Pregnancy and Sleep

Pregnancy is an exciting time full of joy, anticipation, and utter bliss. But this happy time can be rocked by serious sleep disturbances that make it anything but joyful. It is normal for women to be tired from carrying around a new life. 78% of women report sleep disorders during pregnancy even if they have never had problems with sleeping before. 

Sleep disturbances affect pregnant women for several reasons. Changing hormones during pregnancy can cause them to feel more tired. Numerous trips to the bathroom during the night can contribute to this as well. Excessive daytime sleepiness in the first trimester usually happens due to rising progesterone levels. Snoring may occur due to hormonal changes that have inhibitory effect on muscles. Pregnant women who are obese may be at risk of developing sleep apnea and should see their doctor if this becomes an issue. Complications such as low birth weight, preeclampsia, and gestational hypertension may be associated with sleep apnea.

Pregnancy can cause or worsen existing sleep disorders. A study of over 600 pregnant women with sleep disorders revealed that 26% of them reported the restless leg syndrome (RLS). Another issue is GERD or gastroesophageal reflux disease; a study found that 30 - 50% of pregnant women experience problems with acid reflux. 

Poor sleep can also affect the labor and delivery times. Researchers from the University of California discovered that pregnant women who slept less than 6 hours per night had longer labors and were 4.5 times more likely to have their babies by cesarean. This has become such an issue that doctors now regularly discuss sleep habits with patients as part of their basic prenatal care. Pregnant women should make sleep a priority as early as possible.

First-time mothers have a hard time sleeping because of anxiety about labor and delivery or balancing work and motherhood. Getting enough sleep is even harder once the baby is born. Loss of sleep caused by frequent bathroom trips, nausea, and occasional insomnia can take a toll on your health if it persists. 

Symptoms

It is not uncommon to have sleep issues during your pregnancy. Here are some symptoms that may keep you awake at night:

Frequent urination – You may urinate frequently during the night due to increasing pressure on the abdomen. This leads to poor sleep.

Nocturnal gastroesophageal reflux   – GERD is a common problem in pregnancy. The stomach acid rises into the esophagus and throat at night when you lie down. The symptoms are lessened by sitting up or raising the head at a 45 degree angle. GERD can damage the tissue in the esophagus if not treated.

Sleep apnea – Sleep apnea is a sleep disorder in which you may experience repeated pauses between breaths and gasping for air upon waking. A common symptom of sleep apnea is heavy snoring and choking sounds on waking from sleep.

Restless legs syndrome (RLS) - If you have the urge to stretch, rub, or move your legs during the night, you might have a disorder known as RLS or the restless legs syndrome. A symptoms of RLS is a tingly, achy, itchy, or otherwise unpleasant sensation in the legs that makes you want to move them.

Insomnia – Symptoms of insomnia include trouble falling asleep, staying asleep, or waking up too early. Episodes of insomnia are often related to stress or anxiety and center around labor, delivery, or life changes that motherhood will bring. Fetal movements, back pain, and nausea can frequently disturb sleep during pregnancy as the pressure on the body increases.

The effects of pregnancy on sleep

Changes in sleep patterns happen frequently during pregnancy. Things like frequent nighttime awakenings, trouble going back to sleep, fatigue, or excessive daytime sleepiness affect the quantity and quality of sleep.

Some sleep issues that emerge in the early stages of pregnancy may disappear as pregnancy progresses, or worsen in intensity. A high number of women experience increased nighttime awakenings especially during the third trimester. Hormonal changes, psychological adjustments, and physical discomfort impact sleep and result in its deficit.

Hormones and sleep

Pregnancy is dominated by hormones. Changes in the growing body put pressure on vital organs resulting in physical discomfort while standing, sitting, and lying. Dramatic hormonal changes during pregnancy affect mood, metabolism, and sleep pattern. With so much going on in the body it is easy to see why women tend to be cranky in the latter stages of pregnancy:

Oxytocin - can bring on strong contractions that disrupt sleep. The increase in oxytocin may also lead to a higher incidence of labor and delivery during the night.

