All About Maternal Obstetric Palsy

Introduction:

Maternal obstetrical palsy is a rare illness that causes sensory and motor deficits in certain leg muscles during labor or hours later. Since Von Basedow's initial description in 1838, over 200 cases have been reported in the literature. A variety of factors, including hypovitaminosis, inflammation, infections, and maternal toxemia, can cause the lesion. However, it is more commonly seen in the traumatic group, leading to various theories of causation. This is in contrast to obstetric palsy (also known as Erb's palsy), which occurs when the infant's brachial plexus is injured during birth.

What Is Maternal Obstetric Palsy?

Maternal obstetric palsy is a lumbosacral plexus injury that manifests itself during or after childbirth. Maternal obstetric palsy appears to overlap with obstetric fistula, in which a prolonged second stage of labor causes the patient to experience lower-limb neurological symptoms in addition to vaginal fistula. According to available information, the illness is rare, affecting only a few women.

Recent research reveals that postpartum motor and sensory dysfunction occurs at a rate of 1 percent; However, this figure does not distinguish between the causes of dysfunction, such as labor analgesia or labor intrinsics. It is worth emphasizing that much of the research is conducted in well-resourced countries where anesthetic therapies to aid in the labor phase and medical interventions (such as cesarean sections) to avoid protracted labor are readily available.

What Are the Causes of Maternal Obstetric Palsy?

Obstetric palsy is thought to be caused by a traumatic lesion at birth, and it occurs in 1 in 10,000 births. Breech delivery has a 175 times higher incidence of harm. Two different factors can cause obstetric palsy. Both large newborns with cephalic presentation and shoulder dystocia, as well as petite infants delivered breech, are in danger during delivery. Obstetric palsy can develop after a seemingly normal delivery, as well as has even been observed following a cesarean section.

What Are the Risk Factors for Maternal Obstetric Palsy?

Risk factors differ depending on whether the dysfunction is caused by labor analgesia or the intrinsics of labor.

• Spinal anesthesia versus epidural anesthesia.

• Short stature.

• Mid forceps rotation.

• Fetal malpositioning.

• Macrosomia (greater than average size of fetus).

• Cephalopelvic disproportion.

• Delayed or prolonged labor.

• Static posture of the lower extremities throughout an extended second stage of labor.

What Is the Clinical Presentation of Maternal Obstetric Palsy?

The absence of biceps or deltoid function after three months of age strongly indicates brachial plexus exploration. Other requirements include no elbow flexion or extension, forearm extension, or thumb or finger movement by nine months of age. Most surgeons advocate probing before 6 to 9 months of age.

For upper palsy:

• Symptoms may include discomfort, numbness, sensory loss in the L-5 dermatome, and ankle weakness leading to foot drop.

For lower palsy:

• Perineal sensory-neuropathy.

• Sexual dysfunction.

• Urinary incontinence.

• Fecal incontinence.

What Is the Mechanism of Injury and Types?

The absence of biceps or deltoid function by three months of age strongly indicates brachial plexus exploration. Other factors include the lack of elbow flexion, forearm extension, or finger extension at nine months of age. Most surgeons propose exploration before six to nine months of age. Mechanical trauma can cause nerve tissue stretch, compression, or transection, resulting in neurological damage.

A compromised blood supply can also result in nerve damage. Injury to the lumbosacral plexus during labor or delivery causes the mother to have clinical symptoms and signs that appear during or after labor. The mother may have autonomic and motor dysfunction, such as impaired sensations of afferent pain, warmth, pressure, and proprioception. The peroneal nerve is often damaged.

Hunerman (1892) attributed its frequency to its location in the lumbosacral plexus. Still, it has also been connected to prolonged posturing that compresses the nerve at the posterior knee joint, including extended squatting or usage of stirrups. Femoral or obturator neuropathy can also occur, causing dysfunction of the knee extensors, leading to functional restrictions such as an inability to climb stairs, diminished patellar response, and femoral sensory loss.

Signs and symptoms, as well as electrodiagnostic investigations, have served to differentiate lumbosacral plexopathy into subgroups, including:

• Intrapartum Maternal Lumbosacral Plexopathy: It includes lumbosacral plexopathy that is easily diagnosed while the woman is in labor.

• Postpartum Maternal Lumbosacral Plexopathy: This occurs after childbirth.

How to Diagnose Maternal Obstetric Palsy?

A complete subjective history should be obtained from the patient, including information about the labor process and any medical interventions. The indications and symptoms will determine objective diagnostic procedures.

• Complete Assessment - Complete physiotherapy assessment of the ankle, knee, and hip.

• Neurological Examination - A neurological examination examines the nervous system to detect and diagnose anomalies impairing function and daily activities. It should enable individuals to develop individual, patient-centered goals and, eventually, a tailored treatment plan based on the client's requirements.

• Functional Gait Assessment - The functional gait assessment (FGA) is a modified version of the dynamic gait index (DGI) that employs higher-level tasks to make it more applicable to people with vestibular disorders.

• Compound Muscular Action Potential (CMAP) - The compound muscular action potential (CMAP) measures motor nerve fibers from their origin in the anterior horn cells to their termination along muscle fibers.

• Sensory Nerve Action Potentials (SNAP) - The sensory nerve action potential (SNAP) gives information on the sensory nerve axon and its journey from the skin's distal receptors to the dorsal root ganglia.

• Electromyography (EMG) - EMG is the evaluation and recording of muscle activity. Electromyography records the electrical activity and converts it into visual or audible information.

How Is It Managed?

The therapy goals are to relieve pain, reduce muscle spasms, improve sensation, increase muscle strength, avoid further degeneration, and retrain lower limb function. Cryotherapy, transcutaneous electrical nerve stimulation (TENS), isometric strength exercise, proper alignment of the lower limbs with the hips in extension and slight abduction and the knees in extension, splinting of the ankle joints in dorsiflexion, as well as gait re-education have been used to achieve these results. As per one incident, the use of cryotherapy to alleviate muscle spasms was adjusted after the first week of treatment when the team discovered that there was an immediate reduction in spasms after cryotherapy, the relief of symptoms was only temporary, and the patient had considerable pain afterward.

Different physiotherapy management methods are as follows:

• Proprioceptive neuromuscular facilitation.

• Tactile stimulation.

• Electrical muscle stimulation.

• Targeted exercises.

Conclusion:

In conclusion, physiotherapy management and therapies are successful in treating maternal obstetric palsy. Transcutaneous electrical nerve stimulation (TENS) alleviated pain linked with the condition while strengthening exercises for muscles, such as isometric and resisted exercises, as well as functional exercises, increased muscle strength in the targeted muscle groups and improved functional independence.