1. Wisner, Kirsten PhD, RNC-OB, CNS, C-EFM

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Lower extremity nerve injury (LENI) can occur during labor and birth when the childbearing person's nerves are compressed or stretched. Although reported incidence of LENI is low, estimated at 0.3% to 2.3% of those who give birth, effects can be devastating (Association of Women's Health, Obstetric, and Neonatal Nurses [AWHONN], 2020). It is likely underreported because patients with mild or short-term symptoms may not seek care. Symptoms depend on affected nerve(s) and may include pain, paresthesia, and impaired muscle function affecting ability to bear weight or walk. Though LENI typically resolves within 6 months, it may linger for years or be permanent (AWHONN). A recent AWHONN (2020) practice brief about LENI highlights key preventive strategies for perinatal clinicians. Note that though LENI may occur from gynecologic surgeries and cesarean birth, the practice brief (AWHONN) focuses on interventions during vaginal birth.


Positioning, particularly during the active pushing stage of labor, is often the cause of LENI. Use of neuraxial analgesia increases risk because the patient may not feel warning sensations that would cause them to adjust their position to ease nerve compression (AWHONN, 2020). The femoral nerve may be compressed and damaged as the patient's thighs are pulled back during pushing while the hips are rotated and abducted. Peroneal nerve damage may occur during prolonged knee flexion when the squatting, kneeling, or lithotomy position is used, or when using stirrups. The peroneal nerve may be damaged during prolonged pressure below the flexed knee when holding the leg in this position, especially with excessive pressure from the fingertips versus flat hand. Damage may occur when a patient's knee rests against a hard surface such as a bedrail or stirrup edge (AWHONN).


Numerous strategies can be used to prevent LENI and should focus on education of the multidisciplinary maternity team including information on causes and prevention. Documentation should be tailored to capture positioning during labor, particularly during second stage. Specific intrapartum and postpartum strategies are as follows (AWHONN, 2020):


Intrapartum positioning:


* Avoid hyperflexion of the knees and thighs > 90 degrees, especially while abducting and externally rotating the hips. If the McRoberts maneuver is used for shoulder dystocia, reposition the patient's legs in a neutral position as soon as possible. Avoid hyperflexion and abduction when using stirrups.


* Encourage repositioning every 10 to 15 minutes during second-stage labor.


* Avoid the lithotomy position.


* Protect the patient's legs from hard surfaces such as side rails or stirrups.


* Avoid deep and prolonged pressure from fingertips, especially at the lateral knee and posterior thigh areas. Use flat hands for leg support.


* Promote use of nonmotor blocking neuraxial analgesia to allow mobility and sensation.



Postpartum care:


* Educate patients about signs and symptoms of LENI and associated risks for themselves and their newborn.


* Regularly assess for LENI symptoms, such as pain, paresthesia, numbness, weakness, or loss of function and promptly notify obstetric and anesthesia providers as needed.


* Implement fall precautions, including assistance when ambulating and consider use of an obstetric fall assessment tool.


* Use mobility aids as needed when LENI is detected and discharge with appropriate home care to support self- and newborn care.


* Arrange specialty consultations as needed.



Clinicians and patients may be unaware of LENI and how easily it can be prevented. Nurses can advocate for patients by promoting multidisciplinary and patient education about LENI and ensuring that their practice setting has implemented appropriate assessment, education, and documentation strategies to detect and address it (AWHONN, 2020).




Association of Women's Health, Obstetric, and Neonatal Nurses. (2020). Lower extremity nerve injury in childbirth (Practice Brief No. 11). Nursing for Women's Health, 24(6), 470-472.[Context Link]