Intrapartum Care for Women with Multiple Sclerosis: A JBI-Guided Scoping Review and Evidence Synthesis of Clinical Practices and Maternal Outcomes

Abstract

Aim

This scoping review aimed to map and synthesize current evidence on intrapartum care practices reported for women with MS, maternal and neonatal outcomes associated with childbirth among women with MS, and implications for midwifery and nursing care for women with multiple sclerosis (MS). Despite the increasing prevalence of MS among women of reproductive age, intrapartum management remains inconsistent and insufficiently synthesized, which may contribute to unnecessary interventions and variability in clinical decision-making.

Methods

This scoping review followed the methodology of the Joanna Briggs Institute and adhered to PRISMA-ScR guidelines. Searches were conducted in PubMed, MEDLINE, CINAHL, Scopus, and grey literature for studies published between January 2020 and January 2025. Two independent reviewers conducted study selection and data charting using the Population–Concept–Context framework. Methodological quality was assessed using an adapted Kmet checklist. Findings were synthesized narratively and organized using the PAGER framework.

Results

Eleven studies met the inclusion criteria. Women with MS experienced higher rates of cesarean section compared with the general obstetric population, despite evidence that MS alone is not an indication for surgical birth. Neuraxial analgesia and anesthesia were consistently reported as safe and were not associated with postpartum relapse or disability progression. Maternal outcomes included increased fatigue, mobility limitations, and emotional concerns during labor. Postpartum relapse was primarily associated with pre-pregnancy disease activity. Neonatal outcomes were generally reassuring, with adverse outcomes mainly linked to disease activity and exposure to disease-modifying therapies. The PAGER synthesis identified patterns of conservative care, advances in analgesia safety, and gaps in fatigue management and interdisciplinary coordination.

Conclusion

Intrapartum care for women with MS remains conservative and inconsistently aligned with current evidence. Midwives and nurses play a key role in supporting evidence-based decision-making, managing fatigue and anxiety, and promoting woman-centered, interdisciplinary intrapartum care.

Introduction

Multiple sclerosis (MS) is one of the chronic autoimmune neurological disorders that is characterized by varied symptoms ranging in relapsing remitting phases.¹ The disease is characterized by worsening of cognitive, physical, psychological and social functions throughout unexpected pattern.² Worldwide prevalence of MS has increased over the last three decades to affect about 2.9 million people. There is estimated one case of MS in every 3000 people.³ In spite of the advanced disease-modifying therapies, there is no absolute cure for MS. Therefore, individuals with MS may experience physical deteriorations that affect their ability to perform daily living activities. Fatigue and limited functional independence have negative impact on their quality-of-life and psychosocial well-being.⁴

Multiple sclerosis prevalence among women is about two-thirds of the total cases. Notably, the incidence of MS among Jordanian and different Middle Eastern and North African countries is rising.⁵ The peak onset of MS usually occurs between 20 and 40 years of age which represents the reproductive phase for women.⁶ Therefore, increasing number of women with MS have to deal with pregnancy journey surrounded with many uncertainties and ambiguity. Women with MS face several difficulties regarding the peripartum period: pregnancy, birth, and postpartum. This includes anticipated flare-ups, compliance with disease-specific medications, decision regarding mode of birth and breastfeeding, and risk of postpartum relapse.⁴ The course of MS during pregnancy is unexpected, it might go smoothly, yet the risk of relapse still jeopardizes maternal and fetal conditions.⁷

Besides, the physical impact of MS women faces the emotional and psychological worries during pregnancy and childbirth. The need to use immunosuppressive medications during pregnancy to prevent relapse is an added challenge to women and their Healthcare professionals (HCP). This includes a wide range of medications such as azathioprine, methotrexate, and rituximab.⁸ The need to use such medications brings a dilemma, especially in the context of limited randomized controlled trials in human fetuses. Particularly, most available evidences are derived from case reports or retrospective studies.⁶ Collectively, the peripartum period for women with MS is embedded within unique challenges during childbirth. These women may suffer from worsened neurological symptoms, extreme weakness, limited mobility, and poor adaptation to the stress of childbirth.⁹ They have to deal with the possibility of postpartum relapse, management of medications, decisions regarding breastfeeding and family planning.^10,11

For women with MS, if complications or adverse effects occurred during childbirth, they will experience a medicalized form of birth experience rather than a normal birth.¹² This is also complicated in the context of unavailability of structured, evidence-based guidelines and multidisciplinary care approach.¹³ Previous studies imply that these challenges extend beyond the medical sphere into emotional and psychosocial domains. Women with chronic diseases, including MS, experience emotional anxiety and poor satisfaction during their pregnancy and birth journey. Therefore, an interdisciplinary, person-centered approach that brings together maternal health nurses, obstetricians, and autoimmune disease specialists is crucial to alleviate stress and provide evidence-informed, clear communication.¹⁴

Despite the availability of several research on antenatal and postnatal outcomes among women with MS, there is limited attention to intrapartum care practices. Healthcare professionals caring for women with MS face ambiguity in deciding the best mode of birth,¹⁵ type of analgesia,¹⁶ breastfeeding,¹¹ and the risk of anticipated postpartum relapse.¹⁰ Moreover, women with MS may face several challenges during their peripartum experience. This includes exaggerated fatigue, limitation of mobility, and worsening of neurological symptoms during childbirth.⁷ Furthermore, they are at greater risk to experience emotional concerns related to the possibility of disease exacerbation before and after birth, and anticipated side effects of the MS medications on the fetus.³ The prior issues are central to nursing and midwifery care provision.