Estrogen - enlarges blood vessels which can lead to swelling or edema in the legs and feet. It may also cause congestion which interferes with breathing during the night. It can reduce the dreaming phase of sleep - the REM sleep. 

Progesterone - contributes to frequent urination, nasal congestion, heartburn. It reduces the amount of rapid eye movement (REM) sleep (a stage of sleep responsible for lucid dreaming).  

Melatonin levels tend to increase during pregnancy and increased levels of prolactin in the body may lead to more slow-wave sleep. 

Sleep cycles during pregnancy

Studies have shown a dramatic change in sleep patterns during pregnancy. Sleep efficiency or the amount of time spent asleep while in bed decreases due to frequent nighttime awakenings. 

Here is a look at how sleep changes over all three cycles of pregnancy:

• The first trimester (12 weeks): During this phase the quantity of sleep as well as the amount of slow-wave (deep) sleep may decrease due to frequent nighttime awakenings. On the other hand total sleep time may increase as napping is frequently needed during the day. 
• The second trimester (weeks 13 - 28): Sleep tends to improve as the number of nighttime awakenings decrease. However, the quality of sleep will decrease again towards the end of the 28th week.
• The third trimester (weeks 29 till delivery): Women entering the third trimester experience more physical discomfort and frequent nighttime awakenings which contribute to poor sleep. Sleep is lighter with an increase in stage 1 and 2 sleep. Napping increases during daytime.

Sleep problems during pregnancy

Sleeping can be difficult when pregnant. When you have other issues going on at the same time, it can compound the problem. Symptoms of sleep disorders appear more often during pregnancy due to the physical changes in the body.

For some women pregnancy is the only time they suffer from a sleep disorder. Their quality of sleep prior to becoming pregnant was normal. Existing sleep disorder such as the restless legs syndrome or sleep apnea may worsen in pregnancy. We will look at each trimester and see the effects of changes on the body at each stage until labor and delivery:

The first trimester

During the first trimester women may experience excessive daytime sleepiness. Daytime napping is common and may increase as time progresses. As the body produces more progesterone, sleep is often fragmented and disturbed. Up to 37,5% of women report an increase in daytime sleepiness in the first 7 weeks.

Morning sickness (nausea and vomiting), tender breasts, increased appetite, back pain, increased urination, and anxiety are some of the chief complaints of this phase of pregnancy. These physical and psychological issues can interfere with healthy sleep. Anxiety can become problematic if the pregnancy was unplanned and contribute to episodes of insomnia.

The second trimester

During the second trimester sleep typically improves. Nausea and vomiting usually disappear. Urination gets less frequent.

Towards the end of the second trimester sleep might be disrupted by stomach pain or irregular contractions known as Braxton-Hicks contractions. Due to an increase in weight sleep may be disrupted by the movements of the baby during the night, increased heartburn, and possible snoring from nasal congestion.

The third trimester

In the final trimester sleep may become even more disturbed. Sleep issues and nighttime awakenings happen more often due to increased pressure on the bladder. Issues affecting sleep during this phase of pregnancy include:

• Anxiety
• Nightmares or vivid dreams
• Itching
• Breast tenderness
• Joint and back pain
• Heartburn 
• Shortness of breath
• Leg cramps
• Frequent urination.

At this time the most physical demands are put on the woman’s body and sleep deficits become apparent. Episodes of sleep apnea and RLS or other sleep disorders may appear due to increased weight. It is harder at this stage to get comfortable for sleeping and many women report more joint and back pain due to the larger size of the baby. Pillows and lumbar supports can provide some relief.

Due to the increased size of the fetus and the pressure put on the vital organs more women may experience heartburn or the gastro-esophageal reflux disease (GERD). A wedge pillow can reduce discomfort and provide some relief. This is an important time to watch for increased swelling of the ankles, hands, or face. During this phase of pregnancy preeclampsia (high blood pressure only occurring during pregnancy) may occur, which has an impact on sleep and circadian rhythms. 

Treatments for sleep issues

Treating sleep issues is difficult when a woman is pregnant. Many of the medications used to treat insomnia can harm the developing baby and are not recommended for pregnant women or nursing mothers. However, it is possible to manage sleep issues related to pregnancy without the use of pharmaceuticals by practicing good sleep hygiene. 

