Pregnancy and sleep

Introduction

The challenge of sleeping for two (or more!)

Expectant mothers are often advised to get plenty of rest, but for many women, that's easier said than done. As many as 97% of pregnant women say that their sleep is disturbed, especially in the third trimester.

A recent poll in the US suggested suggested that the most common reasons for disturbed sleep in the third trimester were frequent bathroom trips, or 'nocturia' (92%), aches and pains (66%), leg cramps (54%), heartburn (51%) and disturbing dreams (38%).

This guide suggests some practical steps for tackling sleep problems, answers common questions and explains some of the science of sleeping during your pregnancy. While you can't prevent the biological changes that can disrupt your sleep, at least you can understand what is happening, and why. Cognitive and behavioral strategies can help you to prioritize sleep, to reduce worry and increase your chances of getting back to sleep.

Why is sleep so difficult in pregnancy?

Physical challenges

Physical changes and changing hormone levels can play havoc for even the most accomplished sleeper, and can increase the risk of sleep disorders. Progesterone and oxytocin are pregnancy hormones which may cause fragmented sleep. In the later stages of pregnancy, carrying a budding footballer can make it seem impossible to get comfortable!

Emotional ups and downs

Pregnancy can be hugely exciting, but it can also be nerve-racking and stressful. Lack of sleep can also be a cause of low mood. If you do start to feel persistently low or anxious, talk to a midwife or doctor for advice.

Needs of a growing family

A new pregnancy can feel like even more of a strain when you're already caring for a young family. Juggling the needs of infants and toddlers with your own sleep is a difficult balancing act.

Many sleep aids are off the menu

Many sleep aids, including over the counter medication, are not recommended for pregnant mothers. If you were taking sleep medication before your pregnancy, talk to your doctor to check whether you can continue.

Preparing for good sleep: what to do during the day

Regular exercise is good for sleep, and can help reduce leg cramps. Doctors recommend keeping up a normal routine of physical activity for as long as you feel comfortable. If you weren't super fit before pregnancy, take it gently. If you can hold a conversation while you're exercising without becoming breathless, it's probably not too strenuous.

If you experience heartburn, or reflux:

• avoid citrus fruits and juices, rich or fatty foods and spicy dishes
• eat small, regular meals, to reduce the content of the stomach at any one time
• caffeine and alcohol are likely to make reflux worse, and could also keep you awake at night.

If you feel sleepy during the day:

• If you're looking after young children, nap when they nap
• If you're at work, a lunchtime nap in a spare meeting room, or even in your car, could help you stay awake through the day
• Napping for less than 40 minutes at a time should help you to avoid feeling groggy. Set an alarm, and/or ask a friend to wake you up.

If you suffer from cramp, regularly stretching out your calves during the day and before bed may help to prevent problems occurring at night.

Drink plenty of water to stay hydrated during the day, but cut back two hours before bedtime to reduce overnight bathroom trips.

Winding down and drifting off: what to do at night

Practicing a familiar 'wind down' routine an hour or so before bed can help your body and mind to switch off. The body comes to anticipate and recognize rituals such as taking a warm shower or bath, reading a chapter of book, or drinking hot milk, and these can become signals to release melatonin and help bring on sleep.

To help reduce the urge to go to the toilet at night:

• Avoid diuretics like tea and coffee which make you lose more water
• When you do go, lean forwards on the toilet to help empty your bladder each time.

If you're feeling sick because your stomach is empty:

• Try a light snack before you go to bed: a milky drink, cereal, toast or crackers are quick to prepare and should avoid heartburn.
• Put a few crackers or plain biscuits by your bed just in case you wake up feeling queasy.

To get comfortable at night:

• Use pillows to relieve pressure on aching muscles, and to support the bump
• Sleep on your left side to reduce the pressure on the vessels returning blood to the heart. Don't panic if you wake up in another position, just ease back onto your left side.
• To reduce heartburn, sleep in a slightly more upright position, propped up by pillows

If you're struggling to get to sleep, experiment with some relaxation techniques:

• Being 'mindful' means to pay attention and to accept the present moment. Focusing on the here and now, rather than worrying about the past or future, has been linked to better wellbeing. Mindfulness is skill, developed through the practice of mindfulness meditation. In pregnancy, mindfulness can be helpful for managing pain and discomfort, reduce the risk of depression, and can also help with getting to sleep.
• Autogenic training is a relaxation technique which involves developing sensations of warmth and heaviness in your body, enabling you to to 'let go' and relax more deeply. It can be particularly useful for discomfort and pain.

Recognizing sleep disorders in pregnancy

Breathing-related sleep disorders, restless legs syndrome, and insomnia become more common during pregnancy. The good news is that they are all treatable, and symptoms usually disappear when your body gets back to normal postpartum (at least until the new arrival causes a new wave of sleep deprivation challenges!)

If you suspect that you're suffering from any of these sleep disorders, ask your doctor for advice.

Breathing-related sleep disorders

It's common to feel unusually sleepy during the day when you're pregnant, but if you or your partner also notice that you have started snoring noisily, or that you are pausing or gasping during your sleep, you may have developed a breathing-related sleep disorder. These include snoring, upper airway resistance syndrome (requiring greater than normal effort to breathe), and obstructive sleep apnea (OSA). In OSA, the walls of the throat narrow during sleep and temporarily obstruct normal breathing repeatedly through the night.

Estimates vary, but as many as 1 in 3 women start snoring in pregnancy, and 1 in 10 may develop symptoms of OSA. Causes include weight gain, the changed position of the diaphragm and fluid accumulation in the breathing passages due to hormonal changes.

Research shows that women with breathing related sleep disorders are more likely to suffer from preeclampsia (high blood pressure) and gestational diabetes, but the relationship may not be a causal one.