Childbirth represents a dynamic opportunity for midwives and nurses to provide women with MS a person-centered care. Their care for women should also be grounded in evidence-based practice in order to provide patient-centered care that is tailored to the most specific needs of laboring women with MS. In spite of the increased percentage of women who suffer from MS during the reproductive age, coupled with the vast range of medicalized interventions during birth, there is no inclusive synthesis to direct nurses and midwifes practices. This might lead to unreliable clinical decisions and more dangerously might exaggerate the use of unnecessary medical and obstetric interventions. There is a gap in literature regarding the maternity nursing and midwifery caring aspects. These aspects are essential to manage pain, alleviate fatigue, enhance mobility and provide support throughout childbirth journey within an interdisciplinary care team. The availability of synthesized evidence might contribute to consistent clinical practice and help in decision-making.

No comprehensive scoping review is available about the intrapartum care for women with MS. Therefore, the current study has synthesized the available evidence regarding the intrapartum interventions and care for women with multiple sclerosis. This would aid to address the research gap of clinical practices and midwifery. This scoping review aimed to address the following research questions: (1) What intrapartum care practices are reported for women with multiple sclerosis? (2) What are the maternal and neonatal outcomes associated with childbirth among women with multiple sclerosis? and (3) What are the implications for nursing and midwifery practice?

Methods

Design

This scoping review presents methodological originality through concentrating precisely on intrapartum care for women with multiple sclerosis, which has not been an area that has not been extensively synthesized in prior reviews. Moreover, the use of the PAGER framework enabled structured identification of patterns, advances, and research gaps, providing improved systematic extent beyond conventional narrative synthesis.

The current paper followed the methodology of the Joanna Briggs Institute (JBI) for scoping reviews. JBI offers a robust construction for identifying types of available evidence, clarifying key concepts, and investigating how research is conducted on a precise ground. The progression was further guided by the methodological stages proposed by Arksey and O’Malley (20025) and refined by Levac et al, (Arksey & O’Malley, 2005) guaranteeing a translucent and reproducible approach.¹⁷ Reporting was strictly aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), please see Figure 1.

Figure 1.

PRISMA-ScR flow diagram of the study selection process.

Eligibility Criteria

The Population–Concept–Context (PCC) framework was used to define the scope of the review.

• Population: Pregnant women with a confirmed diagnosis of MS, encompassing all disease phenotypes, including relapsing-remitting (RRMS), primary progressive (PPMS), and secondary progressive (SPMS). Studies involving other demyelinating diseases of the central nervous system, such as Neuromyelitis Optica or MOGAD, were excluded.

• Concept: The review focused on intrapartum care and its associated maternal and neonatal outcomes. This included labor management, mode of birth (vaginal versus caesarean section), and the administration of anesthetic or analgesic interventions.

• Context: Hospital-based inpatient or outpatient obstetric settings and perioperative care related to delivery were included.

The following studies were eligible to be included in the current scoping review. This included quantitative, qualitative, or mixed methods, randomized controlled trials, prospective and retrospective cohort studies, case-control studies, systematic reviews, and consensus guidelines studies published in English between January 2020 and January 2025. Case reports with fewer than three cases, editorials, letters, and publications lacking original data or clinical outcomes were excluded. See Table 1.

Table 1.

Eligibility Criteria

Criteria	Inclusion Criteria	Exclusion Criteria
Population	Pregnant women diagnosed with Multiple Sclerosis (all phenotypes: RRMS, SPMS, PPMS).	Pregnant women with other demyelinating CNS diseases (eg, Neuromyelitis Optica, MOGAD) or clinically isolated syndrome (CIS).
Concept	Intrapartum care, including labor management, mode of delivery (vaginal vs. cesarean), and anesthetic/analgesic interventions.	Studies focused solely on pre- conception counseling, infertility treatments, or breastfeeding without intrapartum data.
Context	Inpatient or outpatient obstetric settings; perioperative care related to delivery.	General MS management unrelated to the pregnancy/delivery window.
Outcomes	Maternal: Relapse rates (postpartum), EDSS progression, anesthetic complications. Neonatal: Birth weight, APGAR scores, neonatal intensive care admission.	Studies reporting only biological/molecular markers without clinical obstetric or neurological outcomes.
Study Design	Randomized controlled trials (RCTs), prospective/retrospective cohort studies, case-control studies, and systematic reviews.	Case reports (n < 3), editorials, letters to the editor, and expert opinions without original data.
Timeframe	Published between January 1, 2020, and January 31, 2025.	Studies published prior to 2020.
Language	Full-text available in English	All other languages unless a translation was accessible.

