Maternal Obstetric Palsy

Original Editor - Onigbinde Omotola Adam

Lead Editors  

Introduction

Maternal obstetric palsy or obstetric maternal palsy or obstetric maternal lumbosacral plexopathy refers to an injury to the lumbosacral plexus whose signs and symptoms become evident during labor or after childbirth.

Epidemiology

The population of women with maternal obstetrical palsy are relatively small, hence the absence of the condition in many textbooks[1]. Feasby et al. reported two cases in 1992[1], Katirji et al. had seven (7) women reported in 2002[2]. And some others had nineteen (19) patients in the year 2000.

Risk factors[1]

Short stature

Macrosomia

Cephalopelvic disproportion

Delayed/Prolonged labor

Mid forceps rotation

Fetal malpositioning

Clinically Relevant Anatomy

Lumbar-plexus-and-its-branches.png

The lumbar plexus and sacral plexus, if taken as one entity becomes the lumbosacral plexus, the largest spinal nerve plexus. It consists of nerves originating from spinal segments L1 to S4, lumbar plexus taking its origin from L1 to L4 and sacral plexus from L5 to S4 respectively. Nerves arising from the lumbosacral plexus generally course behind the psoas major, piercing the abdominal wall antero-laterally, then course antero-medially, upon the pelvic rim or iliac crest to enter into the lower limb.

Mechanism of Injury / Pathological Process

The position of the lumbocsacral plexus predisposes it to compression during prolonged labour, especially in some categories of women e.g. short women. Any trauma, or compression or injury to the trunks of the lumbosacral plexus creates clinical signs and symptoms in the mother. Katirji et al. (2002) concluded that intrapartum foot drop occurs mostly in short women and is caused by lumbosacral trunk compression by the fetal head at the pelvic brim primary pathology being predominantly demyelination and recovery is complete in up to 5 months.[2]

The peroneal nerve is frequently affected and "Hunerman in 1892 attributed its frequency to its position in the lumbosacral plexus."

Types

Presentation of signs and symptoms and electro diagnostic studies have helped in differentiating lumbosacral plexopathy into sub-groups

Types according to research articles reviewed are

1. Intrapartum maternal lumbosacral plexopathy: it involves the lumbosacral plexopathy easily recognized while the woman is in labour[2]

2. Postpartum maternal lumbosacral plexopathy: this manifests after childbirth[3]

Electrodiagnostic studies further describes postpartum maternal lumbosacral plexopathy into Upper and Lower Lumbosacral Plexopathy. Upper lumbosacral plexopathy involves the muscles of the lower limb and affectation to motor and sensory functions, while ,lower plexopathy only involves the lower part of the plexus (s2-s4).Lower postpartum lumbosacral plexopathy is evoked when perineal sensory disturbances whether or not associated with urinary or fecal incontinence persist after a history of a difficult vaginal delivery with no associated lower limb sensory or motor deficits noted[3] "The first, second and third sacral roots entering into the formation of the sacral plexus lie on the piriformis muscle and are thus unprotected against pressure on the bone"[4]

Clinical Presentation

For the upper palsy: pain, paraesthesia, weakness of ankle dorsiflexion, eversion, and inversion, and sensory loss in the L‐5 dermatome, foot drop.


For the lower palsy[3]

Perineal sensori-neuropathy

Urinary incontinence

Fecal incontinence

Sexual dysfunction

Diagnostic Procedures

Subjective history taking form the patient. Intrapartum palsy would have been observed during parturition.

Objective diagnostic procedures include the use of Electrodiagnostic devices vis a vis: EMG in determining the level of affectation. Compound Muscle Action Potential (CMAP), Sensory Nerve Action Potential (SNAP) are recorded to know the exact site of injury.

Outcome Measures

Functional Outcome Measure Scale (see Outcome Measures Database)

Physiotherapy Management / Interventions

Electrical Muscle Stimulation

Tactile Stimulation

Proprioceptive Neuromuscular Facilitation

Prescription of ankle foot orthoses

Differential Diagnosis

Spinal Cord Injury

Guillain-Barre Syndrome

Injection Neuritis

Resources

Feasby TE, Burton SR, Hahn AF. Obstetrical lumbosacral plexus injury. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine. 1992 Aug;15(8):937-40.

Ismael SS, Amarenco G, Bayle B, Kerdraon J. Postpartum lumbosacral plexopathy limited to autonomic and perineal manifestations: clinical and electrophysiological study of 19 patients. Journal of Neurology, Neurosurgery & Psychiatry. 2000 Jun 1;68(6):771-3.

References

[1]Feasby TE, Burton SR, Hahn AF. Obstetrical lumbosacral plexus injury. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine. 1992 Aug;15(8):937-40.

[2]Katirji B, Wilbourn AJ, Scarberry SL, Preston DC. Intrapartum maternal lumbosacral plexopathy. Muscle & nerve. 2002 Sep;26(3):340-7.

[3]Ismael SS, Amarenco G, Bayle B, Kerdraon J. Postpartum lumbosacral plexopathy limited to autonomic and perineal manifestations: clinical and electrophysiological study of 19 patients. Journal of Neurology, Neurosurgery & Psychiatry. 2000 Jun 1;68(6):771-3.

[4]Tillman AJ. Traumatic neuritis in the puerperium. American Journal of Obstetrics and Gynecology. 1935 May 1;29(5):660-6.

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