Cerebral palsy is a condition that midwives are familiar with in that there is always concern for the fetus and neonate related to potential risk factors that may lead to the condition developing. The main symptom of the condition is motor impairment, often with spasticity, but the range of possible symptoms is wide and each individual will have very different levels of severity of effects. Following an extensive literature review Odding et al (2006) offer a very comprehensive insight into the incidence of the condition, the impairments that may occur and the risk factors associated with the condition developing. Their findings are summarised below.

It appears that the worldwide incidence of cerebral palsy has increased since the 1960s probably due to the increased survival of pre-term and small babies. Prevalence is greater in babies from low socio-economic families. The UK figures discovered by Odding et al are 3.33 per 1000 births in the most deprived population compared to 2.08 in the most affluent groups of society. This difference in rate remains noticeable even when birth weight is normal.

There are many possible causes of cerebral palsy although the cause may not actually be known. Odding et al’s findings are summarised as follows:

Odding et al state that 20–80% of people with cerebral palsy may have additional conditions. The following list of possible conditions has again been summarised from their literature review:

The organisation SCOPE focuses on the needs of people with cerebral palsy and offers information and support. Their online information sheet related to pregnancy and parenthood for people with cerebral palsy (Scope 2005) offers key information and advice. Preconception care and advice will enable the medication taken for muscle spasm or epilepsy to be reviewed prior to conception as some drugs may be teratogenic i.e. they have the potential to harm the fetus. General health and fitness can be improved through diet and exercise and folic acid supplements. The support of a physiotherapist may be beneficial in planning an exercise programme that helps to increase strength and flexibility of muscles and joints.

There appears to be no increased risk of miscarriage, premature birth or a baby with cerebral palsy. During pregnancy symptoms may improve. Swollen ankles are common in people with cerebral palsy and this may worsen during pregnancy. Some women find muscle spasms and tiredness increase, and labour pain may initiate muscle spasms. Frequent changes of position, massage or bracing may help to lower the number and frequency of spasms. Epidural analgesia can be used during labour in some cases but may not be possible if muscle spasms prevent the woman from keeping still during and after the procedure (Scope 2005). Attention to pressure and friction areas must be given to avoid damage to skin during times of immobility or spasms.

When motor function is affected transfer to the examination couch or bed may be difficult and will be improved if the equipment is height adjustable. Welner & Temple (2004) discuss the possible difficulty in examining a woman if her lower limbs are particularly rigidly flexed. This may have an impact during labour for vaginal examination and the birth if abduction of legs is compromised. Alternative positions need to be explored during pregnancy with a ‘dry run’ of positions that will enable these processes to take place. Lateral or even a modified knees-chest position may be useful. Midwives working in conjunction with a woman will enable the best solutions to be found. A key point is to ensure that any change of position is undertaken slowly to minimise the risk of initiating spasms (Welner & Temple 2004).

Following the birth additional rest and adequate family support may be necessary to combat fatigue. If lack of strength is an issue in the upper limbs alternative strategies may need to be developed for handling the baby. The help of an occupational therapist could be elicited during pregnancy and afterwards to work with a mother and her midwife to find alternative acceptable solutions. Breast-feeding is not contraindicated unless the medication a mother is taking is prohibitive. Again, if upper limb strength and dexterity are a problem changes in position and use of strategically placed supports for the baby may make feeding successful. If dexterity is impaired breast-feeding may be an easier option than making bottles of formula.

Contraception advice postnatally is offered to mothers if they wish it. If dexterity is impaired the diaphragm is unlikely to be suitable. If lower limb immobility is present the combined oral contraceptive pill is probably unsuitable because of the risk of deep vein thrombosis (DVT), and is not suitable when breast-feeding. The progesterone-only pill or other progesterone methods may be suitable depending on any medication a mother is taking. An intrauterine device or system may be suitable, unless a woman is unable to abduct her legs due to spasticity which makes insertion problematic.

This is a complex non-inflammatory condition that leads to widespread muscular pain, joint pain and stiffness, and tender points on examination throughout the body. Csuka (2004) states that this tenderness is a cardinal sign for diagnosis of the condition, which is more common in women than men, and may have been present for many years prior to diagnosis. Csuka warns that diagnosis is difficult and misdiagnosis is common as symptoms are in many ways similar to osteoarthritis and rheumatoid arthritis, but the joints show no signs of damage. Additional symptoms include tiredness, non-satisfying sleep, gastro-intestinal problems, and swollen joint sensations (Csuka 2004, Schaefer & Black 2005). It is a relatively recently recognised condition that Cramer (1998) explains has similar symptoms to chronic fatigue syndrome (see myalgic encephalomyelitis below) and can cause the sufferer feelings of lack of control and loss of self-esteem. The American College of Rheumatology recognised the condition in 1989 (Schaefer & Black 2005).

The aetiology of the condition is unclear and medicinal relief of symptoms is patchy according to Csuka (2004). Aerobic exercise, treatment of sleep disorder, general health improvement and treatment of any concurrent depression or anxiety appear to be the best management (Cusak 2004). Cramer (1998) notes that, although short-term muscle activity that requires strength is affected during exercise, the cardio-vascular element of exercise is not. The most significant symptom is the fatigue that disrupts daily life, work and relationships, and the simultaneous depression (Schaefer & Black 2005). It is unclear if the depression is part of the syndrome or as a result of the debilitation that it leads to.