Search Strategy

A widespread three-step search approach was applied through the following databases: PubMed, MEDLINE (Ovid), CINAHL (EBSCO), and Scopus. The following search Medical Subject Headings (MeSH) text words related to multiple sclerosis, pregnancy, and intrapartum care (eg, labor, childbirth, neuraxial anesthesia) were utilized in the search (See Supplementary Table S1). To guarantee the inclusion of grey literature and reduce publication bias, further searches were conducted through Google Scholar, ProQuest Dissertations, and the websites of professional organizations such as ACOG and NICE. The search period was restricted to 2020–2025 to reflect contemporary clinical practices and pharmacological advancements. A condensed summary of the complete search methodology, a full, unabridged search log with step-by-step results for each line, is available from the corresponding author upon request and is provided with this submission in Supplementary Table S2.

Study Selection

Endnote was used to manage citations; this facilitated the removal of duplicates. Preliminary review of titles and abstracts was conducted by two independent reviewers against the inclusion criteria. This was followed by a rigorous full-text assessment of possibly relevant articles. Inconsistencies were determined through consensus or by consultation with a third reviewer. A summary of the search results and screening flow is presented in Supplementary Table S2.

Data Charting and Synthesis

Data were extracted using a standardized charting tool developed for this review. The information that was extracted included the following: author, year, country, design, participant demographics, intrapartum interventions, and maternal/neonatal outcomes. Narrative synthesis and thematic organization was conducted to the findings. To articulate implications for practice and research, the PAGER framework (Patterns, Advances, Gaps, Evidence for practice, Research recommendations) was applied.¹⁸

Quality Assessment

To enhance the interpretation of the evidence recruited in the current scoping review, instead of merely excluding studies, the methodological quality of the included studies was examined descriptively. An adapted version of the Kmet et al checklist for quantitative research was used as an administrative outline to evaluate key methodological structures through the included studies.¹⁹ Items not appropriate to the study designs (eg, randomization or blinding) were omitted, and selected standards were contextualized to reflect intrapartum care and neurological outcomes in women with multiple sclerosis. Two reviewers independently reviewed all 11 included studies, with any incongruities determined through conversation. The appraisal findings were used to provide an overview of methodological strengths and limitations across the evidence base and are presented in Appendix 1 and Appendix 2; no studies were excluded on quality grounds.

Data Extraction

Data were extracted from studies that met the methodological quality criteria. Two reviewers independently extracted the collected data to ensure accuracy and avoid errors. The details about the aims, study design, population (sample size; neonates’ gestational age), intervention(s), comparator(s), outcome measures, and results are significant to the review question.

Data Synthesis

Narrative summary synthesis was used to report results. A comparative analysis of intervention outcomes across the included studies was conducted and reported in a single table (Table 2). Findings were synthesized narratively and organized into thematic categories to provide a comprehensive overview of the current evidence base.

Table 2.

Characteristics of Included Studies (n = 11)

