Spinal cord injury and labour - the road to safe delivery for tetraplegic women

Gay Keegan from Hampshire, UK and Paula Selchert from Iowa, USA are two women with spinal cord injury who have both experienced episodes of autonomic hyper-reflexia during labour.

Women with spinal cord injuries can deliver babies safely. However, there is a particular need to be well-informed both on the part of the pregnant woman and on the part of those health professionals involved in her care. Women with an injury above the level of T6 are at risk of autonomic hyper-reflexia (also called dysreflexia) which is an attack of excessively high blood pressure caused by any painful stimulus in the region of the bowel, bladder or uterus. If untreated the woman is at risk of serious consequences ranging from severe, and often persistent, headaches to epileptic fits or cerebral haemorrhage.

While all medical specialists in spinal cord injury are aware of hyper-refiexia unfortunately not all obstetricians or midwives are. It is therefore critical that women are themselves well-informed about the potential dangers.

Gay’s story

I have a spinal cord injury, C6/7, as a result of a car accident in 1982, hence I am tetraplegic. Since my accident I have had two children - Alexander, who is now 3 years old, and our new baby, Alice-Amber, who is six months old. This is the story of my two pregnancies and deliveries.

Alexander... born December 1989, North East of England.

When I discovered I was pregnant, my husband and I were over the moon. We had known since the time of my accident that I would still be able to have children, since the spinal injuries consultant had reassured us when we had questioned him at that time. However, our pleasure on knowing I was pregnant was tempered by an uneasiness with regard to how I would cope during pregnancy and, in particular, how the delivery would be managed. Almost immediately I decided that I was not prepared to go to the hospital with the spinal injuries unit in order to have my baby. For a start, the hospital was 70 miles away from where we lived, which would have meant that I would have to go into hospital as much as two weeks early, in order to be sure that I was on site when my contractions began. There was very little research or material available, but what there was suggested that tetraplegic women:

  • tended to go into labour early;
  • tended to have short labours;
  • didn’t always recognise the onset of labour.

All these factors suggested that I either needed to be in hospital when my labour started, or I needed to be very close to the hospital to get there in good time.

At that time, we were living less than two miles from the general hospital, so we asked our GP if I could be delivered in that hospital with my husband sleeping in with me to look after my personal nursing needs, whilst the hospital nurses catered for my obstetric needs. This was successfully negotiated, and we were well catered for, since the hospital had suitable facilities for husbands to stay in with their wives, which were designed to be used by bereaved parents. The only disadvantage with these facilities was that they were physically separated from the rest of the ward, and whilst this had its advantages, there were also disadvantages, in that I missed the company of other new mothers.

My pregnancy progressed very well with absolutely no problems. My meetings with the consultant obstetrician caused me some alarm because he was so laid back and unworried about my needs, that I was convinced he was over-looking something important. There did not seem to be any close liaison between the obstetrician and the spinal injuries unit in the North, and furthermore, the spinal injuries unit were unresponsive to our request for articles that would have been informative and might have helped us in our preparation.

We had developed a sense of trust in the spinal injuries consultant we had met in the South of England and my husband contacted him for information and articles which he duly sent. I clearly recall the obstetrician saying to me, “Well, there’s one advantage you have - you won’t need any pain killers or an epidural!“ This pleased me because, like many other mums-to-be, I wanted to give birth to my baby in as natural a way as possible, and the thought of everything being natural without pain was rather exciting.

The articles we had acquired described something called ‘autonomic hyper-reflexia’, which occurred in tetraplegia, but was not something I had ever experienced, and I was sure that I would probably avoid it during pregnancy and delivery too.

My pregnancy went smoothly, in fact, once the first few weeks were over, I had never felt better before in my life. I went into labour spontaneously (10 days late - first expectation squashed!), I recognised that labour had started (going to the toilet every half hour in the middle of the night, waves of ‘butterflies’ in my tummy, physical appearance of the contracting muscles - second expectation squashed!). I took a shower and packed my things, arriving at the hospital at 8.45 a.m. (plenty of time - third expectation squashed!)

The first stage of my labour was very pleasant; my husband and I spent most of the time alone together, playing music tapes and feeling mounting excitement that the time was drawing near. Then at about 11.15am I entered the second stage of labour and my head nearly exploded. The pain was intense and unbearable. I rolled my head from side to side in agony on the bed. It seems that as the baby’s head engaged, autonomic hyper-reflexia had struck. The hospital staff sprang into action, the baby was getting distressed and I thought I was going to die. I was given a forceps delivery, which required 10 stitches, and Alexander arrived at 11.45 a.m.