From their comprehensive literature review and Schaefer’s studies of women with fibromyalgia Schaefer & Black (2005) offer some valuable information related to the childbirth continuum. Preconception care and advice should encompass discussion about medication; diet, including folic acid supplements; and recognition and management of any anaemia. Women, their partners and families need to discuss how the increased tiredness associated with pregnancy will impact on their lives in order to plan and develop coping mechanisms.

Spontaneous miscarriage appears not to be increased, but symptoms of the condition may increase and are similar to those experienced by many women during pregnancy, for example back pain, nausea and vomiting. Schaefer & Black advise women to consider these increased symptoms as pregnancy orientated although they do warn that uterine cramps may also occur similar to those of pre-term labour. Tender points in the body may become worse due to the increased pressure from the growing uterus and this may make lying on the side too painful. Analgesics may be needed.

During labour adequate analgesia is important and every effort is made to ensure a mother’s comfort by using heat e.g. warm water, alternative positions and mobilisation, for example using a birthing ball and walking to maintain joint movements and lessen pain especially in knees, elbows and hips. Strategically placed cushions or foam wedges may help when lying down. Bright light and noise need to be avoided as these factors may increase pain perception and fatigue.

The postnatal period continues with the chronic fatigue and skeletal and muscle pain. Help and support from a woman’s family is important and she needs to ensure that she has adequate rest. Breast-feeding is possible provided that the additional support is available and that a mother does obtain the additional rest. Varying a baby’s position at the breast will help to alleviate pain on the sensitive points.

It must be remembered that this is an ‘invisible’ condition that can be excessively disabling therefore mothers need to receive sensitive care. Practitioners need to acknowledge that pain and fatigue are what a woman says they are, thereby showing respect for a mother’s symptoms.

This autoimmune condition may be ‘invisible’ as a disability in the early stages. It leads to a patchy loss of myelin that covers nerves of the spinal cord and brain, thus slowing nerve impulses. Although variable symptoms occur, it commonly presents with weakness, imbalance and fatigue. Additional symptoms may include bladder dysfunction e.g. frequency, incontinence or retention (Balzarro & Appell 2004) and bowel dysfunction, muscular spasms, stiffness and pain, difficulty with speech and vision, loss of sensation and depression. The depression is thought to have a physiological basis although the mechanism is unclear (Olkin 2004). Olkin also explains that people with MS may have cognitive difficulties and bouts of laughing or crying not associated with mood stimulation. MS symptoms can be made worse by fever or a hot environment (Neild 2006). The condition affects young adults (Lorenzi & Ford 2002) and is more common in women than men in a ratio of 2:1 (Olkin 2004). It is characterised by periods of relapse and remission but the disease is progressive over a number of years. However the prognosis appears uncertain and distinctive to the individual.

Neild (2006) explains that a woman’s fertility appears to be unaffected by the condition and pregnancy has no long-term affects on the progress of the disease. Although not considered an inherited condition, there does appear to be a higher incidence of MS in the children of parent(s) with the condition (Neild 2006). Preconception advice would include discussion about the drugs taken to modify the condition or alleviate symptoms and these may need to be stopped for 3 months prior to conception. Drugs taken to modify the condition e.g. methotrexate and cyclophosphamide are not suitable during pregnancy (Ferrero et al 2004) while others are safer, including steroids e.g. prednisolone (Baschat & Weiner 2004). Higher rates of congenital abnormalities have been noted with methotrexate and cyclophosphamide (Chakravarty et al 2003, Gordon 2004, Le Gallez 1999) and Gordon (2004) warns that steroids are associated with high blood pressure, pre-eclampsia, diabetes and infection risk. It must be remembered that if a woman has been taking steroids during pregnancy she is likely to need a loading dose during labour (Baschat & Weiner 2004) to enable her body to cope with the additional stress. Some drugs e.g. azathioprine and cyclosporine have a slight risk of causing intrauterine growth retardation (IUGR) and prematurity (Ferrero et al 2004).

During pregnancy the condition often improves or is stable (Ferrero et al 2004, Lorenzi & Ford 2002) especially during the third trimester (Vukusic et al 2004). This improvement is thought to be as a result of the altered immune state of the mother (that prevents rejection of the ‘foreign’ fetal protein) influencing the course of the condition (Lorenzi & Ford 2002) by some temporary re-myelination of the nerves. However, it must be acknowledged that this will not be so for some women. Additionally, as Neild (2006) warns, fatigue, balance and back pain may worsen during pregnancy due to the weight of the gravid uterus and the altered centre of gravity. In these circumstances a walking aid may help mobility and confidence.

If a mother’s lower limbs are weak she may need time and help to get into position on the examination couch during antenatal visits. Existing bladder and bowel problems may be aggravated. Baschat & Weiner (2004) recommend the consideration of prophylactic antibiotics if urinary infection has been problematic. As one symptom of the condition is tiredness, anaemia should be avoided and prophylactic iron supplementation may need to be considered (Baschat & Weiner 2004).

The mode of delivery is not influenced by the condition (Ferrero et al 2004). Baschat & Weiner (2004) do warn that some women may not feel the onset of labour. It is important that midwives explain to women during pregnancy that there is a possibility that they may not perceive pain during contractions, and show them how to palpate the uterine fundus in order to feel the rise during a contraction. This will enable women to be alert to any hint of labour and seek admission to hospital or the attendance of a midwife. Otherwise there is a risk of a precipitate labour and an unattended birth occurring.