Study Author (Year) and Country	Design	Aim	Sample Size (MS Patients)	Key Findings Relevant to Intrapartum Care	Neonatal Outcomes Reported	Maternal Outcomes Reported	Intrapartum Interventions/Practices Reported
(De Giglio et al, 2020) Italy20	Observational Retrospective Study	Investigate if MS diagnosis influences delivery modality	250 HS and 157 MS patients	Women diagnosed with MSpre group showed a lower frequency of natural delivery and a higher frequency of both planned and urgency caesarean sections compared to healthy subjects	Gestational weeks and birth weight were lower in MS patients compared to healthy subjects. The study suggests that lower gestational age, often associated with caesarean section, might influence these neonatal outcomes. Exposure to DMT during early pregnancy has been linked to lower baby weight and length	The study observed that women with an MS diagnosis are more likely to undergo caesarean sections, with increases in both planned and urgency procedures. Caesarean section increases the risk of maternal mortality and morbidity, including uterine rupture, abnormal placentation, ectopic pregnancy, and preterm birth. However, caesarean sections can offer benefits such as less frequent incontinence and urogenital prolapse, particularly for MS patients with severe bladder/bowel symptoms.	The study specifically focused on the modality of delivery, noting a higher frequency of both planned and urgency caesarean sections in MS patients, particularly those diagnosed before pregnancy. The authors suggest that the gynecologist’s “aprioristic choice” may contribute to the increased rate of caesarean sections in MS patients.
(Liguori et al, 2020) Argentina21	Consensus guideline (review and expert opinion)	To develop guidelines for family planning and pregnancy in MS, including intrapartum care	Not specified (review of literature and expert consensus)	Recommendations emphasize interdisciplinary management, preconception counseling, and appropriate maternal care; limited specific intrapartum practices detailed	Not specifically reported; focus on postpartum and management strategies	Postpartum relapse management, breastfeeding recommendation, relapse prevention strategies	Emphasis on early planning, interdisciplinary approach, and tailored management during pregnancy and postpartum
(de Barros et al, 2021) Brazil22	Retrospective and descriptive case series, with cross-sectional and quantitative design.	Evaluate the changes in MS during and after pregnancy, and to describe the obstetric outcomes of patients.	26 women and 38 pregnancies	There was a significant increase in the prevalence of relapse during the postpartum period when compared with the gestational period. Higher rates of abortion, prematurity and low birth weight were reported in the group was exposed to DMTs when compared with the one who was not. The rate of cesarean sections in our sample was considered overly elevated (90.6%), since most studies present rates around 40% or lower.	9.4% newborns had low birth weight and 18.8% newborns were premature. There were no reports of neonatal deaths or birth defects.	42.1% of the pregnancies, there was exposure to DMTs 36.8% to interferon β, and 5.3% to fingolimod 23.1% of the assessed women had their first MS relapse postpartum	90.6% pregnancies, the chosen type of delivery was C/S, while the remaining 9.4% were delivered via VD. Spinal anesthesia was used in 71.9% deliveries; epidural was used in other 18.8% women; 6.3% women did not receive any kind of anesthesia; and 3.1% woman could not recall which kind of anesthesia had been used.
(Hellwig et al, 2023) Germany4	Nationwide, prospective, observational cohort study	To describe the absolute risk of severe relapses, persistent disability accrual (using a novel patient-centric definition), and the absolute risk of relapses during pregnancy and the postpartum year following fingolimod cessation.	213 pregnancies in 201 women.	Relapses are common after fingolimod cessation, occurring in 31.46% of pregnancies. Unlike the “natural history” of MS where pregnancy is protective, adjusted relapse rates during pregnancy were slightly higher (RRR 1.24) compared to the year before pregnancy.	Not reported in this specific article. The study focused on maternal disease activity and disability.	57.28% of pregnancies experienced at least one relapse during pregnancy or the postpartum year. 6.32% of women retained clinically meaningful disability SRDCS one year postpartum. Severe relapses occurred in 4.23% during pregnancy and 1.41% postpartum	Treatment for relapses during pregnancy included high-dose corticosteroids and, in two cases, apheresis. Postpartum interventions studied (but not found to reduce relapse risk) included exclusive breastfeeding and early resumption of fingolimod within 4 weeks of delivery.
Özkan & Polat Dünya (2023) Turkey (meta-synthesis of international studies)23	Thematic meta-synthesis of qualitative studies	To synthesize qualitative evidence on the experiences of women with multiple sclerosis regarding pregnancy, childbirth, postpartum period, and motherhood.	221 women with MS (across 10 qualitative studies)	Childbirth was described as emotionally complex, with fears of relapse, fatigue, and loss of control. Women emphasized the importance of clear information, respectful communication, and individualized intrapartum support.	Generally healthy neonatal outcomes reported; concerns focused more on potential risks than observed adverse outcomes.	Postpartum relapse anxiety, fatigue, physical limitations, emotional stress, and need for psychosocial and family support.	Concerns and discussions around mode of birth, pain management, epidural use, support during labor, and continuity of care; no routine contraindication to VD identified.
(Bove et al, 2024) USA24	Retrospective observational study	To describe real-world DMT utilization and relapse patterns before, during, and after pregnancy.	944 women with MS	MS does not require C/S; mode of delivery should be based on obstetric indications.	Not specifically reported.	Relapse rates increased postpartum (10.0%) compared to pregnancy (2.6%). High rates of postpartum depression (17.3%) and anxiety (20.1%) were observed.	DMT use declined sharply during pregnancy (from 36.3% preconception to 5.8% by the third trimester). Relapse risk also declined during pregnancy.
Morante-Herrera et al (2024) Spain3	Descriptive phenomenological qualitative study	To explore the lived prenatal and postnatal experiences of women with multiple sclerosis.	17 women with MS	Women expressed concerns about childbirth pain, fatigue, epidural use, and fear of postpartum relapse. Concerns during labor were similar to women without MS, though anxiety related to disease exacerbation existed.	No increased neonatal risks reported; participants worried about fetal health and disease transmission, but outcomes were generally normal.	Postpartum relapse risk, fatigue, functional limitations, breastfeeding challenges related to medication compatibility.	Discussion of epidural analgesia concerns, mode of birth anxiety, medication interruption during pregnancy, and individualized labor support.
(Rahmati et al, 2024) Iran, UK, Canada, USA25	Systematic Review & Meta-analysis	To assess maternal and neonatal outcomes in pregnant women with MS	32,191	MS increases risk of cesarean delivery; MS activity may influence delivery planning	Preterm birth, congenital malformations, Apgar score <7, SGA	No significant association with preeclampsia, gestational diabetes, stillbirth	Not specifically detailed; potential variations in delivery methods noted, including higher cesarean rate in MS women
(Kaya, Aslan, Şimşek, Ozcelik, and Ozakbas, 2025) Turkey26	Retrospective study.	To evaluate the long-term effects of pregnancy on the prognosis of MS by analyzing relapse rates, EDSS scores, and MRI activity over a three and five-year period after delivery.	The study included a total of 196 women with MS. This comprised 111 women who had a delivery after their MS diagnosis and a control group of 85 non-pregnant women with MS.	Delivery after MS diagnosis is linked to higher relapse activity, especially in the first three years postpartum. However, this increased relapse rate did not lead to long-term disability accumulation or increased MRI activity. The findings emphasize the need for personalized postpartum monitoring. Relapses during pregnancy were associated with a higher relapse rate in the third year after delivery compared to those who did not relapse during pregnancy. Relapses in the year prior to pregnancy were linked to worse disability outcomes at three and five years postpartum.	No specific neonatal outcomes reported.	Reports on postpartum relapse rates, EDSS scores, and MRI activity at three and five years after delivery. While postpartum relapse rates increased, there was no significant long-term disability accumulation.	The study mentions DMT use before pregnancy, DMT washout periods for some participants, and the timing of restarting DMT after delivery. No detailed specific intrapartum interventions (such as labor management practices) are described.
(Shakeri, Gharehbeglou, and Avval, 2025) Iran17	Systematic review included 34 studies: 22 case reports, 6 case series, and 6 cohort studies.	Assess the safety of neuraxial anesthesia in MS patients by investigating the incidence of adverse neurological outcomes, including relapse rates and the emergence of new neurological symptoms.	The review analyzed data from a total of 2326 patients with MS.	Postpartum relapses of MS were reported in 364 out of 1139 patients in the cohort studies. However, the use of neuraxial anesthesia was not found to be a direct cause of these relapses. The key predictors for postpartum relapse were a higher number of relapses in the year before and during pregnancy, and a longer duration of MS, rather than the type of anesthesia or mode of delivery.	No specific neonatal outcomes reported.	The primary maternal outcome discussed is the rate of postpartum MS relapse.	No specific intrapartum interventions/practices reported
(Shipley et al, 2025) Not mentioned9	Multicenter retrospective observational cohort study	Describe the clinical characteristics and disease course of women who experienced a pregnancy after being diagnosed with PPMS or SPMS and compare their long-term disability trajectories with matched women who had progressive MS but no history of pregnancy.	138 women with a progressive MS phenotype at the time of pregnancy.	No specific intrapartum care reported. The study focuses on long-term disability outcomes and relapse rates relative to pregnancy, not on the intrapartum period itself.	Term birth ⩾37 weeks’ gestation): 75.0% for PPMS and 73.6% for SPMS. Preterm birth (34–37 weeks’ gestation): 10.9% for PPMS and 11.1% for SPMS. Miscarriage or termination: 14.1% for PPMS and 15.3% for SPMS.	The primary maternal outcome assessed was long-term disability progression, measured by the EDSS. The study found that a history of pregnancy was not associated with a significant difference in long-term disability trajectories for women with either PPMS or SPMS. The study also reported on relapse rates during pregnancy and in the first 3 months postpartum	No specific intrapartum interventions/practices reported. The research does not cover interventions or practices during labor and delivery.

