Sleep in the perinatal period

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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 (n23) 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

History of depression
No history of depression
Coble et al. (1994)
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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 _at_ 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 _at_ 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
• Womens 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?