16: Peripheral Nerve Injury Associated With Labor

INTRODUCTION

The majority of complications involving peripheral nerves are unrelated to the anesthetic technique and more likely due to obstetric circumstances. A survey of 6057 women who delivered in Chicago¹ reported an incidence of lower extremity nerve injuries of approximately 1% (24 lateral femoral cutaneous nerve, 22 femoral nerve, 3 peroneal nerve, 3 lumbosacral plexus, 2 sciatic nerve, 3 obturator nerve, and 5 radicular injuries).¹ Significant risk factors for peripheral nerve injury (PNI) were nulliparity and a prolonged second stage of labor, but not neuraxial anesthesia. The findings of this survey corroborate those of the Leeds study,² stating that “that postpartum neurologic dysfunction is more frequent if specifically sought, and support the clinical impression that significant neurological deficits occur irrespective of the use of regional anaesthesia.”

EPIDEMIOLOGY

The detection of PNI may be spuriously increasing as a result of the routine follow-up performed by the anesthesia team in the immediate postpartum period to detect complications linked to the practice of neuraxial anesthesia (eg, postdural puncture headache, epidural hematoma, nerve root damage). On the other hand, with the changes in obstetric practices regarding intolerance for protracted labor and difficult forceps delivery, the prevalence of these complications will likely decrease. The new obstetric guidelines show a preference for cesarean delivery as opposed to prolonged labor and forceps assistance in these situations.

Neurologic complaints due to factors associated with labor and delivery are seen in 1.6 to 4.8/10,000 of parturients, and those attributed to the possible deficits related to regional anesthetic techniques are found in 0 to 1.2/10,000 of parturients.³

MECHANISMS OF PERIPHERAL NERVE INJURY

Acute nerve injury may occur as a consequence of transection, traction, compression of a nerve, or vascular injury.⁴

• Compression or traction on a nerve can result in compromised perineural blood flow and lead to ischemia. This may cause focal demyelination and conduction block. However, symptoms are usually transient, because the focal demyelization is a reversible phenomenon.

• In more serious injuries, the axons of the nerve can be damaged. In this case, the damage can be permanent, or if temporary, the symptoms will disappear slowly.

• Neuraxial anesthesia can mask the early symptoms of PNI. Residual numbness or weakness can be attributed falsely to residual local anesthetic effect. Thus, a high index of suspicion for PNI must be maintained in the face of unintended extended sensory or motor block.

RISK FACTORS FOR PERIPHERAL NERVE INJURY

Risk factors may be maternal or fetal.^5,6

• Maternal obesity

• Abnormal presentation

• Persistent occiput posterior position

• Fetal macrosomia/fetus large for gestational age

Risk factors may be related to the labor.^5,6

• Breakthrough pain during epidural labor analgesia

• Prolonged second stage of labor

• Difficult instrumental delivery

• Prolonged use of the ...