Results

The search of the literature and the comprehensive assortment procedures produced 11 studies that met the inclusion criteria. The last sample included systematic reviews and meta-analyses (n = 2), retrospective observational cohorts (n = 5), a prospective observational study (n = 1), a qualitative study (n = 1), a thematic meta-synthesis of qualitative research (n = 1), and a consensus guideline (n = 1). These studies included a widespread geographical distribution and vast sample sizes. This ranged from 17 participants in qualitative studies to more than 32,000 in meta-analytical studies. The characteristics and key findings of included studies are summarized in Table 2. The PRISMA-ScR flow diagram (Figure 1) provides detailed information about the study selection process (JBI, 2025). Moreover, the PAGER (Patterns, Advances, Gaps, Evidence for practice, and Research recommendations) framework was implemented to organize the findings and illuminate suggestions for practice and research.^18,19

Current growths in clinical awareness validate an agreement that neuraxial anesthesia can be safely used and that MS alone is not a reason for caesarean delivery. However, recent evidence indicates that women with multiple sclerosis (MS) experience higher rates of cesarean section (CS), and postpartum relapse is often linked to pre-pregnancy disease activity. Regardless of this, there are still plenty of gaps, such as the lack of systematized fatigue management techniques and intrapartum care pathways personalized to MS. The results support the use of neuraxial anesthesia, collaborative planning to maximize results, and supporting vaginal birth in the absence of obstetric indications in clinical practice. Future research should concentrate on developing nurse-led decision-making tools, evaluating fatigue management techniques, and experimenting with interdisciplinary care models in order to increase intrapartum benefits for women with MS. The PAGER synthesis, which is described in more detail below, is summarized in Table 3.

