Childbirth for females with cerebral palsy

Abstract

A recent update of the description of cerebral palsy (CP) emphasizes the unique experience of each individual.¹ For a (currently unknown) proportion of females with CP, conception, pregnancy, childbirth, and motherhood are part of this uniqueness, including with regard to the associated health issues. Women's health issues have often been marginalized with respect to both clinical care and medical research, and this situation is compounded when intersecting with disability. Females with physical disabilities consistently report negative experiences throughout maternity related to inadequate support and systemic neglect, and they are underrepresented in studies.²

Very little information is available on childbirth in females with CP. Reported surveys and observational studies are limited, and difficult to interpret and generalize. Additionally, small groups of females with CP have also been part of larger samples of disabled females in maternity studies. These studies conclude that most disabled females experience uneventful pregnancies and delivery of healthy babies, though pregnancy course and outcomes vary widely. The mechanisms affecting pregnancy or even risk factors remain unclear. Inflammatory conditions, including urinary tract infections, venous thromboembolism, respiratory issues, mental health issues, reduced mobility, and limitations in access to care, for example, might deserve special attention. In CP, pregnancy-related risks may be exacerbated by genetic vulnerability factors underlying CP, preexisting nutritional deficiencies, medication for chronic health issues, and difficulty in obtaining and/or maintaining adequate prenatal care. Conversely, pregnancy-related changes can worsen spasticity, dystonia, musculoskeletal pain, and fatigue. Additionally, limited mobility enhances challenges in accessing prenatal monitoring and care.

One challenge in applying knowledge gained from studies on maternity in general disability, physical disability, or even CP, is that CP is characterized by particularly high complexity and heterogeneity.¹ Females with CP may have widely varied movement and posture disorders, with different levels of impairment and functioning, and other features, such as cognitive and communication difficulties that may influence their experience. A survey of 76 females with CP reporting 149 pregnancies in high-income country tertiary centres found functional level to be an important determinant of pregnancy experience. Seventy-one percent reported decreased mobility during pregnancy. Fifty percent underwent caesarean section.³ This is difficult to interpret, as elective caesarean section can be proposed, for example, for cephalopelvic disproportion or abnormal fetal position, but also the assumption, or at least a concern that abnormal motor control would make vaginal delivery difficult. However, this has not been established. On the contrary, experience suggests that females with CP often have successful vaginal deliveries, though they may need adapted obstetric management. The survey also highlighted a high rate of low birthweight infants.³ A population-based cohort study conducted in another high-income country confirmed an increased risk of caesarean delivery in females with CP.⁴ It also documented increased risk of preterm birth, low birthweight, and low 5-min Apgar score compared to females without CP after adjusting for confounders. All these are risk factors for CP, but neither of these studies reported CP as an outcome in the infants of these mothers.