Pregnancy exacerbates most problems associated with spinal cord injury (SCI).
Diagnosis of labour in women with spinal cord injury above T10 of the spinal cord can be challenging.
Women with SCI should aim for a vaginal delivery.
Autonomic dysreflexia is life threatening and requires immediate treatment.
Early epidural analgesia in labour will reduce the incidence of autonomic dysreflexia.
Antenatal management of women with SCI.
Care of a woman in labour.
Diagnosis and treatment of autonomic dysreflexia.
Women with chronic SCI are knowledgeable about the management of their disability, at times more than the attending medical personnel. Not listening to them may undermine the confidence they have in their care.
Women with SCI are concerned that a spinal or epidural analgesia may cause further injury to their spinal cord.
The Paralympic games were conceived with an aim to improve the quality of life of those with disability through sports therapy. Similarly, a patient survey of women who delivered children after a spinal cord injury (SCI) showed that 96% of them had stated that ‘becoming a parent improved the quality of their life’. The obstetric unit of Stoke Mandeville Hospital is regularly referred women with SCI in pregnancy since it is on the same site as the national spinal injuries centre. The management of traumatic spinal cord injury described in this paper is based on available literature and clinical experience of the senior author.
Pregnancy exacerbates most problems affecting women with spinal cord injury. Women with lesions above the level of T6 of the spinal cord are susceptible to autonomic dysreflexia (AD), spasms, breathing difficulties with advancing pregnancy, bradycardia and hypotension. All women with SCI are at high risk of pressure ulcers, anaemia and urinary tract infections (Figure 1). These women commonly complain of inappropriate management by medical personnel of problems secondary to SCI. They are knowledgeable about their condition and listening to their views on management will optimise their care.
Spinal cord injury is defined as an insult to the spinal cord resulting in a change, either temporary or permanent, to its motor, sensory or autonomic function. Management is based on the level of injury as well as the SCI being complete or incomplete. At present there are over 40 000 people with SCI in the UK, the majority of them are young and 26% are female.[4, 5] A study by Jackson and Wadley found that approximately 14% of their study population had at least one conception post injury. With good care, rehabilitation and community support, these individuals have a good quality of life and are fully integrated into society.
Obstetrics is high risk in this population, because of SCI associated morbidity, such as AD, spasms and contractures of the pelvis, decubitus ulcers, urinary tract infections and respiratory infections (Figure 1). Women hoping to conceive after spinal cord injury are ideally reviewed before conception. They are then reviewed in early pregnancy, by an obstetrician with experience in caring for women with SCI. Here, a care plan is documented, involving a multidisciplinary team (MDT) with experience in caring for women with SCI.
Pregnancy after spinal cord injury
Pre-conception care and booking visit
Women with SCI are encouraged to attend a pre-conception clinic. Ideally a planned pregnancy is recommended after physical and emotional rehabilitation is complete. Women are counselled about the psychological and practical aspects of being a disabled parent. The couple are encouraged to join SCI forums and given information about relevant websites. Of importance is that pregnancy limits mobility further in 4.5% of women with SCI, and they need to continue with physiotherapy and meticulous skin and bowel care throughout the antenatal period.
A care plan is discussed based on the woman's disability and available support. Women are reassured that the rate of stillbirths and congenital malformation is not increased when conceiving after spinal cord injury. Table 1 is a summary of this visit.
