Common Peroneal Nerve Injury in Labour

A Naik S Attarbashi A S Yassin

Case Report

A 30 year old primigravida was admitted to the labour ward at 37+5 weeks in labour. She had no significant antenatal history.The onset of labour to delivery was 16 hours and during this time she was on “all fours” and squatting position for 6 hours on a stretch. Leg rests were not used during labour and delivery. She had an Epidural anaesthesia after 15 hours of onset of labour. Due to a pathological CTG, she had a ventouse delivery.Second day post delivery she complained of inability to move legs and paraesthesia on both the feet. There was no back pain. On examination, there was weakness of dorsiflexion, 2/5 on the left and 3/5 on the right. There was also weakness of eversion 3/5on the left and 4/5 on the right. Sensation was normal on right side and on the left side she had mild hyposthesia on the dorsum of foot. Her gait was high stepping. There was grazing and swelling on both the knees. Reflexes and proprioception was normal.She had no history of metabolic, endocrine or neurologic disorder before this event.There was nothing to suggest an underlying nerve susceptibility.X-ray of both the knees were normal. She was discharged with anti foot drop splints. On subsequent follow up she made good recovery with grade 4 dorsiflexion on both sides, near normal sensation and normal eversion.She stopped using the foot drop splints after 4 weeks and had complete recovery after 6 weeks of the incident.

Discussion

The common peroneal nerve is quite vulnerable to compression as it passes near the neck of the fibula.1Compression of this nerve manifests as aperoneal palsy with clinical “foot drop” in many instances.“All fours” is a gravity neutral position adopted by women in labour.2The position removes the weight of the baby from the women’s lower back and sacrum and may provide room for a baby to rotate to the anterior position.2Forced flexion of the kneein the squatting position (stretch) and“all fours”(compression)appears to play an important role in the pathophysiologic mechanisms of this type of injury1,4. A high index of suspicion for peroneal neuropathy after prolonged squatting must be present.5Surgical intervention is recommended for patients with predominantly axonal lesions and for those who do not improve within 3 months provided that the diagnosis has been confirmed with electrophysiological studies.6

This case highlights the importance of changing positions during labour and the need to be aware of possible neuropathies while caring for women in labour. This becomes more important as the RoyalCollege of Midwives (RCM) and the RoyalCollege of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies.7

References

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  1. Simkin, P. & Ancheta R. (2000). The labor progress handbook. Malden, MA: Blackwell Science
  1. S. S. Hashim & O. Adekanmi. Bilateral foot drop following a normal vaginal delivery in a birthing pool.Journal of Obstetrics and Gynaecology, Volume 27, Issue 6 2007 : 623 – 624
  1. R. L. Koller; N. K. Blank Strawberry pickers' palsy : Arch Neurol, Vol. 37, Issue 5, 1980;37:320.

5. Babayev M, Bodack MP, Creatura C. Common peroneal neuropathy

secondary to squatting during childbirth.Obstet Gynecol. 1998 May;91(5

Pt 2):830-2.

6. Fabre T, Piton C, Andre D, Lasseur E, Durandeau A. Peroneal nerve

entrapment. J Bone Joint Surg Am. 1998 Jan;80(1):47-53

7. RoyalCollege of Obstetricians and Gynaecologists/Royal College of

MidwivesJoint statement No.2, April 2007