On his arrival my headaches disappeared, but continued to return over the next two or three weeks whenever my bowels or bladder were full. Although I told the midwife and GP about these headaches, there was no understanding of the extent of the pain and I was told to take paracetamol.

The effects on my health and adjustment following the birth were also marked - it took me several months to recover from the pain and discomfort and general exhaustion. I feel, in retrospect, that this affected my experience considerably at this time. Breastfeeding was not very successful, although I persisted, with bottle supplements until Alexander was 4 months old, and I felt a desperate tiredness even when I returned to work nearly four months after the birth.

Fortunately, there were no long-term side effects that I am aware of, and Alexander is a strong, intelligent, extremely healthy child. I stayed in hospital for nearly six days and things were a little fraught on my return home, because of the repeated agony of the headaches, and my near exhaustion.

Alice-Amber … born August 1992, South of England

Our second baby was carefully planned, as was Alexander. We had moved with my job down to the south of England. Again, I planned to have my baby in my local general hospital, which this time was over 10 miles away from our home. The GP, consultant obstetrician and everyone we met at the hospital were extremely supportive and helpful. The domestic facilities at the hospital were not quite so comfortable as previously, but a camp bed was to be arranged for my husband so that he could sleep in with me.

Again, we discussed the arrangements for the delivery. This time we were informed by experience and both my husband and myself urged the obstetrician to help us consider how to avoid the pain of the second stage of delivery. There seemed to be three options:

  1. To do nothing, and have arrangements for a forceps delivery on stand-by.
  2. To use a drug called Nifedipine which reduces blood pressure and so relieves the symptoms of autonomic hyper-reflexia. This would be taken at some point during the first stage of labour and would hopefully prevent the autonomic hyper-reflexia from occurring.
  3. To have a continuous epidural attached which would allow the hospital staff to monitor and control my blood pressure throughout the labour. This could be supplemented by Nifedipine as necessary.

The thought of the third option alarmed me, and for some considerable time during the pregnancy, I was keen to follow the second option.

The first option was out of the question, because we had learnt in retrospect how dangerous that half an hour of headache had been, and how I might have had a cerebral haemorrhage, with quite a different outcome to the whole experience. The pregnancy progressed well again with probably more nausea for a longer period in the first few months. Then, once again, feelings of well-being and energy. I think, overall, I was more tired - inevitably so since with Alexander, there was far less time to pamper myself! As the expected time drew near, we had further discussions with both the obstetrician at the hospital and with the spinal injuries consultant who was based at a hospital some 50 miles away. The obstetrician had discussed my case with a senior anaesthetist at the general hospital, who had done some research and reading of her own, and was recommending the third course of action outlined above.

My discussions with the spinal injuries consultant were thorough and explored the options carefully. If I depended on the drug alone, he felt that avoidance of the symptoms could not be guaranteed, whereas the epidural should prevent the hyper-reflexia occurring altogether. And if the symptoms were avoided during the second stage of labour, they should not occur at all alter the birth, since my body would not be sensitised to any after effects.

There did not seem to be any choice left, and with some regret I agreed that option three was the one to go for. I say ‘regret’, because the thought of having an epidural fitted was not one I relished. There were the technicalities of fitting it, and the possibility that the needle could touch my spinal cord, thus giving me a headache anyway! I was also concerned about the possible effects on my baby - would it be drowsy and unresponsive when it was born as a result of the epidural?

The spinal injuries unit gave me a card explaining the symptoms of autonomic hyper-reflexia to carry around with me at all times, together with the drug Nifedipine, just in case I should suddenly go into labour and not get into the hospital in time for the epidural to be fitted.

This time the start of contractions was not so pronounced as before, but still recognisable. Alice- Amber was over two weeks late (on scan dates) and I was getting tired of waiting. We phoned the hospital to say we were on our way, and reminded them to call in the senior anaesthetist, who had asked to be called in as soon as I went into labour, day or night.

The epidural was put into place at about 7.30 am. This was my most anxious time, but the skilled anaesthetist reassured me and fitted the needle successfully. Unfortunately, from that point onwards I was rather immobile, but I was seated in an upright position on the bed, and so I was able to watch television, listen to music, talk with my husband and the nurses.

The sensation of the contractions was considerably reduced and my eyes were fixed on the printout from the monitor to reassure myself that labour was still progressing. There was continuous monitoring of my blood pressure, by machine, so I was well wired-up!

At about 11.45 a.m. the contractions stopped. The midwife checked that my waters were broken, which they were, but labour did not start again.

Apparently, this is not uncommon when an epidural is fitted. It was not safe now for the baby to wait around any longer, so oxytocin was introduced via the epidural to restart my labour. Nothing seemed to happen.