Table 1. Summary of discussion at pre-conception and initial antenatal visit
Spinal cord injury and disability
1. Woman’s understanding of her condition
2. The nature and limitations imposed by her disability: autonomic dysreflexia, spasms, pelvic contractures, injury to pelvis
3. Age and extent of spinal and pelvic injury
4. Review medication for potential teratogenicity
The effect of pregnancy
1. Worsening mobility with advancing pregnancy
2. Worsening breathing with advancing pregnancy
3. Possible change of bladder care (may need an indwelling catheter towards the end of pregnancy)
Care in pregnancy
1. GP, community midwife, local obstetric unit, obstetric unit at place of delivery if different, occupational therapy2. Anaesthetic review early in pregnancy 3. Carer support, social services
1. Ideally a vaginal delivery is planned 2. Admission to delivery suite early in labour
1. Information regarding websites 2. Adaptive equipment. For example, low baby-changing tables, wheelchair friendly prams
At the booking visit, in addition to that discussed at the pre-conception visit, a definitive plan is made for the place and mode of delivery. A dating scan is recommended. Vaginal birth is the usual mode of delivery in women with SCI unless there is a suspicion of cephalo pelvic disproportion. If there has been SCI at a young age or pelvic trauma, clinical pelvimetry is performed (if not performed at the pre-conception visit) and a caesarean section booked for 39 weeks. CT pelvis or MRI pelvis are not usually requested.
General antenatal care is as recommended by NICE antenatal guidelines. Problems imposed on the pregnancy by SCI are managed on an individual basis. These women are assessed by a dedicated consultant obstetrician in the first trimester and referred as necessary to members of an MDT comprising an obstetric anaesthetist, spinal nurse, specialist midwife and nurse, physiotherapist and occupational therapist. They will have a named spinal consultant, but will not usually be reviewed unless required. If the woman lives a distance from the unit, she will continue to have concurrent care with an obstetrician and community midwife at her local hospital, reducing the number of visits to the specialist centre. Admission late in the third trimester is recommended to prevent an unattended delivery.
More detailed information is available via the disability network and SCI parents. Table 2 summarises the possible problems imposed on pregnancy by SCI.
Table 2. Antenatal problems in spincal cord injury
Respiratory system (above T6)
Reduced ability to cough and breathe adequately
Excess bronchial secretions
Reduced mobility can cause ventilation perfusion mismatch
Risk of gestational diabetes or undiagnosed type 2 diabetes mellitus
Normocytic, normochromic anaemia
High risk in acute spinal cord injury
Increased risk of mood disorder in pregnancy
Inability to respond appropriately to acute illness
Thermoregulation (above T6)
No reactive shivering, sweating
Inadequate response to environmental temperature changes
Able to respond to inflammation or infectious insult with a febrile response
Antenatal problems in lesions above T10
Perception of fetal movements will be normal with lesions below T10. In lesions above T10 perception of fetal movements is altered. Fetal movements sometimes perceived in the form of minor episodes of AD have been described in complete lesions as high as T3 and C3.
The perception of uterine contractions are also altered in lesions above T10. Women are taught to palpate fetal movements and contractions.
There is a higher frequency of breech or transverse lie, especially in lesions above T10. The reason for this is unknown, however, it may be related to reduced muscle tone in abdominal muscles. The senior author's practice is to offer an external cephalic version (ECV) for uncomplicated breech presentations. When required, admission is to the spinal ward. These women will have contact numbers for the spinal ward and delivery suite.
There is an increased risk of thromboembolism in the first 6 months after SCI. Following this, the risk is almost the same as that in the general population. This is attributed to vessel remodelling and other physiological changes occurring below the level of SCI. Local practice is to follow current RCOG guidelines on thromboprophylaxis, scoring ‘one’ for immobility in chronic SCI.
In lesions above T4 there may be partial or complete paralysis of ventilation muscles. This makes breathing more difficult as the pregnancy advances. Respiratory function is assessed at booking in lesions above T6. Ohry et al. recommend chest physiotherapy, continuous positive airway pressure (CPAP) and mechanical ventilation if respiratory function is suboptimal. Vital capacity in patients with spinal injuries can be used to predict the need for ventilation. A value below 12–15 ml/kg requires mechanical ventilation.
The blood pressure and pulse rate is recorded at booking and at every antenatal visit. This provides a baseline reference, for tetraplegic women with bradycardia (40–50 bpm) and hypotension (80/50 mmHg). A rise in systolic blood pressure of 20–40 mmHg above baseline is a considered a sign of AD. Bradycardia may resolve with time, but can recur during suctioning of the respiratory tract or during episodes of hypoxia and dysreflexia leading to cardiac arrest.[17, 18]
Physiologic changes of pregnancy may exacerbate urinary incontinence. The incidence of urinary tract infections is increased. This is due to several factors, including incomplete emptying of bladder, neurogenic bladder and catheterisation. Antibiotic treatment of asymptomatic bacteriuria is controversial. However, in the authors’ locality bacteriuria is only treated if it is symptomatic, i.e. cloudy urine, fever, frequent spasms or AD and significant pyuria.
