The Role of Acute Physical Therapy in the Postpartum Evaluation of Peripheral Nerve Injury and Impact on Mental Wellness: A Case Study

Abstract

Postpartum peripheral nerve injury (PPNI) often stems from prolonged positioning, compression, or stretch during labor. While rare, PPNI can severely impair mobility and postpartum function. Negative birth experience, operative birth, and decreased social support are risk factors for developing postpartum PTSD. This case study reports on a 26-year-old (41.2 weeks of gestation) who experienced a traumatic birth including a failed vacuum-assisted vaginal delivery (VAVD) and subsequent cesarean section. Post-epidural, she presented with persistent lower extremity weakness, sensory deficits, urinary incontinence (UI), and inability to ambulate independently. Acute physical therapy (PT) focused on gait training, stair negotiation, pain management, establishing a toileting schedule, and safety with newborn handling. Despite documented medical necessity, insurance denied coverage for durable medical equipment (DME). The patient was discharged with a pre-owned walker, pre-owned shower chair, and referral to outpatient pelvic floor physical therapy. Despite these systemic hurdles, the patient reported high self-efficacy at discharge. Acute PT is essential for postpartum safety and psychosocial support, particularly after suffering physical disability from a traumatic birth. Furthermore, integrating acute PT into the maternity unit allows for a holistic assessment of the home environment, support systems, and the emotional toll of birth trauma, ensuring the mother is physically and psychologically equipped for the fourth trimester.

Introduction

Postpartum peripheral nerve injury (PPNI) affects 0.3–2% of deliveries, often stemming from prolonged positioning, compression, or stretch during labor.1 PPNI most commonly involves the femoral lateral cutaneous nerves. While less commonly affected nerves include the femoral, peroneal, or obturator nerves. PPNI present with a sensory and/or motor impairment. While the prognosis for nerve regeneration is generally favorable, the acute phase presents significant risks, including falls and inability to perform Mobility-Related Activities of Daily Living (MRADLs).1,2 Physical therapy (PT) in the acute setting is essential not only for functional rehabilitation but for ensuring maternal-infant safety during the transition to home.

Research suggests between 1-6% of women develop post traumatic stress disorder (PTSD) after childbirth.3 Risk factors for developing PTSD after childbirth include having a perceived negative birth experience, operative birth (assisted vaginal or cesarean), or dissociation.4 While research regarding PTSD in the postpartum population is relatively limited, it is suggested that positive psychology and emphasizing resilience have shown positive outcomes in non perinatal populations. Components of resilience can be characterized by the ability to recover from a traumatic event and to have sustainability. Adults who have more optimism, social support, active coping, and sense of purpose, tend to exhibit greater resilience. Furthermore, research in perinatal populations suggest that increasing positive emotions, autonomy, and sense of purpose during pregnancy, childbirth, and postpartum may reduce postpartum PTSD.4,5

Case Presentation

The patient, a 26-year-old female, was admitted at 41.2 weeks of gestation. Labor was complicated by a two-hour second stage, a failed vacuum-assisted vaginal delivery (VAVD), and an emergent cesarean section. Post-epidural, the patient exhibited persistent motor and sensory deficits in the lower extremities, alongside new-onset urinary incontinence (UI), and inability to ambulate without the support of a walker. PT screened each body system during the evaluation. Ambulation was encouraged per the patient’s goal of seeing her infant in the NICU. Ultimately, a wheelchair was required due to buckling of the patient’s knees making further ambulation unsafe.

Figure 1: Detailed demographics, screening, and physical therapy evaluation.

Physical Therapy Intervention

The patient was seen over a four day hospital admission post-delivery. Treatment consisted of post-surgical pain management, desensitization, abdominal binder use, and mobility strategies.6,7 Mobility training for safe discharge planning included gait training with a walker, stair negotiation, caregiver training, and energy conservation techniques. Additionally, UI was addressed with implementation of a toileting schedule and diaphragmatic breathing.8,12 The complex patient presentation, environmental barriers for home re-entry, and psychosocial status required extensive time instructing both the patient and her significant other. Furthermore, once the infant was discharged from the NICU, treatment shifted to maternal-infant care including ergonomics for holding the infant, safety with newborn care, energy conservation strategies, and identifying her support system.

Figure 2: Individual treatment and patient outcome.

Outcomes & Systemic Barriers

Clinical documentation supported that the patient’s mobility limitations significantly impaired her ability to perform MRADLs without DME.10 PT recommended using a walker for ambulation, as she continued to exhibit impaired single leg stance without upper extremity support. Additionally, a shower chair was recommended to reduce fall risk. However, a significant barrier arose during discharge planning as insurance providers and DME vendors noted that pregnancy-related ICD-10 codes often do not qualify for DME coverage, regardless of the secondary neurological impairments. Ultimately, the patient relied on community resources to obtain a pre-owned walker and shower chair to ensure safety with MRADLs. Outpatient pelvic floor physical therapy evaluation was also established prior to her hospital discharge. Despite these systemic hurdles, the patient reported high self-efficacy and patient satisfaction at discharge. A follow-up testimonial indicated that the individualized PT interventions provided confidence returning home and psychosocial support while processing a traumatic birth experience.

Discussion

This case highlights a critical gap in postpartum care. This case was not just about PPNI. It was about the psychosocial transition to motherhood with a physical disability. The patient had a negatively perceived childbirth requiring an emergency cesarean section, followed by an unexpected NICU admission, and physical disability that resulted from delivery. These combined factors increase the risk of developing perinatal mood disorders and postpartum PTSD.4,11 We can hypothesize that the steady presence of PT providing individualized education regarding her condition and recovery, along with self advocacy, helped shape the patient’s traumatic birth into a more optimistic scenario. While the medical team managed the physiological recovery from the cesarean birth, PT served as the bridge between the medical trauma of the delivery and the functional reality of going home.

Furthermore, this case underscores a maternal inequity disclosing the lack of standardized DME coverage for postpartum patients who suffer a physical disability during childbirth. Clinicians must be prepared to advocate for patients beyond the clinical scope, often assisting in navigating community-based equipment sourcing when insurance fails. PT is an essential component of postpartum recovery that should be implemented in the acute phase.12 Integrating acute PT into the maternity unit allows for a holistic assessment of the home environment, support systems, and the emotional toll of birth trauma, ensuring the mother is physically and psychologically equipped for the fourth trimester.

References

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