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This article provides an overview of normal sleep in the perinatal period, including sleep cycles, functions of sleep, measurement of sleep, sleep disturbances in pregnancy and the postpartum period, and the relationship between sleep and postnatal depression. It also explores possible interventions to improve sleep during pregnancy.
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Sleep in the perinatal period Dr Andy Mayers Lauren Kita
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
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
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
How we can measure sleep • Polysomnography (PSG)
Sleep cycles • Sleep for ALL humans presents in cycles throughout night • This is an example of healthy adult sleep
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!
Perinatal sleep Non-first time mothers First time mothers Lee, Zaffke & McEnany (2000)- Obstectrics & Gynecology, 95 (1)
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)
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
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)
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
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
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
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)
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)
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
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?