We report on a 32-year-old, female wheelchair user with spina bifida who underwent a successful vaginal delivery.
Advances in management options for women born with spina bifida are starting to result in these patients becoming old enough to conceive and undergo successful pregnancies. The role of obstetricians is changing from prevention and early diagnosis of neural tube defects, to managing the pregnancies of these complicated patients. While pregnancies in women with spina bifida have been reported since 19731, they are rare and historically result in caesarean section.2
The nulliparous patient, who will be named Jane here, was referred by her GP and seen in antenatal clinic at 19 weeks. She had been diagnosed with a coccygeal meningocele at birth, complicated by an abnormal spinal canal and L2-3 vertebral body fusion. After undergoing several corrective surgeries until the age of six, a sudden, overnight deterioration resulted in flaccid legs and incontinence. Her recovery was incomplete and Jane required a wheelchair and callipers for mobilisation. The resultant neurogenic bladder has been successfully managed with four-hourly self-catheterisation and a bladder augmentation at nine years of age; however, episodes of cystitis remain common. Thoraco-lumbar scoliosis was corrected at age 15 with anterior spinal fusion of T10-12. The patient was also diagnosed with polycystic ovarian syndrome in her teens and struggled with fertility. This was further limited by her partner’s sub-fertility; however, conception was finally achieved through in vitro fertilisation.
Antenatal care was obstetrician-led, with hospital reviews every two-to-three weeks until 36 weeks and weekly thereafter. During the booking visit, several risks were identified relating primarily to her significant surgical history. These included her anaesthetic options, recurrent cystitis and moderate paraplegia complicated by significant hip deformity and range limitation.
Jane was aware of the high risk of caesarean section before the first meeting and had researched independently the delivery options for women with spina bifida. The treating team had long discussions with Jane and her partner about these options and their associated issues and it was decided that a vaginal delivery would be possible with appropriate risk management. The following areas proved to be the most challenging.
Vaginal deliveries have been reported in this population; however, the author was only able to identify a single case where the patient was a wheelchair user owing to spina bifida, similar to Jane. Arata et al4, the largest series to date on pregnancy complicated by spina bifida, reported that only one of the five wheelchair-using patients delivered vaginally. Comparatively, ten out of 18 non-wheelchair-using patients were able to proceed to vaginal deliveries. Successful labour and vaginal delivery is known to be possible for patients with acquired spinal cord abnormalities.5
Patients like Jane are often poor candidates for regional anaesthesia secondary to their significant vertebral abnormalities and the resultant corrective procedures. Regional techniques have been discussed for such patients3; however, these carry high risks and are technically difficult. Consultation with anaesthetic staff in our hospital revealed a hesitation to perform anything except general anaesthesia, ruling that a spinal or epidural anaesthetic would be inappropriate for our case. Jane was made aware of the risks of general anaesthesia to herself and the fetus, but she found these trivial compared with the subsequent loss of skin-to-skin contact with the baby that she had fought so hard to conceive. Guided by Jane’s strong desire for vaginal delivery, the team worked hard to achieve this for her.
Mobility and positioning considerations
The greatest obstacle in achieving Jane’s wish for a vaginal delivery was her significant mobility limitations from bilateral hip and lumbar spine flexion restriction. This was secondary to severe tonicity, moderate lower limb paraparesis and congenital vertebral dysfunction. Ellison6 reported on a case where such limitations were deemed reason enough to abandon vaginal delivery in favour of caesarean section. Concordantly, there was doubt that the patient would be able to tolerate the significant mobility and logistical challenges present during labour and delivery without considerable improvement to this level of function.
In order to facilitate this, an orthopaedic assessment was requested and regular physiotherapy undertaken upon recommendation. Jane underwent lumbar spine and hip stretching exercises to reduce tonicity and strengthening exercises aimed at increasing patient movement and independence. Following several weeks of this treatment during the second and third trimesters, a trial of comfort and mobility on the birthing bed and in stirrups was undertaken at 36 weeks. Unfortunately, for research sake, no comparison was made prior to the physiotherapy intervention with Jane’s severe tonicity enough for the treating team to forego prior stirrup testing.
The two areas of most concern to the treating team were Jane’s ability to maintain a lithotomy position for delivery and to successfully achieve a McRobert’s posture with assistance in the case of shoulder dystocia. Both of these activities were achieved successfully during a trial at our birth suites.
Jane’s pregnancy was complicated by mild, asymptomatic pre-eclampsia and cystitis at 38 weeks, requiring admission and antibiotics. Spontaneous labour ensued one day later, with spontaneous rupture of membranes, appropriate progression of labour and strong contractions. Stirrups were used during the second stage without patient discomfort. Although she developed the urge to push, a forceps delivery and episiotomy were required owing to a non-reassuring cardiotocography trace and insufficient maternal effort. This resulted in a healthy, live infant and a very happy mother. Postnatal recovery was unremarkable with no bladder or bowel complications.
Pregnancy in this population, while high risk and potentially complicated, needs to be no less rewarding than for any other woman. We have shown that significant hurdles may be overcome to fulfill maternal desire for a vaginal delivery with the use of multidisciplinary team input and careful planning.
- Vaginal delivery in patients, although often complicated by many factors, can be achieved successfully with extensive patient communication and multidisciplinary team involvement.
- Patient joint and limb mobility may be increased during the antenatal period to a level in which the positions required in labour and vaginal delivery can be successfully achieved. This can be augmented by orthopaedic and physiotherapy input and outcomes assessed in the labour ward prior to delivery.
- Appropriate progression in labour, without augmentation, can be achieved in patients with congenital spinal abnormalities.
The author would like to thank the following people for their assistance in preparing this article: Dr Sabaratnam Ganeshananthan MBBS, MD, FRANZCOG, Staff Specialist, Obstetrics and Gynaecology Department, Logan Hospital; and Dr Pooi Leng Lee BA MB, BCh, BAO (Hons) FRANZCOG, Staff Specialist, Obstetrics and Gynaecology Department, Logan Hospital.
- Fujimoto A, Ebbin AJ, Wilson MG, Nakamoto M. Successful pregnancy in woman with meningomyelocele. Lancet. 1973 Jan 13;301(7794):104.
- Blasi I, Ferrari A, Cominiti G, Vinci V, Abarate M, La Sala GB. Myelomeningocele and pregnancy: a case report and review of the literatue. J Matern Fetal Neontal Med. 2012 July;25(7):1176-8.
- Nuyten F, Gielen M. Spinal catheter anaesthesia for caesarean section in a patient with spina bifida. Anaesthesia 1990; 45:846-7.
- Arata M, Grover S, Dunne K, Bryan D. Pregnancy outcome and complications in women with spina bifida. J Reprod Med. 2000 Sep;45(9) 743-8.
- Robertson D. Pregnancy and labour in the paraplegic. Paraplegia. 1972; 10:209-12.
- Ellison F. Term pregnancy in a patient with meningomyelocele, utero-ileostomy and partial paraparesis. Am J Obstet Gynaecol. 1975; 123: 33-4.