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Pregnancy, Labour and Autonomic Dysreflexia

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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.

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).

Autonomic dysreflexia is aggressively managed using sublingual nifedipine or intramuscular clonidine 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 uterine tone and cervical dilation and effacement is important (Skrowronski & Hartman 2008). It should be noted that the acute onset of AD in labor can be difficult to distinguish from preeclampsia, but that making the correct diagnosis and initiating appropriate therapy can be life-saving (Pereira 2003).

Gap: The Influence of SCI on Breastfeeding
Source of evidence
The Influence of Spinal Cord Injury on Breastfeeding Ability and Behaviour. Holmgren, Lee, Hocaloski, Hamilton, Hellsing, Elliott, Hultling & Krassioukov 2018 (in press). Journal of Human Lactation. 22 May 2018, 34(3):556-565

Intro

Although fertility is typically not affected, little is known about the challenges faced by women with SCI both during and after, including breastfeeding (Alexander, Aisen, Alexander, & Aisen, 2017). Lactation dysfunction following disability has been noted in the literature (Charlifue, Gerhart, Menter, Whiteneck, & Scott Manley, 1992; Morton et al., 2013); however, the extent of lactation dysfunction and influence of SCI on breastfeeding ability and behaviour is not well understood

Study

To assess differences in breastfeeding experience and challenges, researchers in Stockholm, Sweden and Vancouver, Canada conducted a retrospective self-report study with mothers with SCI; participants were divided into two groups for analytic purposes – high-level SCI (Injury at T6 or above (n=18)) and low-level SCI (Injury below T6 (n=20)).

They found three significant differences between the mothers with high-level SCI and the mothers with low-level SCI:

  •  Women with high-level SCI breastfed exclusively (i.e., without formula supplementation) for an average of 2.78 months, a significantly shorter period of time than the mothers than in the low-level SCI group who breastfed exclusively for an average of 6.45 months.
  •  More women with high-level injury (14 or 77.8%) reported insufficient milk production or ejection versus women with low-level injury (7 or 35%).
  •  39% of women with high-level SCI experienced an episode of Autonomic Dysreflexia (AD) whereas none of the women in the low-level SCI group experienced an episode of AD.

Management

Though this is the first study comparing breastfeeding in mothers with high-level or low-level SCI, there are some clinical implications we can draw from the work to date:

  1. Mothers with SCI are capable of breastfeeding, but there may be significant barriers or problems with: disrupted lactation, impaired milk ejection, mobility challenges and AD. Clinicians should be aware of these difficulties and considerations for high-level versus low-level SCI.
  2. Clinicians should be prepared to provide education and appropriate support (e.g., nursing pillows) to facilitate positioning during breastfeeding, a difficulty reported by most women in the study, regardless of their level of injury.
  3. There is a need for more in-depth and longitudinal research to be conducted with mothers with SCI, particularly research that addresses blood pressure, AD and SCI. Blood pressure in people with SCI is lower than their able-bodied counterparts, especially when the SCI is cervical or high thoracic (Phillips & Krassioukov, 2015). As AD is typically initiated by any stimulus below the injury level, it is possible that an infant’s suckling, breast engorgement or mastitis would be sufficient to trigger an AD episode.

The benefits of breastfeeding for the infant are well-known, but researchers have shown that mothers also experience benefits from breastfeeding including: higher levels of oxytocin, lower levels of blood pressure, lower rates of post-partum hemorrhage, and reduced maternal risk of ovarian and breast cancer (Johnston and Amico 1986; Light et al. 2000; Jonas et al. 2008; Ebina and Kashiwakura 2012; Chowdhury et al., 2015; Feng, Chen, & Shen, 2014; Horta & Victora, 2013b; Saxton, Fahy, Rolfe, Skinner, & Hastie, 2015; Victora et al., 2016 ). It would be useful to have evidence that showed if the benefits of breastfeeding for mothers with SCI outweighed the risks, particularly from a cardiovascular perspective.

 

Conclusion

There is level 4 evidence (Skowronsky and Hartman 2008) that women with SCI may give birth vaginally. With vaginal delivery or when Cesarean or instrumental delivery is indicated, adequate anesthesia (spinal or epidural) 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.

  • Adequate anesthesia (spinal or epidural if possible) is needed for vaginal, Cesarean, or instrumental delivery.

    Epidural anesthesia is preferred and effective for most women with AD during labour and delivery.