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?
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