In women with impaired bladder function, continence is maintained by intermittent, indwelling, or suprapubic catheterisation. With advancing gestation, some women may need to change to an indwelling catheter due to limited mobility and incontinence. Bladder drainage is particularly important in women predisposed to AD, because urinary retention can precipitate an episode. In those with a suprapubic catheter, hospital policy is to change the catheter within 24 hours of surgery to reduce wound infection.
Pregnancy and spinal cord injury are both independent risk factors for constipation. In susceptible women this can trigger AD. Maintaining the bowel care routine is important. A good bowel care routine involves increased fibre, timed bowel movements, utilising gastrocolic reflex, laxatives or digital evacuation.
There may be an increased risk of decubitus ulcers in pregnancy, due to weight gain, tissue oedema and relative immobility. Jackson and Wadley quoted a 6% incidence although Westgren et al. reported that only a few of the women in their study developed decubitus ulcers. Local practice is an admission and a ‘Waterlow score’ pressure ulcer risk assessment. As an inpatient, regular skin examination, meticulous skin care, the use of pressure relieving mattresses and position changes every 2 hours will reduce this risk. Postpartum pressure mapping and adequate protection is recommended prior to discharge.
A spinal cord injury at the level of T6 or above results in loss of supraspinal control of the greater splanchnic sympathetic outflow. AD results from disconnection of the sympathetic nervous system from supraspinal regulation, disabling the negative feedback loop. A noxious stimulus below the level of the SCI will result in an uncontrolled sympathetic outflow below the level of the lesion. This causes a rise in blood pressure, activating the vagus nerve via baroreceptors, (that have ‘reset to fire’ at a lower blood pressure since the SCI) causing bradycardia. AD is a medical emergency and can be fatal. Treatment is by removing the noxious stimuli, or medical management in the absence of an identifiable trigger. Tables 3, 4 and 5 describe the symptoms, signs and pharmacological treatment of AD. Delayed or suboptimal management can lead to maternal intracranial bleeding, death and fetal bradycardia or heart rate irregularities due to paroxysmal hypertensive episodes.[20, 21] This is in contrast to pregnancy-induced hypertension, usually (but not always) presenting as a gradual and sustained rise in blood pressure.
Table 3. Potential causes of autonomic dysreflexia
Deep vein thrombosis, pulmonary embolism, excessive alcohol intake or caffeine intake, substance abuse, trauma
Table 4. Clinical features of autonomic dysreflexia (AD)
Symptoms of AD
Nausea, anxiety, malaise, prickling sensation in skull, ringing in the head, throbbing headache
Signs of AD
Sweating, blushing, pilo-erection, tremor, nasal congestion, increased spasms, twitching, increased blood pressure >20 mmHg above baseline, papillary dilatation, transient loss of consciousness, retinal bleed, sub arachnoid haemorrhage, cerebrovascular accident, stroke, death
Reactive sinus bradycardia, prolonged PR interval, atrioventricular blocks (usually second degree), ventricular ectopic beats, disappearance of P waves.
Fetal bradycardia with AD in the mother
Table 5. Pharmacological treatment of autonomic dsyreflexia in pregnancy
Pharmacological treatment of autonomic dysreflexia
Nifedipine sublingual capsules /
tablets : bite and swallow
10 mg–40mg (10mg every 15 min)
GTN patch or spray
Nitroglycerine 2% ointment
(To skin above the level of the lesion)
1 inch of ointment
50–100mg over 20 min
Nitroprusside alone is inadequate unless used together with an epidural
An early sign of AD, rising blood pressure in a tetraplegic, is frequently missed. This is because of a low basal blood pressure; an individual's baroreceptors are reset to fire at a lower level than in those without SCI. For example, a blood pressure of 120/80 mmHg in a tetraplegic may be a sign of AD and would require immediate sublingual nifedipine if the cause for AD is not identified or removed.
