Sleeping for Two
A Guide for Expectant Mothers and their Partners
Deepak Shrivastava, MD
Board Certified Sleep Specialist
Preface
Christian Guilleminault, MD
Sleeping for Two
Cradle Song
Sweet dreams form a shade,
O’er my lovely infants head.
Sweet dreams of pleasant streams,
By happy silent moony beams.
Sweet sleep with soft down.
Weave thy brows an infant crown.
Sweet sleep Angel mild,
Hover o’er my happy child.
Sweet smiles in the night,
Hover over my delight.
Sweet smiles Mothers smiles,
All the livelong night beguiles…
William Blake
Introduction
Sleep is a vital component to human health. It is when the body restores, renews, and reenergizes itself. When you are awake, the body is focused on getting things done instead of taking care of it. When you sleep, your body can repair the damage done during the waking hours. The body repairs and rebuilds bones, muscles, and skin.
Sleep is a very complex biological process. Physicians who study sleep have analyzed brain activity during sleep and have identified two distinct states. The first is called non-rapid eye movement (N-REM) sleep and the second is rapid eye movement sleep (REM). Non-rapid eye movement sleep is divided into four additional stages (Stage 1 -3). The brain is subdued during N-REM sleep while the body may be more active. It is during REM sleep that the brain is most active while the body is immobile. It is during REM sleep that most dreaming occurs. During sleep, a person will start at N-REM stage 1, then stage 2, then 3, and then enter REM sleep. During the night, a person will cycle through this pattern between four to six times. This cycle is very delicate and depends on very complex interactions between the brain and the rest of the body. The various sleep stages and the cycling through the N-REM – REM stages represent an ideal model, where in actuality the sleep stages and cycles can vary from person to person and can vary over an individual’s lifetime.
Circadian Rhythms
An important aspect to understand regarding sleep is the circadian rhythm. Circadian rhythms follow a 24-hour period and are physical, mental, and behavioral changes, which respond to light and darkness in the environment. Circadian rhythms are based on both biological processes as well as external environmental factors. These rhythms influence sleep-wake cycles, hormones, and body temperature. Circadian rhythms can be disturbed with travel (jet lag) and shift work (swing shift, graveyard shift, etc). Disruptions to the circadian rhythm can have multiple adverse health effects including an increased risk of cancer, the metabolic syndrome, and cardiovascular diseases. In addition, disruptions to the circadian rhythm can have negative consequences on a woman’s fertility and on her pregnancy. Circadian rhythms play an important role throughout pregnancy in relation to the production of hormones. During the first trimester estrogen and progesterone, levels rise to aid the implantation and gestation of the fetus. A study of nurses who worked the night shift had a higher risk of having small for gestational age and low birth weight infants as well as preterm delivery. Pregnant women who have circadian rhythm disturbances also have a greater risk for depression and preeclampsia.
There are several circadian rhythm disorders including delayed sleep phase disorder, advanced sleep phase disorder, jet lag disorder, shift work disorder, and irregular sleep-wake rhythm. People with delayed sleep phase disorder are often called “evening types” as they typically stay awake until 1am and wake up later in the morning. People with advanced sleep phase disorder typically go to sleep between 6 and 9 pm and wake up between two and 5 am. Jet lag disorder affects travelers who cross time zones. Jet lag is a temporary condition that resolves within a few days. Shift-work disorder occurs when a person works hours, which could be considered normal sleeping hours. Irregular sleep wake rhythm is a circadian disorder in which a person’s sleep is fragmented into a series of naps over 24-hours. The symptoms of circadian rhythm disorders include sleep loss, excessive sleepiness, insomnia, depression, and stressed relationships.
Sleep Deprivation
Sleep deprivation, which is defined as a decrease in either the amount or quality of sleep, has become an epidemic problem in the modern world. Research has shown that Americans are sleeping less and less with over 30% of Americans reporting less than 6 hours of sleep each night. There are a number of reasons for this lack of sleep ranging from work commitments and family obligations, to modern technology. Sleep deprivation has been linked to any number of health problems both medical and psychological. A lack of sleep has been linked to high blood pressure and obesity to Alzheimer’s disease, depression and in severe cases sleep deprivation can cause hallucinations.
Research has suggested that women have born a greater degree of sleep deprivation than men have. Women have developed a greater presence in the workforce over the last 60 years. This increase in work outside of the home has come in addition to their work at home such as caring for children and other family members, cooking, cleaning, and hundreds of other responsibilities.
Sleep and Pregnancy
Sleep becomes even more vital during pregnancy as the woman’s body must not only take care and restore itself, but also create a brand new body in the form of the growing child. Sleep for a pregnant woman is vital for the well-being of the baby. The blood-flow to the uterus and placenta as well as important hormones for the baby’s growth is at the highest during sleep. While sleep is of vital importance to a pregnant woman and her baby it is common for a pregnant woman to suffer great difficulty in getting enough sleep.
