Birthing decisions will always be guided by individual conditions such as Multiple Sclerosis; spinal cord lesions (complete or not); level of the lesion and extent of impairment, sensation or motor impairment; Myasthenia Gravis, Gillian Barre syndrome, joint diseases etc.
A few years ago it was thought that women with disabilities could not conceive and, if they did, they should have a caesarean (C) section. There are instances where a C-section is imperative, including pelvic or spinal abnormalities (kyphosis, scoliosis, deformative osteoarthritis, pelvic and hipfractures etc.), co-morbid conditions, fetal or maternal complications, certainplacental abnormalities, uterine abnormalities and diseases. Fetal distress, and when fetal life is at risk during a normal delivery (due to placentalabruption, a prolapsed umbilical cord, breech presentation, twins or tripletsetc) would all indicate for a C-section. Maternal conditions could also be anindication for a C-section including uncontrolled hypertension (high bloodpressure), diabetes, SLE (systemic lupus), cardiac disease, cephalo-pelvicdisproportion (CPD – baby’s head is large compared to the mother’s pelvis) and problems with, or during, labour.
There is, however, modern evidence to show that a normal delivery has advantages over a C-section such as: decreased breathing problems at birth for baby, lower risk of prematurity (and associated complications), shorter hospital stays for both mom and baby and no anaesthetic risks - to mention a few.
Having said that, there are still a number of additional situations that you, and your doctor, need to consider.
Women with mobility impairments, like all women, are at risk for earlypregnancy complications such as ectopic pregnancy, miscarriages, excessive vomiting and abnormal fetuses, but these complications may be missed in women with disabilities if care is not taken. Fertility treatments also carry risks for women including multiple pregnancies and ectopic pregnancy. On top of the usual risks, women with a disability are at higher risk of going into early labour (due to recurrent urinary tract infections), malpresentation of the fetus, unstable lie (when the baby changes position a lot), fetal growth restriction, poor progress in labour and complications as a result of prolonged immobility and pregnancy changes such as thrombosis.
If the pregnancy progresses normally, and there are no identifiable risks to mother or baby during labour, a normal delivery could be considered. Considerations regarding normal delivery include: waiting for spontaneous labour vs induction of labour; mothers being able to recognize that labour has started (if they have no sensation in their lower body); getting to the hospital in time; care and monitoring early in labour; the use of, and need for, analgesia duringlabour including epidural pain relief, and how to determine the appropriate timefor birthing as the mother may not know when to push, and need to be monitoredclosely so as to prevent unattended delivery and the complications associated with that.
During the labour phase concerns would centre on normal protocols suchas: time to progress to the next phase, duration of second stage labour and the dosages of certain medications used in labour. Labour is usually monitored on a chart (partogram) and norms are strictly adhered to for good outcomes. The question is: would the same apply for spinal cord injuries and other disabilities?
Delivery staff follow the “Rules of P” to determine progress and intervention: Power, Passage, Passenger and Psyche, but how do you monitorPower (the strength of the contractions) when electronic monitoring is not accurate and the mother cannot feel them?
As labour progresses monitoring becomes difficult and, during the second stage of labour, the rules are not clear: to assist or not to assist and how long to wait. Can the mom bear down herself and will the reflexes be strong enough if she is not able? Could an episiotomy be used, and taken care of post-delivery, keeping in mind the risk of sepsis?
Post-birth care in any mother includes wound care (if she had anepisiotomy, tear or C-section) and monitoring for puerperal sepsis (infection in the birth canal). For the immobile the risk of pressure sores, urinary tractinfections, thrombus formation and care of the newborn baby are a fewchallenges - nothing new but still a concern.
Ensure good health when planning your pregnancy. Check with your obstetricianwhether your condition allows for a vaginal delivery. Learn about the various signs of labour. Make sure you have easy access to the required health carefacilities. Be involved in the birthing/delivery plan and don’t forget aboutfamily spacing!
I would like to thank Dr Pirani for her assistance with this article and wish you all good luck with your birthing and family planning choices!