In patients with a history of AD, a prophylactic epidural is recommended early in labour.[9, 16] Epidurals and spinal analgesia are useful because opioid analgesia and local analgesia that are used to block the efferent and afferent nerves, help to attenuate potential triggers for autonomic dysreflexia.
Spasticity is a ‘symptom of upper motor neurone disorder, resulting from intact spinal reflexes persisting below the level of the injury’. Spasms protect bone by reducing osteoporosis in limbs although at times may cause injury by throwing a person off their wheelchair. In their study, Jackson and Wadley reported a 12% incidence of worsening of spasticity in pregnancy. Treatment of spasms in pregnancy is with baclofen (ideally via an intrathecal pump).
Oral baclofen has been associated with neonatal withdrawal symptoms – from irritability and poor feeding to seizures. This effect has not been reported with the use of intrathecal baclofen.[22, 23] Local practice is to use oxybutinin for the control of bladder spasms in pregnancy, discontinuing oral baclofen if possible. Please see Table 6 for the medical management of spasms.
Table 6. Medical management of spasms in SCI
Pharmacological treatment of spasms
Baclofen tablets or intrathecal baclofen pump
Oxybutinin for bladder spasms
Clonidine (not recommended in pregnancy)
Tizanidine (not recommended in pregnancy)
Women with SCI are anxious about regional anaesthesia. Women with incomplete lesions are especially concerned about further damage to their spinal cord. General anaesthesia is high risk in pregnancy. The risk of failed intubation in pregnancy is several times higher than in the non-pregnant patient. In previous cervical spine injury, pregnancy increases this risk further. Table 7 is a summary of the anaesthetic consultation.
Table 7. Anaesthetic review in pregnancy
History of SCI
Date and mechanism of injury
Level of injury
Complete / incomplete
Respiratory tract infection, ITU admission / history of tracheostomy / vital capacity assessment in lesions above C7
Spasms, contractures, pressure sores
Recent imaging of head and spine, chest X-ray
Airway, neck movements
Full blood count, renal and liver function tests, (vital capacity in lesions above C7)
Lesions above T6
Hambly and Martin advise epidural analgesia to control dysreflexia. Current practice in the authors’ unit is for an early epidural or combined spinal epidural in women susceptible to AD. Ideally inserted as soon as labour is diagnosed or prior to artificial rupture of membranes.
A block height of T8–10 is adequate. The effectiveness of epidural analgesia is determined by the absence of AD, as it is not possible to test the level of the block in women with a complete lesion of the spinal cord. Sometimes scar tissue prevents adequate spread of local anaesthesia in the epidural space. In this instance continuous spinal anaesthesia (CSA) may be considered after senior anaesthetic review.
Lesions below T6
Women have their choice of analgesia in labour, including epidural analgesia for labour and delivery. Epidurals may be difficult to insert, if the patient has undergone previous surgery of the lumbar or lower thoracic spine. Lesions above T10 may not require analgesia as the sensory nerves from the uterus enter the spinal cord between L1 and T11.
The risk of preterm labour in women with an SCI has in the past been reported to be high. Recent research, however, does not confirm this finding. Frequent surveillance, appropriate use of tocolysis, as well as adequate treatment of urinary tract infection and decubitus ulcers has reduced the incidence of preterm labour. A rate of 15%, predominantly late, preterm births was seen in unpublished data at Stoke Mandeville Hospital.
Labour and delivery
Symptoms associated with the perception of labour are dependent on the level of injury. Uterine contractions travel via Frankenhauser's plexus and into the spinal cord at T10. Cervical dilatation is perceived at levels T11 to T12 and sensation in the perineum and vagina reach the spinal cord via lumbosacral root afferents. Therefore women with lesions below T10 will have painful contractions.
In lesions above T10, perception of labour is by concurrent sympathetic symptoms, such as, scalp tingling, AD, an increase in the frequency of spasms or abdominal self-palpation, or labour is not perceived at all.
