Women with SCI are able to conceive, carry and deliver a baby; however, there is an increased frequency of complications during pregnancy, labour and delivery (Baker & Cardenas 1996; Jackson & Wadley 1999; Morton et al. 2013). Bladder problems, spasticity, pressure sores, autonomic dysreflexia and problems with mobility can pose a threat to the pregnant woman with SCI (Baker et al. 1992; Jackson & Wadley 1999; Skrowronski & Hartman 2008). Frequent and sometimes lengthy hospital admissions during pregnancy can occur due to these and other reasons (Skrowronski & Hartman 2008). Autonomic dysreflexia is aggressively managed using sublingual nifedipine or intramuscular clonidinen during labour, but pre-emptive epidural anaesthesia before or during labour is preferred: the latter can also be used in the postpartum period (Skrowronski & Hartman 2008). Difficulties exist because medications that lower blood pressure can potentially cause acute hypotension, which in turn may affect fetal bloodflow. Since labour can go undetected, regular monitoring of utuerine tone and cervical dilation and effacement is important (Skrowronski & Hartman 2008). Obstetric outcomes include higher rates of Caesarian-sections and increased incidence of low birth-weight babies (Jackson & Wadley 1999; Morton et al. 2013). Fewer women practice breastfeeding post-SCI (Jackson & Wadley 1999). Challenges with breastfeeding arise from autonomic dysreflexia, inhibition of the milk ejection reflex (i.e. above T7) and problems with infant handling (Cowley 2005, Skrowronski & Hartman 2008). In summary, a cohesive multidisciplinary team including obstetrics, physiatry, nursing, and occupational and physical therapy is essential throughout pregnancy, labour delivery, and the post-partum period.
The below section is presented with tables in full in the Autonomic Dysreflexia chapter (see section on Prevention of AD during Pregnancy and Labour), but is presented in condensed form here.
In North America, women represent a third of the SCI population (Ackery et al. 2004). Approximately 3,000 American women of childbearing age are affected by SCI (Cross et al. 1992). The ability of women to have children is not usually affected once their menstrual cycle resumes (Jackson & Wadley 1999). There are increasing numbers of women with SCI who have healthy babies (Cross et al. 1992). However, during labor and delivery, women with SCI are at high risk of developing uncontrolled AD (Sipski 1991; Sipski & Arenas 2006).
Recognition and prevention of this life threatening emergency is critical for managing labour in women with SCI (McGregor & Meeuwsen 1985). The majority of women with SCI above T10 experience uterine contractions with only abdominal discomfort, an increase in spasticity and AD (Hughes et al. 1991). Numerous observational studies, case reports and expert opinions recommend adequate anesthesia in women with SCI during labor and delivery despite the apparent lack of sensation. However, there are only five studies (n=54) (Ravindran et al. 1981; Hughes et al. 1991; Cross et al. 1991; Cross et al. 1992; Skowronski & Hartman 2008) with observational evidence recording the management specific to AD during labour. The American College of Obstetrics and Gynecology emphasized that it is important that obstetricians caring for these patients be aware of the specific problems related to SCI (American College of Obstetrics and Gynecology 2002).
There is level 4 evidence (Skowronsky and Hartman 2008) that women with SCI may give birth vaginally. With vaginal delivery or when Cesarean delivery or instrumental delivery is indicated, adequate anesthesia (spinal or epidural if possible) is needed to reduce the episodes of AD associated with birth.
There is level 4 and 5 evidence (from 2 case series and 2 observational studies) (Cross et al. 1992; Hughes et al. 1991; Cross et al. 1991; Showronski and Hartman 2008) that epidural anesthesia is preferred and effective for most patients with AD during labour and delivery.