioning in normal labor and delivery.
        The American College of Obstetricians and Gynecologist. 2011; 118: 421-423
        • 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.
        Journal of Neurology. 2017; 264: 529-540
        • 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.
        International Journal of Obstetric Anesthesia. 2017; 31: 5-12
        • Rowland C.
        • Kane D.
        • Eogan M.
        Postpartum femoral neuropathy: Managing the next pregnancy.
        British Medical Journal Case Report. 2019; 12: e232967
        • Sahai-Srivastava S.
        • Amezcua L.
        Compressive neuropathies complicating normal childbirth: Case report and literature review.
        Birth. 2007; 34: 173-175
        • 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.
        British Medical Journal Open. 2016; 355: i4919
        • 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.
        International Journal of Obstetric Anesthesia. 2019; 41: 35-38
        • True B.A.
        • Sleutel M.
        On analgesia and anesthesia in the intrapartum period: Evidence-based clinical practice guideline.
        Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2020; 49: 227-229
        • Webb J.
        On analgesia and anesthesia in the intrapartum period: Evidence-based clinical practice guideline.
        Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2020; 49: 230-231
        • Wong C.A.
        Neurologic deficits and labor analgesia.
        Regional Anesthesia and Pain Medicine. 2004; 29: 341-351
        • Wong C.A.
        Nerve injuries after neuraxial anaesthesia and their medicolegal implications.
        Best Practice & Research Clinical Obstetrics and Gynaecology. 2010; 24: 367-381
        • 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.
        Obstetrics & Gynecology. 2003; 101: 279-288
        • Zillioux J.M.
        • Krupski T.L.
        Patient positioning during minimally invasive surgery: What is best practice?.
        Robotic Surgery: Research and Reviews. 2017; 4: 69-76


      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.