Table 3.

PAGER Framework Table

Patterns	Advances	Gaps	Evidence for Practice	Research Recommendations
Across observational studies, women with MS experience higher rates of caesarean section compared with women without MS, often without clear obstetric indications.20,22,25	Growing consensus that MS itself is not an indication for caesarean section, and mode of birth should be based on obstetric factors rather than neurological diagnosis alone.24,25	Lack of MS-specific intrapartum clinical pathways guiding decision-making around mode of birth and labor management.	Nurses and midwives should support vaginal birth when obstetrically appropriate, addressing misconceptions that MS necessitates caesarean delivery.	Development and evaluation of evidence-based intrapartum care protocols specific to women with MS.
Intrapartum decision-making appears influenced by provider caution and anticipatory clinical bias, rather than documented neurological risk.20	Improved understanding that neuraxial anesthesia is generally safe in women with MS and not independently associated with postpartum relapse.17	Limited prospective data evaluating labor analgesia choices and their short- and long-term neurological outcomes.	Epidural and spinal anesthesia may be offered based on clinical need and patient preference, not MS diagnosis alone.	Prospective cohort studies comparing analgesia strategies and neurological outcomes during and after labor.
Postpartum relapse risk is consistently reported as higher than during pregnancy, particularly in women with active disease prior to conception4,22,26	Identification of key predictors of relapse (pre-pregnancy disease activity, relapse history, DMT interruption) rather than intrapartum factors.4,17	Insufficient integration of postpartum relapse risk planning into intrapartum and immediate post-birth care.	Intrapartum teams should initiate early postpartum planning, including neurology referral and relapse monitoring.	Intervention studies examining early postpartum support models initiated during labor and birth admission.
Neonatal outcomes are generally favorable, though some studies report higher rates of preterm birth and low birth weight, particularly with DMT exposure.20,22,25	Large population studies demonstrate no major increase in congenital anomalies or perinatal mortality attributable to MS.9,25	Limited differentiation between disease-related versus treatment-related neonatal risks in intrapartum literature.	Nurses should provide reassurance and evidence-based counseling regarding neonatal outcomes while monitoring for prematurity risks.	Studies disentangling effects of MS, DMT exposure, and delivery mode on neonatal outcomes.
Qualitative studies reveal that childbirth is experienced as emotionally complex, with heightened anxiety around fatigue, pain, loss of control, and relapse.3,23	Increasing recognition of the importance of individualized, respectful, and communicative intrapartum support for women with MS.	Lack of research translating women’s experiences into structured intrapartum nursing interventions.	Continuous labor support, clear communication, and fatigue-sensitive care should be prioritized by midwives and nurses.	Co-designed qualitative and mixed-methods studies evaluating patient-centered intrapartum nursing interventions.
Multidisciplinary involvement is recommended but rarely operationalized during labor and birth.21	Consensus guidelines emphasize interdisciplinary planning across neurology, obstetrics, and nursing care.	Absence of evaluated multidisciplinary intrapartum care models specific to MS.	Early coordination between obstetric, anesthesia, nursing, and neurology teams should begin before labor onset.	Implementation studies testing multidisciplinary intrapartum care pathways for women with MS.

Mode of Birth and Clinical Indications

The rates of CS are higher than those of the general population. More specifically, about 90.6% of women with MS had CS according to the retrospective research of de Barros et al.²⁷ This practice clearly deviates from clinical guidelines for childbirth. According to Liguori et al,²² many high-quality foundations, such as consensus recommendations and large cohort studies (eg, Bove et al²¹), agree that MS is not a medical indication for surgical birth. This implies the need to utilize only the well-known obstetric indications to regulate the method of childbirth. Research points to “a priori choice” or physician prudence as the possible cause of these higher rates rather than physiological need.

Safety of Neuraxial Analgesia and Anesthesia

One of the major themes regarding intrapartum clinical procedures for women with MS is the degree of safety of the use of neuraxial interventions, particularly epidural and spinal anesthesia. Systematic reviews (eg, Shakeri et al¹⁶) and cohort research constantly confirmed that these techniques are safe for women with MS and do not increase the possibility of postpartum relapse or long-term debility evolution. Pre-pregnancy disease activity and medication washout periods were linked to postpartum relapse more than intrapartum use of anesthesia.