Sleep changes throughout pregnancy. The time spent asleep tends to increase during the first trimester, then decreases through the second and third trimesters, and continues to decrease through the postpartum period. Studies have shown that women report a decrease from 8 hours to less than 6 hours of sleep over the course of pregnancy. Further studies have revealed that pregnant women are actually sleeping 30 minutes less than they think they are. In addition to the quantity of time spent asleep, the quality of that sleep also diminishes with up to 72% of pregnant women reporting sleep disturbances affecting the quality of their sleep.
A woman’s ability to sleep during pregnancy and in the postpartum period is affected by a large number of hormonal and physiological changes. Hormones play key roles in sleep regulation throughout life. The hormones related to pregnancy can disrupt sleep or else are negatively affected by a lack of sleep. Oxytocin a hormone that is responsible for uterine contractions peaks at night, which can possibly cause sleep disruptions. Estrogen can reduce REM sleep and progesterone can reduce N-REM sleep. Estradiol may play a role in the development of restless legs syndrome, which is a sleep disorder that interrupts sleep. Prolactin an important hormone that regulates lactation and other maternal behaviors has been shown to be impaired by a lack of sleep. The levels of these hormones change throughout the day and night responding to the circadian rhythm. Disturbed sleep can cause the levels of these hormones to become unbalanced, which can lead to a variety of harmful effects on the mother and child.
In addition to the hormonal changes related to pregnancy there are a host of other factors that can disrupt sleep. Heartburn and other gastrointestinal problems are prevalent in pregnancy. One study reported that heartburn occurred in 75% of pregnant women studied. Treatment consists of small frequent small meals and antacids. The need to urinate during the night because of the growing baby putting pressure on the bladder, what doctors call nocturia can interrupt sleep. The baby’s movements such as kicking can cause the mother discomfort and make sleep difficult. The physical changes during pregnancy such as weight gain, and the awkwardness that the growing baby can cause back pain and other discomfort can make it difficult to sleep. Nasal congestion, what doctors call rhinitis, is common in pregnancy can aggravate allergies and can negatively affect sleep. Nightmares that are common during pregnancy can also interrupt sleep.
Effects of Sleep Deprivation on the Mother and baby
Sleep deprivation can have serious consequences on the health and well-being of both you and your baby. Sleep deprivation has been linked to pregnancy induced hypertension and the closely related condition of preeclampsia, gestational diabetes, depression, postpartum depression, and even miscarriage. Sleep deprivation can even affect the labor and delivery of your child. A mother’s sleep deprivation has also been linked with pre-term birth, low-birth weight babies, longer hospital stays, and higher Apgar scores for her baby.
Pregnancy induced hypertension, which is defined as blood pressure of over 140/90 and the associated condition of preeclampsia, which is defined as blood pressure of over 140/90 with the presence of protein in the urine, what doctors call proteinuria, are potentially dangerous medical conditions that can have far-reaching serious implications on the mother and child. These conditions are often diagnosed after the first 20 weeks of pregnancy. If untreated the high blood pressure can develop into preeclampsia; preeclampsia can further develop into eclampsia which causes the mother to have seizures which could be life threatening for both the mother and baby. Preeclampsia can damage the mother’s lungs, kidneys, liver, heart, and brain. It can also cause placental abruption in which the placenta separates from the wall of the uterus. Placental abruption can lead to shock, blood loss, and kidney failure for the mother, and premature birth or stillbirth for the baby. It can also restrict the baby’s growth and reduce the amount of amniotic fluid that surrounds the baby in the womb. The amniotic fluid helps to protect the baby from shocks, allows the baby to move, helps the baby’s lungs to develop, and keeps the baby warm. To treat pregnancy induced hypertension or preeclampsia your doctor may recommend lifestyle changes (healthy diet and exercise) and possibly medication. The only cure for these conditions is the delivery of your child after which your blood pressure should gradually return to pre-pregnancy levels.
Gestational diabetes is a type of diabetes that occurs in pregnant women who did not have diabetes before. Diabetes is a condition in which the body no longer responds to the hormone insulin. This results in a disruption for blood sugar in the body. This type of diabetes resolves after the child has been born. Gestational diabetes is typically treated with a healthy diet and exercise routine and at times medication. Gestational diabetes can have serious affects on both you and your child. It can result in an extra large baby as the excess blood sugar can “overfeed” your child. An extra large baby can lead to a need for C-section, with longer recovery for the mother. A large baby is also at risk for shoulder dystocia in which pressure is put on the child’s shoulder during vaginal birth and can cause nerve damage and oxygen loss for the baby and heavy bleeding and tearing of the uterus, vagina, cervix, and rectum for the mother. Gestational diabetes can also lead to preeclampsia.
