This condensed section is presented in full in our Autonomic Dysreflexia Module page, Prevention of AD During Pregnancy and Labour.
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).
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.