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 1 st 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 3 rd 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 Coble et al. (1994) History of depression No history of depression

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 3 rd 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 3 rd trimester is related to PND Specific relationship remains unclear PND related to longer sleep & more naps in 3 rd T (Wolfson et al. 2004) PND related to poor subjective sleep quality & sleep disturbances in 3 rd 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 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 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?