Sleep in the perinatal period

Dr Andy Mayers

Lauren Kita

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An overview of normal sleep

1/3 of our lives are spent asleep!

What is normal sleep?

Average sleep 6½ - 8 hours each night

Regulated by 25-hour circadian rhythm

Borbely - 2 process model

Adjusted to coincide with normal wake-sleep routines

Use cues from environment

Clocks and sunlight/darkness

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Sleep cycles

Sleep EEG stages

Stage 1 – light sleep

Stage 2 – getting deeper…

Stage 3 – deeper sleep

Stage 4 – deepest sleep

Stages 3 and 4 represent slow-wave sleep (SWS) Rapid-eye-movement (REM) sleep

Appears after 1st cycle Periods of intense brain activity Frequent and intense bursts of eye movement Referred to as ‘active sleep’ in younger children

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Functions of sleep

Sleep is crucial for our survival! SWS is the most restorative stage – growth hormone is

released REM sleep is important for memory consolidation and

possibly emotional regulation Sleep deprivation is associated with:

Depression Decreased cognitive functioning Obesity Reduced immune system functioning - reduced t-cells,

increased cytokines – more likely to become ill

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How we can measure sleep

Polysomnography (PSG)

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Sleep cycles

Sleep for ALL humans presents in cycles throughout night

This is an example of healthy adult sleep

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Sleep in the perinatal period

Sleep disturbances are common in pregnancy

Physical changes Backache Uncomforatable sleeping position Needing to urinate Snoring (Baratte-Beebe & Lee, 1999; Facco et al. 2010)

Sleep disturbances are common in postpartum period

Hormonal changes

The baby!

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Perinatal sleep

Non-first time mothers

First time mothers

Lee, Zaffke & McEnany (2000)- Obstectrics & Gynecology, 95 (1)

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Perinatal sleep

Sleep becomes worse throughout 3rd trimester

• Amongst women in 3rd trimester (n=23) weeks pregnant associated with:

• Poorer subjective sleep quality (r=.66)• Poorer subjective sleep satisfaction (r=.47)• Poorer subjective sleep depth (r=.71)• Less TST (r=.60)

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Perinatal sleep - quality

• Pregnancy is associated with decreased REM & SWS (deep sleep)

• Early postpartum period associated with a SWS rebound(Lee, Zaffke & McEnany, 2000; Hertz et al., 1992; Karacan et al., 1968)

Non-first time mothers

First time mothers

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Sleep in women with a history of depression

Women with a history of depression have increased risk of PND Differences in sleep throughout pregnancy

Greater changes in TST over course of childbearing 2-3 x greater decrease in TST between 36 wks and 1 month PP

compared to no-history group More subjective sleep disturbances Reduced REM latency

Coble et al. (1994)

History of depression

No history of depression

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Sleep disorders in pregnancy

Obstructive Sleep Apnea (OSA) Snoring increases during pregnancy Incidence of OSA remains unknown

Weight gain increases risk Reduced REM sleep may reduce risk

OSA and the risk of adverse pregnancy outcomes (Chen et al., 2012) Pregnant women with OSA are at increased risk for having LBW, preterm,

and SGA infants, C-Section, and preeclampsia, compared with pregnant women without OSA.

Restless legs syndrome (Mancoli et al. 2005) 2-3 x higher risk in pregnancy (mainly 3rd trimester)

11-27% pregnant women Related to iron / folate deficiency Majority of cases disappear after birth Tiring days, caffeine, iron deficiency and anxiety can make the

restlessness worse

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Sleep and Postnatal Depression

• Cross-sectional studies• Women with PND report poorer subjective sleep quality (e.g. Da

Costa et al., 2006; Dorheim et al., 2009)

• Unclear whether actual (objective) sleep is poorer (Posmontier, 2008; Dorheim et al., 2009)

• Longitudinal studies• Sleep in 3rd trimester is related to PND • Specific relationship remains unclear

• PND related to longer sleep & more naps in 3rd T (Wolfson et al. 2004)

• PND related to poor subjective sleep quality & sleep disturbances in 3rd T but not objective sleep (Bei et al., 2010)

Subjective sleep more important?• Lack of research using PSG

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Why is it important?

What factors affect how women perceive their sleep?

Help to identify those at greater risk of PND

Easy to talk about sleep issues

Harder to talk about signs of PND

May help to provide a talking point

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Possible interventions – Mind-Body

Growing evidence for mind-body interventions Reducing stress & anxiety during pregnancy Beddoe & Lee (2008) - review of mind-body interventions

during pregnancy (e.g. relaxation, hypnosis, visual imagery,

meditation, yoga, biofeedback, tai chi, qi gong)• Associated with increased BW, shorter labor, fewer instrument-

assisted births, reduced stress / anxiety

Preliminary research evidence that yoga

during pregnancy can improve sleep

(Beddoe et al. 2010)

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Possible interventions – Infant Sleep

• Hiscock & Wake (2001)• 3-part intervention on infant sleep @ 6-12 months-

controlled crying & sleep management plan• vs. control group with infant sleep information (no

advice)• Decreased infant sleep problems and maternal

depressive symptoms

• Stremler et al. (2006)• 45 min meeting with nurse @ 6 weeks to discuss

infant sleep strategies, 11-page booklet & weekly calls

• vs. control group with basic sleep hygiene and calls (no advice)

• Improved maternal and infant sleep & mothers rated infant sleep as less problematic (using actigraphy & diaries)

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Practical implications

Talk about sleep problems – ask questions & encourage discussion Women’s expectations of sleep throughout this period Looking out for sleep problems

restless legs / sleep apnea very poor self-reported sleep affecting well-being

The importance of sleep for the mother and baby Discussing possible strategies (e.g. infant sleep)

Discussing individual situations Setting realistic goals & reviewing them

Encouraging rest & relaxation Yoga / breathing exercises to reduce stress & anxiety &

improve sleep

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Over to you!

How might you use this information in your role as a health visitor?

What can be done to make sure mother is sleeping OK?

What is best method for baby sleep?

Controlled crying?

Gentle intervention?

Anything goes?