A recent Dutch study recommended hospital care from 36+6 weeks of gestation onwards, for daily CTG and 4 hourly monitoring for uterine activity. Others recommend home labour monitors with surveillance online or by fax. Common practice is to educate patients about other signs of labour and abdominal palpation.
First stage of labour
Women are admitted to the delivery suite early in first stage, to settle into their new environment and be reviewed by obstetric and anaesthetic teams. An early epidural is recommended, especially in higher lesions at risk of AD. A distended bladder, sometimes the result of a blocked catheter, would trigger an episode of AD. To prevent this, if bladder management is not already by indwelling catheter, one should be inserted.
Vaginal examinations and insertion of an indwelling catheter need to be performed gently, with prior application of a topical anaesthetic to prevent triggering AD or spasms. Electronic fetal monitoring is advised to detect fetal distress secondary to AD.
Care in labour is provided by both a midwife and a nurse with experience in spinal cord injury. This ensures appropriate management of complications specific to SCI, such as spasms, AD and care of pressure areas.
Second stage of labour
Spasms may complicate delivery. This is overcome by optimal positioning depending on the woman's disability and preference. It is important not to force flexion during these episodes.
If AD is difficult to control in second stage, an instrumental delivery will shorten labour and remove the trigger. However, standard analgesia is essential prior to an instrumental delivery. Sometimes a rapid spinal anaesthetic can also be inserted to control severe AD.
The following extract from Disability, Pregnancy and Parenthood International (April 1993 - A patient's perspective of autonomic dysreflexia) illustrates AD during labour from a patient's perspective.
‘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 dysreflexia had struck. The hospital staff sprang into action, the baby was getting distressed and I thought I was going to die. I was given forceps delivery, which required 10 stitches and my baby arrived at 10.45 am. On his arrival my headaches disappeared, but continued over the next two or three weeks whenever my bowels or bladder were full’.
C 6/7 (Reproduced by permission of Disability, Pregnancy and Parenthood International).
Third stage of labour
Physiological or active management of the third stage is as indicated. It is not necessary to avoid ergometrine in women not at risk of AD. In women with a history of AD, data from Stoke Mandeville (unpublished) show no untoward episodes provided ergometrine is not used during AD. However, more data are required on the use of ergometrine in this group.
Caesarean sections should only be performed for obstetric indications. Westgren et al. reported a high rate of caesarean section compared to that in the general obstetric population; 47% in SCI at level T5 and above and 26% below T5. The indication for caesarean section was liberal and an improved standard of care with a reduced caesarean section rate is predicted, if managed at an institution with expertise in caring for patients with SCI in labour. The rate of caesarean section in women with SCI was 28.8% from local unpublished data.
In women with a suprapubic catheter, a lower segment caesarean section via a low transverse incision can be safely performed (see Box 1). Post surgical care should be by nurses with experience in caring for women with SCI. Gentle physiotherapy is started early to prevent thrombosis; turns every 2 hours and meticulous nursing can prevent decubitus ulcers. Hoisting and regular physiotherapy is only commenced on the fifth day post surgery. Sutures are removed on the tenth day after surgery. Post-delivery thromboprophylaxis is as recommended by RCOG guidance.
Suturing must be performed with standard analgesia, because pain fibres are stimulated, and although not perceived as pain, can stimulate spasms and AD.
The use of suture material with reduced foreign body reaction or absorbable suture material, has not been associated with an increase in perineal wound breakdown in women with SCI. A study by Demasio and Magriples demonstrated no increase in perineal wound breakdown above that in the general population.
Postnatal analgesia is prescribed as with patients with no SCI injury and also to prevent episodes of AD and spasms.
Breastfeeding and contraception
Breastfeeding is normal in women with SCI. In women with complete SCI above T4, the initiation of breastfeeding is delayed and requires additional stimulation such as visual stimulation or oxytocin nasal spray. This is because the afferent pathway of the milk ejection reflex is initiated by infant suckling and is carried from tactile receptors in the breast via the dorsal roots of T4 to T6. Long-term breastfeeding can still be maintained in this group of women.
