Hello! Today we’re chatting lower extremity nerve injury (LENI). I read an article in JOGNN (Journal of Obstetric, Gynecologic, & Neonatal Nursing) that was the impetus for today’s topic. After reading the article, I immediately reached out to my dear friend Chelsea – someone I knew personally that experienced LENI and asked if she would share her journey. She shared her story with us this past week (if you missed it, read it here and here!) and although she had a strong recovery, many women do not.
I asked her to share her story because I don’t think we talk enough about LENI as a risk factor of childbirth. I don’t remember having much education (if any) during my midwifery program on LENI. Nerve injury is on the birth consent in the facility I practice in, but it is often glossed over during counseling. Unfortunately, many women don’t actually read the consent and simply sign on the line where they are told. I’ve also seen women during postpartum visits that still struggle with some numbness in a foot or a leg and I wonder: How many women feel that their symptoms are “just normal” and they never say anything?
With that said, I think that there is an opportunity to educate women, nurses, providers (OB/GYNs, anesthesiologists/CRNAs), doulas, or any birth worker about LENI. More importantly, I think that we need to focus on prevention whenever possible as the standard and not the exception.
The authors did an outstanding job with the article. One of the reasons that LENI isn’t at the forefront of obstetric practice is because LENI is rarely mentioned in obstetric literature. Instead, LENI articles are most often published in anesthesia journals. I’m hoping the article by Sleutel, True, Webb, et al. (2020) paves the way for more articles on LENI in nursing and obstetric journals alike.
Let’s get into it! First, did you know nerve injuries from vaginal delivery are cited in literature back to the 1800s? The same nerve injury was also noted from farm workers in the 1900s – something called “strawberry pickers’ palsy” from all of the squatting involved in the occupation (Sleutel, True, Webb, et al., 2020). I had no idea! But I think it’s important to mention it’s not a new phenomenon and even more so to emphasize why talking about it is important.
The basics of nerve injury are simple: nerves are injured by stretching or compression. Symptoms of nerve damage vary among women but can manifest as numbness, paresthesia (tingling, pricking, chilling, burning), pain or loss of muscle function to the area affected (Sleutel, True, Webb, et al., 2020). In birth, a nerve injury can be devastating to the postpartum period – think of all the carrying, walking, diaper changing, etc. a new mama does for her babe.
The incidence of LENI is from five studies and ranges from 0.3%-2.3% depending on the study. Nerve injury can occur in vaginal births with and without anesthesia, operative births (birth assisted by use of vacuum or forceps) and cesarean sections with/without labor (Sleutel, True, Webb, et al., 2020). That’s every birth mode.
Most LENI cases are thought to be caused by positioning. Anesthesia, such as epidurals, are thought to mask early signs of nerve injury more than cause the injury (Sleutel, True, Webb, et al., 2020). This makes sense! If you wouldn’t lay with a peanut ball between your legs on your side for three hours on your couch at home, why would that be a good position in labor? Without anesthesia, your body would give you signs that you are uncomfortable in that position and that discomfort would prompt you to change positions.
Nerves are like any other tissue in the body – they need blood supply with oxygen. The femoral nerve and peroneal nerves are most commonly injured in LENI cases due to the nature of how the hips and knees are positioned in pushing (Sleutel, True, Webb, et al., 2020).
So, how do we work to prevent LENI in practice? Sleutel, True, Webb, et al. (2020) recommend these practices:
- Educate birth workers in every discipline on the following equation:
STRETCH + COMPRESSION + TIME = INJURY
- Laboring women should be encouraged to be mobile and change positions frequently
- Hand position behind a woman’s knees should be placed to prevent deep tissue compression (especially near the lateral knee or posterior thigh)
- Women should be educated on positions to avoid in labor to prevent LENI
- Active pushing should be shortened to allow for passive descent
- If LENI is diagnosed, a multidisciplinary team, including psychological support, should be employed “until full recovery is achieved” (p.520)
- Lastly, if women voice concern or symptoms about the possibility of LENI, that the care team takes time to listen and address those concerns.
Going forward, Sleutel, True, Webb, et al. (2020) mention some really great points that I think are worth mentioning for any one working with birth (these are great long-term goals):
- Electronic health systems should work to make documentation in labor, especially with positions, easy for care givers. The authors recommend offering pictures of birthing positions versus having to select or type out a position would as a great option.
- Future publications should work to make consistent terminology to describe LENI
- “Research is urgently needed on the effectiveness of preventative measures and optimal strategies to prevent recurrence with subsequent vaginal births” (p.521) – I love this recommendation, especially the use of the word urgent.
- Qualitative research is recommended to evaluate women’s experiences of LENI
Wow. I just love everything about this article. It’s a great article to read if you have access to it – especially the review of the LENI articles previously published. If you work in birth settings, please take these recommendations to heart. Education about labor and birth starts in the clinic and LENI should be included in counseling and consent about birth as well as in the education women receive should they choose to receive anesthesia.
If you can’t access the article, you can read AWHONN’s practice brief for LENI for free. Either would be a wonderful journal club article to review with a team or unit!
Hope your Wednesday is lovely!
Sleutel, M., True, B., Webb, J., Valdez, E., & Van Thi Tran, M. (2020). Integrative review of lower extremity nerve injury during vaginal birth. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 49(6), 507-524. https://doi.org/10.1016/j.jogn.2020.09.155