At about 1.15 p.m. the midwife decided to check that my waters were broken again. As she began the examination, a look of shocked surprise appeared on her face - she could feel the baby’s head I I had moved into the second stage with no warning, and certainly no painful symptoms.

The bed was pushed quickly into the delivery room. The midwife suggested using a birthing cushion and she and my husband lifted me onto it. My husband moved away to set up the video camera, the midwife turned her back, and as my husband looked back Alice-Amber slid gracefully into the, world!

The experience was wonderful, enjoyable, relatively painless and in the end, incredibly natural. I needed no stitches, and felt ready to leave the hospital as soon as Alice-Amber was born. However, the medical staff insisted on keeping the epidural in place for some time after the birth, to ensure there was no increase in blood pressure. When it was removed, they continued to monitor my blood pressure well into the evening and during the night.

I left hospital the next day and although a little tired, I felt so well. In comparison to my previous experience, it was unbelievable. I was able to self-catheterise again in under 24 hours, whereas previously it had taken me over three days to achieve this independence again. There were no headaches on bowel evacuations following the birth, and breastfeeding was much more successful, probably because I had more energy and felt well.

Alice-Amber was well and healthy. The epidural appeared to have had no effect on her and she was very alert and suckled immediately when she was born. She is now a bouncing and energetic 6 month old and I am still breastfeeding her morning and night although I’ve been back at work since November.

I still feel rather alarmed when I look back on my first delivery and consider that my blood pressure was not monitored at regular intervals during the labour and delivery, which would have enabled the medical staff to be aware of the onset of autonomic hyper-reflexia and to provide appropriate treatment.

The experience of both pregnancies has underlined for me the need for the pregnant spinal cord injured woman to be her own expert and to ensure that medical staff planning treatment and care are well informed. I do not feel it is appropriate for the patient to have to go to a spinal injuries unit to have her baby, since this affects the quality of life both for herself and the rest of her family. If a spinal injuries unit is well informed and helpful, they can co-ordinate services with the woman’s local general hospital to provide the best possible local care and service.

Paula’s story

I am a 26-year old woman with a spinal cord injury at the C8/T1 level. Since my injury in 1984, I have given birth to two healthy boys.

In 1987 I learned I was pregnant with my first child. My feelings at the time ranged from extremely excited to dreadfully fearful. Fears such as “Would I be able to take care of a fragile newborn?”, Would I be able to have a natural childbirth?”, “Would doctors in my area be aware of the dangers of dysreflexia in spinal cord injured women?”

My doctor did several ultrasound checks throughout my pregnancy to ensure complications would not arise. My blood pressure was taken at each check-up and was within normal range each time. Two days prior to my due date I started to have some mild contractions and had noticed a little bit of blood on my sheets when I woke up that morning. I called my doctor who told me that this was a sign that I was close to B-Day and to report to the hospital. The doctor who was on-call that day was not my primary doctor. I arrived at the hospital around 11.3Oam. They hooked me up to the monitor to keep track of my contractions (still very mild). I was only dilated 2cm and I wasn’t in any pain. The on-call doctor proceeded to check my dilatation every few hours.

Finally, around 11pm that night, he decided it was time to break my water. Everything seemed to be going well and I thought this would be any easy delivery. After he broke my water, he proceeded to leave the building, but before he even made it to the end of the hail, he was called back. I began having a severe headache and the contractions increased in intensity.

It felt as if my head was going to explode. My blood pressure was rapidly increasing. They quickly took me to the delivery room. At this point my blood pressure had doubled from its normal rate. I was wishing for death, which was not so far from reality. My husband and nurses attempted to comfort me but I was in too much pain to appreciate their concerns. They gave me some kind of shot to lower my pressure but it seemed like forever before it took effect. After about an hour and a half, he told me they were going to begin delivering. They had a surgeon on stand-by just in case I needed a Caesarean section. I began to push with all my might. At 12.59am, I gave birth to a 6lb baby boy. My blood pressure began to drop. We had a healthy boy and I was going to be fine. My husband and I were much relieved.

Two years later, I became pregnant with our second child. This experience was much more pleasant. The doctors were very well prepared. When I was close to my due date (one week prior), I was 3.5cm dilated, so they admitted me to the hospital and started an IV with drugs to control the blood pressure before the hard labor began. I was given an epidural to decrease the pain and lessen the blood pressure. They also monitored my blood pressure continuously. About 4 hours later they induced labor. I had no blood pressure problems and barely any pain. Soon after, I gave birth to my second healthy 7lb 9oz boy.

Both boys adjusted well to my disability, even as early as a few months old. I have successfully been able to take care of them independently ever since, although my husband has played an active role too.

First published in Disability, Pregnancy & Parenthood international, Issue 2, April 1993.


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