Maternal Outcomes and Disease Activity

Regarding the maternal outcomes, the majority of studies emphasized the pattern of MS relapse after birth. Pregnancy was found to have a protective role against relapse, yet the risk of relapse after birth in the first six months is a major concern. According to data from the Expanded Disability Status Scale (EDSS), there were no differences in the long-term disability curves related to pregnancy or birth mode. Nevertheless, significant rates of sadness (17.3%) and postpartum anxiety (20.1%) were reported. This emphasizes the need for comprehensive psychosocial support.²¹

Neonatal Outcomes

Reassuring neonatal outcomes were reported in the majority of the studies. Probable adverse effects, including preterm birth or low birth weight, were not directly linked to the management provided for women with MS during childbirth. Instead, there was a link between neonatal adverse effects and the disease activity and exposure to certain disease-modifying therapies (DMTs) during pregnancy.

Patient Perspectives and Psychosocial Concerns

The qualitative synthesized in the current study^3,24 revealed that women with MS experience sophisticated emotional status after birth. The impact of labor-related exhaustion on their capacity to care for the newborn, severe anxiety about managing pain, and the worry that the stress of labor could exacerbate a disease were common worries. High-quality intrapartum care must include interdisciplinary collaboration, personalized assistance, and clear communication, according to women.

Discussion

This scoping review synthesizes recent evidence to demonstrate that while intrapartum care for women with MS is clinically safe, it remains profoundly subjective to conventional practices. These kinds of practices are characterized by cautious decision-making that may not line up with contemporary evidence. The stubbornly high rates of caesarean sections (CS), which frequently occur in the absence of obstetric grounds, are the most obvious example of the conflict between evidence-based tactics and clinical authenticity. However, maternal fatigue is still a serious but treatable clinical problem. More than just physical tiredness, fatigue in multiple sclerosis is a complicated neurological symptom that may reduce a mother’s stamina throughout the second stage of labor. The literature still does a poor job of addressing the lack of interventional studies on fatigue-management measures, such as energy-conserving methods or particular positions.

Patterns, Advances, Gaps, Evidence, and Recommendations (PAGER)

Synthesis of the evidence establishes convergence in significant intrapartum practices and outcomes for women with multiple sclerosis, as well as divergence between emerging evidence and routine clinical practice. The included studies validate steady patterns in intrapartum care and perinatal outcomes among women with MS, together with significant improvements and insistent gaps in evidence. Across observational and population-based studies, women with MS were more likely to undergo caesarean section compared with women without MS, often in the absence of clear obstetric indications. Numerous studies recommended that clinician decision-making and preventive concern regarding neurological deterioration may add to higher caesarean section rates rather than disease-related inevitability.

The latest literature increasingly approves that MS alone is not an indication for operative delivery, and that vaginal birth is generally safe when obstetrically appropriate. Evidence from large observational studies and systematic reviews indicates that neuraxial anesthesia, including epidural and spinal techniques, is not autonomously related to increased postpartum relapse hazard, supporting its use according to clinical need and patient preference. Postpartum disease activity remains a steady concern, with multiple studies reporting greater deterioration rates after delivery, predominantly among women with elevated pre-pregnancy disease activity or recent discontinuation of disease-modifying therapy. However, intrapartum factors such as mode of birth or anesthesia type were not identified as primary predictors of relapse. Neonatal outcomes were largely promising, even though some cohorts reported higher rates of preterm birth and low birth weight, primarily related to exposure to disease-modifying therapies rather than the MS diagnosis itself.

Qualitative evidence indicates that labor is an emotionally difficult event for women with multiple sclerosis, characterized by anxiety related to fatigue, pain management, loss of control, and fear of postpartum recurrence. Women emphasized the need for individualized care, honest communication, and continuous intrapartum support. Few studies have detailed or assessed structured multidisciplinary intrapartum care models, despite interdisciplinary treatment recommendations. Key recommendations for nursing and midwifery practice as well as priorities for further research were found through the synthesis of evidence utilizing the PAGER framework (Table 3). The results highlight the urgent need for a paradigm change in the way this population’s labor is controlled. The proven safety of neuraxial anesthesia has successfully allayed worries about the neurotoxicity of local anesthetics in demyelinated nerves. With this guarantee, nurses and midwives may encourage effective pain management, perhaps reducing maternal stress and the belief that surgery is required.

A prominent finding of this scoping review is the persistently high rate of cesarean section (CS) among women with MS, reaching as high as 90.6% in some cohorts.²⁷ This is significantly higher than the WHO-recommended rates and the rates observed in healthy controls.²³ However, our synthesized data from Rahmati et al²⁰ and Bove et al²¹ suggest that MS itself is not an obstetric indication for surgical delivery. We hypothesize that these elevated rates are driven by an “a priori choice” by clinicians or patient-driven anxiety rather than physiological necessity. The qualitative evidence from Morante-Herrera et al³ supports this, indicating that fears of intrapartum fatigue and physical exhaustion often lead both patients and providers to opt for a planned CS.