Likewise, medications used to treat symptoms of the RLS are also not recommended for pregnant women. However, prenatal vitamins containing iron and folate supplements can reduce the symptoms. Bread, cereals, and whole grains are excellent sources of iron and folate too. Women with low iron and/or dietary folate levels should consider taking vitamins before becoming pregnant.

Pregnant women who gain a lot of weight and have issues with snoring need to be evaluated by their doctors for sleep apnea. CPAP (continuous positive airway pressure) is the recommended treatment for sleep apnea, and is safe for use during pregnancy.

While there is no treatment for frequent nighttime urination, there are helpful suggestions in the tips below which may help to minimize sleep disruption. 

Over-the-counter antacids may be used for gastroesophageal reflux (GERD) as there is no danger in using them during pregnancy.

Once the baby is born, many sleep issues will go away. However, sleep deprivation after giving birth may still be an issue due to the demands of a newborn.

Finding a good sleeping position

It is difficult to find a comfortable sleeping position when you get to the last trimester. However, there are some things that can help you to get comfortable and encourage restful sleep. Here are a few suggestions:

The most comfortable position is lying on your side with your knees bent and some pillows placed under your abdomen or between your legs for additional support. It improves circulation, supplies more oxygen to you and the baby, and reduces pressure (baby’s weight) on the large vein carrying blood back to the heart from your feet and legs.

Shifting positions is something you really have no control over while you sleep. However, you probably won't be able to roll over onto your back because it will be too uncomfortable. If you shift onto your back, you’ll probably wake up from discomfort after a few minutes.

Tips for successful sleep

You should not take any over-the-counter sleeping aids (including herbal remedies) without your doctor's approval. While they are perfectly fine for women who are not pregnant, they may contain ingredients that are not good for the developing baby. If you want to increase your chances of getting a good sleep, follow these tips:

• If you are worried about the delivery, taking a childbirth class should help relieve some of your anxiety. It is helpful to have a support system and knowledge to ease the fears that keep you awake at night. 
• Doing yoga stretches before bedtime can be very relaxing and help you sleep better. It’s great for unwinding and destressing at the end of the day. Just avoid doing any rigorous exercise right before bedtime. 
• Build the habit of going to bed and waking up at the same time every day (even at weekends). This helps to reset your circadian rhythm and fall asleep more easily. 
• Avoid eating a big meal or drinking a lot of fluids several hours before going to bed. Eat earlier in the day, just not in the late evening. You may prefer to eat more at breakfast and lunch and have a small dinner. 
• Nap earlier in the day if you have difficulty falling asleep at night.
• If you have pauses in you breathing associated with snoring, get screened for sleep apnea.
• Restrict your consumption of coffee, tea, and soda as much as possible. Restrict caffeine intake to the morning or early afternoon. 
• Make sleep a priority. Plan a time to go to bed every night.
• If you can’t fall asleep, don’t lie staring at the ceiling. Get up and do something productive for 30 minutes and then try again.
• Sleep on your left side to improve blood flow and make breathing easier. Try to avoid laying on you back for extended periods of time.
• Exercise for at least 30 minutes a day as long as your doctor agrees.
• Eat small meals frequently throughout the day to avoid heartburn. Do not eat large amounts of fried, acidic, or spicy foods.
• RLS can be treated with iron and folate supplements and through diet during pregnancy. Stretching may also help relieve the tension in your legs and prevent cramps or instances of the restless leg syndrome. 
• Install a nightlight in the bathroom and use it instead of turning on the light. It will be less arousing and may help you go back to sleep when you return to bed. 
• Have your blood pressure and urine protein checked regularly. Let your doctor know if you experience headaches or have swollen ankles.
• Sleep on your left side with a pillow placed between your knees, under your abdomen, and behind your back to relieve pressure on the lower back and feel more comfortable.

Keep in mind that insomnia for any reason during pregnancy is short-lived and will usually disappear after the baby arrives. Work with your doctor to minimize sleep deprivation and maximize your nutritional intake for your best health.