As with any new mother, adequate and early breastfeeding support is essential. Nursing, dressing and bathing the infant are facilitated by adaptation, support and rearrangement of equipment. The use of baclofen is safe in breastfeeding as very little is excreted in breast milk.[30, 31] AD is rare with breastfeeding; there has been only one reported case in a tetraplegic in the literature.
Fertility is not affected in women with chronic SCI and contraceptive advice is recommended. Combined oral contraception containing estrogen is not usually recommended because of limited data on the increased risk of thrombosis in chronic SCI. Intrauterine devices and female barrier methods may be used, but need to be prescribed depending on the degree of disability. Insertion can at times provoke AD in susceptible women, whilst contractures and limited mobility impairs checking coil threads. Progestogen only pills, progestogen injections or implants, female sterilisation, or male contraception may be more appropriate.[3, 33]
Spinal cord injury during pregnancy
Spinal cord injury during pregnancy has a higher risk to both the mother and fetus. Maternal resuscitation and preventing supine hypotension in the mother is paramount. There is an increased incidence of miscarriage and fetal anomalies in this group of women, compared with conception after spinal cord injury. This most likely results from hypoxia occurring during the period of spinal shock (with trauma in the first trimester). Later on in pregnancy, direct trauma to the uterus by compression or indirect trauma from flexion of the thoracic spine may cause injury to the fetus.
Once stabilised, women are cared for as inpatients, usually for several months. The hospital community midwifery team (with experience in caring for women with SCI) provides routine antenatal care, enabling the hospital obstetric unit to continue without interruption. Early review by an obstetrician and anaesthetist ensures plans are in place for delivery. Thromboprophylaxis is strongly recommended, as the risk of a thrombotic event is greatest in the first 3 months of injury.
In labour, regional anaesthesia is offered. If general anaesthesia is required, rocuronium would be the muscle relaxant of choice. Suxamethonium is the usual muscle relaxant, for mandatory rapid sequence induction in pregnancy of more than 16 weeks. However, in lesions between 3 days and 9 months post injury, suxamethonium is not used because of the risk of hyperkalaemia leading to cardiac arrest and death.[16, 18]
Women with SCI above T6, are at higher risk in pregnancy, because of the risk of AD. Decubitus ulcers, urinary tract infection, constipation and malnutrition are SCI-related morbidities, which may be exacerbated in pregnancy. Unless there is an obstetric contraindication, a vaginal delivery is recommended. Multidisciplinary care of women with SCI, involving obstetricians, midwives and obstetric anaesthetists with experience in caring for women with spinal cord injury, together with support from the spinal team and physiotherapy is essential for optimal care. If a psychiatric referral is needed, this too should be to a unit with experience in managing women with SCI.
When cared for at a centre with expertise in managing women with SCI, a safer pregnancy and delivery can be expected. Alternatively, the local unit should work in collaboration with the nearest spinal injuries centre.
Box 1. Lower segment caesarean section with a suprapubic catheter in situ
The skin incision is made 2 cm above the suprapubic catheter insertion. The catheter is recommended to be changed 24 hours before surgery. Non-absorbable sutures are used for closing the rectus sheath and skin to reduce the risk of wound dehiscence in denervated tissue. Skin is usually sutured using interrupted non absorbable suture material.
Disclosure of interests
None to disclose. There was no funding and no conflict of interest.
Contribution to authorship
RD reviewed the literature, collected and analysed quoted unpublished data and wrote the paper.
EA collected quoted unpublished data and contributed to writing this paper.
P R-P wrote and reviewed the anaesthetic content of the paper
FA provided expert opinion on the subject, edited, mentored and contributed to writing this paper.
We would like to thank the reviewers and editors for their time and suggestions, seeing this paper through to completion. Also to thank Mrs Sudha Sundar MBBS, MRCOG for data on SCI between 1990 and 1999 and the Disability, Pregnancy and Parenthood information service for permission to use an excerpt from their publication.