Neuraxial anesthesia has historically been reluctantly used due to worries about the neurotoxicity of local anesthetics on demyelinated nerves. Our analysis of current data from 2020 to 2025 offers strong certainty. The systematic review conducted by Shakeri et al¹⁶ found no association between postpartum relapse and neuraxial anesthesia, both spinal and epidural. Alternatively, the chief indicators of postpartum relapse are still pre-pregnancy disease activity and DMT washout times, principally for drugs like Fingolimod.⁴ The qualitative meta-synthesis²⁴ and consensus guidelines²² delineated that there is a critical care gap, namely the requirement of interdisciplinary intrapartum protocols. Management between neurologists, obstetricians, and anesthesiologists is essential for effective treatment in order to address maternal fatigue and ensure the rapid resumption of DMTs after delivery in order to reduce the “rebound effect” seen during the first three months.

Midwifery and Nursing Implications

Midwives and nurses have a central role in helping women with MS through normal vaginal childbirth unless CS is clinically indicated. Midwives and nurses should be equipped with valid and evidence-based information about the safety of normal childbirth as well as the safety of the use of general and local anesthesia during birth. Therefore, the utilization of neuraxial analgesia should be offered and supported as a safe measure for pain management during childbirth. This would aid in reducing fatigue and preserving the mother’s energy for a natural birth and supportive positioning. Midwives and nurses working with women who suffer from MS have a central role in coordinating the resumption of disease-modifying medications, and postpartum planning.

Knowledge Gaps and Future Directions

There are a number of unsolved questions because the majority of the research currently available is observational. The biomechanics of labor in women with progressive MS phenotypes, where spasticity or muscle weakness may require particular adjustments to second-stage care, are not well documented. Additionally, there is still clinical debate on how to strike a compromise between resuming high-efficacy DMTs and exclusive breastfeeding.²⁶

The creation of interdisciplinary protocols and nurse-led decision-support systems that standardize treatment while maintaining person-centeredness should be given top priority in future research. Improving clinical outcomes and maternal satisfaction for women with multiple sclerosis requires shifting the emphasis from “safety” to “optimization” of the delivery experience.

Recommendations

While qualitative research highlighted fatigue as a major concern after birth, there are no interventional studies to evaluate organized fatigue-management strategies during childbirth, including approaches to second-stage management. There is also limited evidence about biomechanics in women with progressive MS phenotypes, predominantly the influence of spasticity and weakness on second-stage labor and the potential role of earlier instrumental delivery. The evidence about the safety of neuraxial anesthesia is reassuring. However, there is a lack of evidence about dose–response relationships and optimum anesthetic regimens in women with extensive spinal involvement. Moreover, more research is needed about the role of exclusive breastfeeding in the disease course after birth. The balance between the duration of breastfeeding and the resumption of disease-modifying medications is under-researched.

Limitations

Findings of this scoping review are limited because of the inclusion studies published only in English which omit data from other linguistic contexts.

Conclusion

This scoping review synthesizes recent evidence regarding intrapartum care for women with multiple sclerosis (MS). The findings, organized via the PAGER framework, reveal a persistent pattern of elevated caesarean section rates that are often discordant with evidence-based guidelines affirming the safety of vaginal birth. Advances in clinical understanding, particularly the established safety of neuraxial anesthesia and its dissociation from postpartum relapse risk, provide a foundation for more rational and less fearful intrapartum decision-making. This scoping review mapped the existing evidence on intrapartum management practices and maternal and neonatal outcomes among women with multiple sclerosis. The findings indicate that, although most women with multiple sclerosis can experience safe vaginal birth, uncertainty remains regarding optimal intrapartum care, including mode of birth, analgesia options, fatigue management, and multidisciplinary coordination.

The review also identified that maternal and neonatal outcomes are generally favorable; however, women with multiple sclerosis may experience increased fatigue, mobility limitations, and emotional concerns during childbirth. Additionally, variations in clinical decision-making and limited evidence-based guidelines contribute to inconsistencies in intrapartum care practices. Furthermore, significant knowledge gaps were identified, particularly regarding nursing and midwifery-led interventions, patient-centered intrapartum care, and interdisciplinary collaboration during labor and birth. These findings highlight the need for further research and the development of evidence-based guidelines to support nurses and midwives in providing individualized, patient-centered intrapartum care for women with multiple sclerosis.

Funding Statement

This research received no specific grant from any funding agency in the public, commercial, or not-for- profit sectors.

AI Statement

The authors used ChatGPT and QuillBot to assist with language refinement and editing to enhance the clarity of the text.

Data Sharing Statement

The data that supports the findings of this review are available from the corresponding author upon reasonable request.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that there are no conflicts of interest for this work.