Restless legs syndrome

Restless legs syndrome (RLS) is defined by a strong urge to move the legs while at rest, accompanied by unpleasant feelings. Some people describe the sensation in their legs as itchy, creepy, crawly, jittery or burning. The need to move your legs gets worse at night and is only relieved by movement. Many people also experience jerky movements of the legs, called periodic limb movements.

Up to 30% of pregnant women experience symptoms of RLS, especially in the third trimester. Most experts agree that women with iron or folate deficiency are at greater risk. RLS makes getting to sleep more difficult and has been linked to depression. Symptoms in pregnancy usually disappear after delivery.

Insomnia disorder

Difficulty getting to sleep, staying asleep, waking too early and non-restful sleep are all symptoms of insomnia. In medical terms, insomnia disorder is defined as chronic sleep problems which interfere with normal daytime functioning, despite adequate opportunity for sleep.

In pregnancy, aches and pains, leg cramps, hormonal changes and emotional stress can all increase the risk of developing insomnia. The short term consequences include fatigue, feeling low and irritable, memory and concentration problems, and strained relationships.

There is some evidence that sleep deprivation in the third trimester is associated with a longer labor and higher perceptions of pain during labor, so it's important that you seek medical help if you're suffering with insomnia.

Treatment can involve both drug and non-drug therapies, but many sleeping pills are not recommended during pregnancy. Research shows that the most effective long-term solution for insomnia is Cognitive Behavioral Therapy, or CBT. This 'talking therapy' approach targets the behaviors and thoughts that interfere with good sleep.

Is Sleepio suitable for pregnant mothers with insomnia?

The Sleepio course is based on proven CBT techniques, and includes information about the lifestyle habits and environmental factors that influence sleep, cognitive techniques to tackle the racing mind, relaxation techniques and a daily sleep diary. During session 3, a technique called 'sleep restriction therapy' is introduced, in which adults who spend a long time unable to sleep at night are advised to reduce the overall window of time they allow for sleeping, and to avoid napping during the day. This is because sleep restriction increases your biological need for sleep. These aspects of the course could be helpful, whether or not you're pregnant.

Sleepio has been evaluated in pregnant women and has been shown to be effective and safe. However, if you are pregnant, you should not reduce your sleep window to below 6 hours.

Common questions

Why have I started getting heartburn?

Heartburn, also known as gastroesophageal reflux disease (GERD), is often a temporary symptom during pregnancy. Progesterone can relax the muscle which usually keeps food in the stomach, so that acidic foods rise back up towards the throat.

Why do I get leg cramps?

Spasms or cramps causing shooting pains up and down the legs are common in the second half of pregnancy. The causes are not entirely clear, but may include an imbalance of magnesium or calcium, which are natural salts circulating in the blood.

Why do I need the toilet so often?

In the first trimester, you both produce more urine and the enlarged uterus presses on the bladder, increasing your need 'to go'. In the second trimester things typically ease, but return with a vengeance in the third trimester with more sodium production and the bigger bump. To find out more about the physiological changes in pregnancy, see The Science of Sleeping in Pregnancy.

Is it normal to have more bizarre dreams in pregnancy?

Pregnancy is often associated with unusually vivid or bizarre dreams. This is probably because more frequent waking makes it more likely that you will remember your dreams, but it may also be that you have more anxiety than usual.

The science of sleeping in pregnancy

On average, national surveys suggest that pregnant women typically sleep for an extra hour per night, but there are big differences over the nine months.

First trimester

The growing fetus is very small, but it is developing rapidly and requires a lot of energy. Even though you may be sleeping for longer, it's still normal to feel tired – high levels of the hormone progesterone increase both daytime sleepiness and your need for sleep. Progesterone also causes you to produce more urine. As your enlarged uterus presses on the bladder, you are likely to get up more often during the night to go to the bathroom.

Second trimester

Sleep often returns towards normal as development of the fetus slows, and the uterus changes position to above the bladder. Restless sleep and sleep complaints increase towards the start of the third trimester.

Third trimester

The heavier, rapidly growing fetus requires a lot more energy and it's normal to feel fatigued. Many women also suffer back ache and discomfort, as well as feeling kicking and moving at night. Leg cramps are common, probably caused by low calcium and potassium levels. Many women complain that they wake frequently and find it difficult to get back to sleep. Frequent trips to the bathroom are normal, partly due to higher overnight sodium release. The hormone oxytocin can add to more fragmented sleep. As pregnancy progresses, women are at higher risk of developing sleep disorders such as restless legs syndrome, breathing-related sleep problems such as snoring and sleep apnea, and insomnia.

Consequences of short sleep in pregnancy

It is increasingly clear from the scientific literature that whether or not you're pregnant, sleep plays a crucial role in emotional control, cognition and physical health. The US National Sleep Foundation recommends 7 to 9 hours sleep every night for the average (non-pregnant) adult to maintain optimal health. When you're pregnant, how you feel is the best guide to how much sleep you need – if you're persistently sleepy during the day, try to make time for one or more short naps during the day, or for extra hours of sleep during the night.

Some research suggests that women who sleep for fewer than 5 or 6 hours throughout pregnancy have higher risks of problems related to high blood pressure, depression and cesarean deliveries than women who sleep for 7 hours or more. However, the mechanisms are not well understood and there is no simple cause and effect relationship. If you're worried about your sleep at any time during your pregnancy, speak to your healthcare professional.

References

Oyiengo D et al. (2014) Sleep disorders in pregnancy Clinics in Chest Medicine 35(3):571-87

Pien, GW & Schwab RJ (2004) Sleep disorders during pregnancy SLEEP 27(7):1405-27

NHS Choices (2014) Pregnancy and baby guide

National Sleep Foundation (2007) Sleep in America Poll, 2007, Women and Sleep