Sleep in the perinatal period

1. Sleep in the perinatal period Dr Andy Mayers Lauren Kita

2. 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

3. 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

4. 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

5. How we can measure sleep • Polysomnography (PSG)

6. Sleep cycles • Sleep for ALL humans presents in cycles throughout night • This is an example of healthy adult sleep

7. 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!

8. Perinatal sleep Non-first time mothers First time mothers Lee, Zaffke & McEnany (2000)- Obstectrics & Gynecology, 95 (1)

9. 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)

10. 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

11. 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)

12. 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

13. 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

14. 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

15. 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)

16. 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)

17. 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

18. 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?