Planning for a Safe Delivery

In patients whose epilepsy is well managed, the risk of obstetric complications is no different from that of the general population. However, it is critical that the pregnant patient and their epilepsy and pregnancy care team collaborate on a labor and delivery logistics plan well ahead of the patient’s due date. 

Share the logistics plan with the patient’s support system and encourage patients to print it out and bring it to the hospital for delivery. It should include: 

  • Delivering in a controlled environment. A hospital setting is the safest birth location for a patient with epilepsy.
  • Prioritizing “sleep as medicine.” Communicate the patient’s need for adequate rest to the patient’s support system and hospital staff. To help the patient sleep during labor, plan to use epidurals. 
  • Consulting with obstetrical anesthesia at about 34-36 weeks of pregnancy (where available).
  • Having the patient bring their medications to the hospital in their original bottles. Hospitals may not have all the patient’s prescribed medications (e.g., extended-release (ER) formulations.)
  • Responding to seizures during labor or delivery.
  • Approaching anti-seizure medication (ASM) tapering following the delivery. The patient’s neurologist should share this tapering plan with the patient and their pregnancy care team, and the patient should bring the taper plan to the hospital when they deliver. Provide patients with an Anti-seizure Medication Tapering Schedule Tool to formulate this approach. 

Topics covered on this page include:

Delivery Methods

Pregnant patients with epilepsy and their pregnancy care teams should create a delivery plan well ahead of the patient’s due date. A patient having epilepsy or taking ASMs should not be a factor in determining how the patient delivers their baby.

Epilepsy alone is not an indication for a C-section. Vaginal deliveries account for two-thirds of deliveries in the United States, and unless there are obstetric indications for a C-section, pregnant patients with epilepsy can deliver vaginally. If there are obstetric indications for delivering by C-section, schedule the procedure before labor begins to provide a more controlled environment for the delivery. 

In rare situations, it may be necessary to deliver patients before their due date when they have poorly controlled seizures (e.g., increasing convulsive seizures in the third trimester).

Sleep as Medicine

Sleep deprivation may lower a patient’s seizure threshold, particularly in frontal lobe and idiopathic generalized epilepsy seizures. When planning for labor, delivery, and early postpartum care, it is crucial to prioritize the concept of "sleep as medicine" with the patient, their partner, support network, and hospital staff. 

Epilepsy is not a contraindication for epidural anesthesia. Encourage epidural use to prevent the patient from being under maximal sustained stress and to limit prolonged periods of wakefulness during labor (including induced labor), which can lead to seizure provocation. 

NOTE: If the patient has space-occupying brain lesions, consult a neurologist and anesthesiologist while planning the patient’s labor and delivery to discuss using an epidural.

To allow the patient to get adequate rest, urge them to sleep and get quiet time during induction and labor. Ask family and well-wishers to visit after delivery, not during labor, and to only stay for a short time.

Planning for Seizures 

The patient’s labor and delivery plan should include preparing for potential seizures. To minimize the risk of seizures:

  • Encourage patients to bring their medications from home to the hospital in their original bottles. Hospitals may not have all the patient’s prescribed medications (e.g., ER formulations).
  • Have patients take all scheduled ASM doses during labor and delivery. If the patient is NPO, they should still take their scheduled ASM dose with small sips of water. Some seizure medication can be administered intravenously if the patient can’t tolerate PO.

In the rare event the patient has a seizure during labor or delivery, the care team should plan to:

  • Rule out eclampsia by checking the patient’s blood pressure, protein in urine, and fetal heart rate. 
  • Have benzodiazepines readily accessible:
    • Give 1-2 mg IV lorazepam for convulsive, repetitive, or prolonged seizures. 
    • Give 1 mg lorazepam for isolated, non-convulsive seizures. Repeat this dose if seizures continue.
  • Turn the patient onto their left side if they are convulsing. Use seizure bed rail precautions.
  • Consult a neurologist for next steps.

Note: the above list is not exhaustive.  

After Delivery

Toxicity Risk

If a patient’s ASMs are increased during pregnancy, they will be at an increased risk for toxicity after delivery. Symptoms of toxicity include dizziness, vomiting, and blurry/double vision. Patients should discuss any concerning signs with their care team. After they leave the hospital, the patient or someone in their support system should call 911 if they experience any critical symptoms.

Following delivery, there are three topics to remind your patient:

  • Tapering anti-seizure medication if their dosage was increased during pregnancy.
  • Prioritizing sleep as medicine. Again, to help control seizures, it is critical that the patient get enough rest. Help your patient and their support system implement a postpartum sleep plan.
  • Restarting contraception immediately. The patient should go back on contraception immediately after delivering. They should discuss options with their OB-GYN and neurologist as some ASMs affect contraception and vice versa.

Refer to the Postpartum Care page for more information on caring for a patient with epilepsy following their delivery.

Guide Your Patients

Labor and delivery may mark the end of a journey your patient has been planning for years. As with all other steps in the pregnancy process, meet their concerns with clarity and facts. Remember:

  • Your patient and their care teams should make decisions about labor and delivery options (e.g., choosing epidurals) well before the patient’s due date. 
  • Prepare for contingencies like seizures during delivery. Let the patient know these preparations are safety measures that should not cause alarm. (Remind them that the risk of obstetrical complications is the same for patients with epilepsy as for the general population.)
  • Be excited for your patient! They’re going to have a baby.

Reviewed by: Page Pennell, MD FAES, August 2023