Depression can worsen or can develop during pregnancy from a lack of sleep or poor quality sleep. Some of the possible symptoms of depression include a lack of interest in activities, deep feelings of sadness, anxiety, irritability, difficulty concentrating, fatigue, and thoughts of suicide. If you suffer from depression and become pregnant or are pregnant and develop depressive symptoms it is vital that you discuss this with your healthcare provider.
Postpartum depression is a serious psychological problem that can affect women after childbirth. Studies have shown that women who suffered postpartum depression in a previous pregnancy and have disturbed sleep are at an increased risk of recurrence. Studies have also shown that women who sleep less than 4 hours per night are at an increased risk for developing postpartum depression. Postpartum depression can cause the mother to neglect the child and in the extreme form can lead to child abuse and even infanticide. The symptoms of postpartum depression are the same as depression. If you feel that, you are developing postpartum depression it is vital that you discuss your feelings with your healthcare provider.
There are other serious consequences to disturbed sleep in pregnancy. Miscarriage, which is the loss of the pregnancy, can have devastating long-term mental and emotional effects on a woman. Studies have shown that women who experience sleep disturbances have a greater risk for miscarriage in the first and second trimesters. Disturbed sleep has also been shown to increase the amount of time spent in labor and delivery, and a greater feeling of pain and discomfort during labor. Studies have also shown that poor sleep increases the occurrence of unplanned c-sections. Cesarean section is a major surgery and carries with it additional risks and longer hospital stays for the mother and her child.
In addition to the risks for the mother, poor sleep has also negative consequences for the child. Studies have shown a link between sleep problems and premature birth. Studies have also shown the possibility that poor sleep can restrict the baby’s growth, leading to low birth weights. It is a common occurrence for premature infants and low birth weight infants to be admitted to the neonatal intensive care unit. This leads to longer hospital stays for the baby and increased burdens on the family. Studies indicate the possibility of a link between sleep disturbances and higher Apgar scores. The Apgar test was developed as a way to gauge the general health of a newborn baby. A lower score indicates a healthier baby, while a higher score indicates that the baby is less healthy and needs special attention.
Specific Sleep Disorders
Sleep Disordered Breathing
Sleep disordered breathing is a broad term that covers a number of conditions ranging from simple snoring to obstructive sleep apnea (OSA). In the population at large obstructive sleep apnea is associated with some of the leading causes of death such as hypertension, heart disease, and stroke. In addition lack of sleep in general can lead to daytime sleepiness and difficulty in concentration which can cause car/traffic accidents or job related accidents. A study showed that out of 47,597 traffic accidents 7% of a car crashes, 13.1% of non-fatal car crashes, and 16.5% of fatal crashes involved a sleepy driver.
Snoring commonly develops during pregnancy; studies suggest that snoring occurs in 14 – 45% of pregnant women versus 4% in nonpregnant women. In another study 45% of 438 women reported snoring during pregnancy while 85% of them did not snore before pregnancy. Snoring is the result of turbulent airflow caused by an obstructed nasal airway. Snoring women are more likely to experience leg selling (edema) than non snorers. Snoring is a significant risk factor is developing obstructive sleep apnea.
Loud snoring, breathing pauses during sleep and excessive daytime sleepiness are classic symptoms seen in most men with obstructive sleep apnea. Women are two to three times less likely than men to report classic OSA symptoms. Women tend to report unusual symptoms such as insomnia, morning headache, fatigue, tiredness, depression, anxiety, memory loss, poor concentration, decreased libido, irritability, worsening unexplained fatigue, and tiredness. It is believed that up to 90% of women are under diagnosed with obstructive sleep apnea. Women go to the doctor and do not report typical symptoms of obstructive sleep apnea and as a result are often misdiagnosed with depression, chronic fatigue syndrome, fibromyalgia, hypothyroidism or anemia. This pattern holds true in pregnant women as their sleep complaints may be misunderstood by their doctor as the regular physical, mental or emotional changes which occur during pregnancy. Women also often go to their doctor appointments alone. They are accompanied by their partner less frequently than men, and so snoring which may be embarrassing may not be mentioned by the woman.
Obstructive sleep apnea is a sleep related breathing disorder. This is a condition that causes the airway to collapse during sleep. This collapse can be either partial, which doctors call hypopnea or total collapse which doctors call apnea. Apnea is defined as the complete cessation of airflow for a minimum of 10 seconds. Hypopnea is defined as a reduction of airflow lasting at least 10 seconds. This collapse causes a reduction in the amount of oxygen that is breathed in and circulating in the blood, which doctors call hypoxia. These collapses can occur as often as 30 times an hour and result in multiple awakenings each night. Studies have found that sleep disordered breathing events increase during pregnancy, and that age and body mass index were major risk factors for obstructive sleep apnea.