Postpartum Care

Developing a Plan for Postpartum Care

Managing epilepsy during the postpartum phase can be complex and involve several considerations. A patient’s pregnancy plan should include plans for the child’s birth and for after the baby is born. The care team should work with the patient and their neurologist on a postpartum plan at least one month before the expected delivery date.

A patient’s pregnancy plans should include labor and delivery, anti-seizure medication (ASM) monitoring and tapering, contraception, sleep management, breastfeeding, postpartum safety measures, and long-term care and monitoring. Ultimately, the goal is to ensure that the patient and new baby receive the necessary care, follow-up, and support during the postpartum period. 

Topics covered on this page include:

• Monitoring & Tapering ASM Levels
• Contraception
• Sleep
• Breastfeeding
• Safety & Postpartum Care
• Long-term Care, Including the Possible Needs for Testing & Early Intervention

Monitoring & Tapering ASM Levels

For patients on ASMs that were increased during pregnancy, dose reduction is necessary in the first few weeks postpartum to avoid toxicity. To ensure a smooth transition, you should establish a postpartum tapering a few weeks before the expected delivery date and share it with the patient and their obstetrician. Delaying this plan until after delivery is impractical and may pose risks in some cases. 

The patient’s postpartum tapering strategy can be tailored to maintain the patient at a slightly higher dose than their pre-pregnancy levels, safeguarding them from the potential impacts of sleep deprivation and added stressors. See Anti-seizure Medication Tapering for guidance on how to taper different ASMs.

Contraception

Discussing the significance of planning for pregnancy with your patient is important during the childbearing years. Contraception plays a critical role in the lives of patients with epilepsy. The use of enzyme-inducing ASMs is associated with an elevated risk of unplanned pregnancies. Some studies found that up to 65% of women with epilepsy reported at least one unplanned pregnancy, making effective contraceptive measures crucial. 

Patients need to have discussions with their OB-GYN and neurologist, as certain ASMs can impact the efficacy of contraception and vice versa. This collaborative approach will enable patients to make informed decisions regarding contraceptive options, protecting their reproductive health and overall well-being. After delivery, patients should promptly resume their contraception to prevent unintended pregnancies. 

Sleep

Sleep deprivation is expected during the third trimester of pregnancy and the postpartum period. Sleep deprivation is also a common seizure trigger (particularly for frontal lobe and idiopathic generalized epilepsy seizures). During your pregnant patient’s second trimester, collaborate with them to develop a comprehensive sleep plan that includes the involvement of their family or other support system. After delivery, this plan should include arrangements for night care, such as family assistance or hiring a night nurse if necessary.

When planning for labor and early postpartum care, prioritizing "sleep as medicine" is crucial, and it should be effectively communicated to the family, partner, and hospital staff. This includes sleep and quiet time during induction and labor to allow adequate rest. To help the patient sleep during labor, plan to use epidurals. 

Work with your patient to establish a plan that includes at-home sleeping arrangements and shifts with other caregivers. The goal is to ensure the patient receives at least one uninterrupted four-hour stretch of sleep and an additional two hours of naps during the day to reduce the risk of seizures.

Breastfeeding

When establishing a feeding plan, patients should consider whether to opt for breastfeeding, formula feeding, or a combination of both. 

You can advise your patients taking ASMs under clinical supervision that research supports they can safely breastfeed their babies. There is little evidence to suggest that ASM exposure from breastmilk has clinical effects on newborns. 

Safety & Postpartum Care

Safety concerns may vary depending on the patient's seizure type and severity, but there are common guidelines for those at risk of seizures with impaired awareness. Refer to the Postpartum Safety & Support page for tips on creating a safety plan for your patients with epilepsy before they bring their babies home. 

Long-term Care, Including the Possible Needs for Testing & Early Intervention

Following delivery, the neurologist should schedule follow-up appointments with patients, in person or virtually, at two weeks and six weeks postpartum. These visits should include monitoring mood and anxiety symptoms to ensure the patient's well-being. 

During the postpartum period, it is common to maintain patients at a slightly higher dose of their ASM due to the effects of sleep deprivation and increased stress. Encourage patients to stay diligent with their neurology appointments and adhere to their prescribed medication regimen. 

The child's pediatrician should know that if any concerning symptoms or developmental delays manifest before the child turns three, early intervention may be necessary to address and manage potential issues.

Guide Your Patients

Developing a postpartum care plan is crucial for the health and safety of the patient and their baby. This comprehensive plan should address the unique challenges that may arise during this period and ensure that adequate support and monitoring are in place. Reinforcing the importance of safety for both parent and baby is vital when discussing the plan. 

It is essential to acknowledge that aspects of the plan may require adjustments or flexibility to ensure the safety of parent and child. By maintaining an open and adaptable approach, patients can feel comfortable making necessary changes to feeding and sleep schedules. The ultimate goal is to ensure a safe and nurturing environment for themselves and their newborn.

Reviewed by: Laura Kirkpatrick, MD, August 2023