The growing body of research on sleep demonstrates the absolute necessity of sleep for every biological function. Your body goes through significant changes during pregnancy and while recovering from birth and breastfeeding. One of the best interventions for your health, recovery and the health of your baby is to get good sleep. Unfortunately, these life stages also come with challenges to your sleep. Those challenges can be in the form of common pregnancy symptoms or a newborn who needs you at all hours of the night. The good news is that there are evidence-based tools and tips to overcome these challenges and improve your sleep.
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Article and Resources
The growing body of research on sleep demonstrates the absolute necessity of sleep for every biological function. This includes learning, memory, brain function, mental health, appetite regulation, immune system function, metabolic function, the health of your gut microbiome, even your cardiovascular health. It is well established in the scientific literature that sleep is a critical component for all aspects of health.
Your body goes through significant changes during pregnancy and while recovering from birth and breastfeeding. One of the best interventions for your health, recovery and the health of your baby is to get good sleep. Unfortunately, these life stages also come with challenges to your sleep. Those challenges can be in the form of common pregnancy symptoms or a newborn who needs you at all hours of the night. These opposing forces are the great paradox of sleep in pregnancy. In an article on sleeping for two, the author writes, “Despite the seemingly imperative need for healthy sleep and our body’s attempt to promote it, many of the normal physiologic and psychological changes accompanying pregnancy make restful sleep all but impossible.”
A separate article with evidence-based tips to improve your sleep is a great place to start. This article continues the discussion on sleep by troubleshooting common pregnancy sleep issues and diving into evidence-based tips to overcome those challenges and sleep better.
Resources for Sleep
In addition to the studies and references linked in this article, I look to a couple of key resources for information on sleep.
Dr. Matt Walker is a professor of neuroscience and psychology at the University of California, Berkeley. He is also the founder and director of the Center for Human Sleep Science at Berkeley. Dr. Walker’s book, Why We Sleep, is a fantastic read. He also has a podcast with excellent information on sleep.
Dr. Andrew Huberman is a professor of neurobiology and ophthalmology at Stanford University School of Medicine. The Huberman Lab podcast is one of my favorite podcasts that explores science and science-based tools for everyday life. Dr. Huberman’s Toolkit for Sleep is an excellent recap of crucial things for sleep.
Fatigue During Pregnancy
Fatigue is very common during pregnancy, especially in the first and third trimesters. We like to blame hormones for pregnancy symptoms, and fatigue or being tired is no exception. This is primarily due to increased levels of progesterone. In addition, your body increases blood volume, and your blood pressure is lower. You increase metabolism and lower your blood sugar. Your body is going through many changes, and all of those changes take energy. If you are tired, the best thing you can do is rest. That could mean taking a nap (discussed later in this article). It could mean going to be much earlier than usual.
Sleep During Pregnancy
Surveys show sleep increases in the first trimester (on average 7.4 to 8.2 hours). In the third trimester, sleep decreases (on average 6.6 to 7.8 hours). Fatigue is most common in the first trimester. In the second trimester, you should feel like you have more energy. Then you may feel fatigued again in the third trimester.
There is a large body of research on the harmful effects of disrupted sleep during pregnancy. In a study of sleep quality and disturbances in pregnant mothers, all 2,427 participants reported waking up frequently. 38% had insufficient nighttime sleep, and 76% reported poor sleep quality.
Evidence shows disrupted sleep experienced during pregnancy is related to increases in inflammatory markers. Research links maternal sleep problems before and during pregnancy with preterm birth and child sleep problems and temperament. A study in China found poor sleep quality in the second trimester is associated with stress and depression symptoms. Research links poor sleep quality and short sleep duration with an increased risk of gestational diabetes. A study shows women in the ninth month of pregnancy who slept less than 6 hours at night had longer labors and were 4.5 times more likely to have cesarean deliveries.
There are also hypotheses that sleep impairment during pregnancy can impact the mother-infant relationship due to maternal fatigue, postpartum depression, or alteration of hormone secretions due to sleep issues.You can see there is a lot of evidence demonstrating the importance of sleep. Let’s examine some of the symptoms that can challenge your sleep.
Stress & Anxiety Keeping You Awake
Stress is a state of mental or emotional strain or tension resulting from adverse or very demanding circumstances. Stressors can be psychological or physical. Pregnancy is a unique phase of your life where you are likely to encounter additional stress. Your body may be under physical stress from common symptoms like morning sickness, heartburn, constipation, or aches and pains. You will go through many emotional changes due to increased levels of hormones. You are also embarking on a new journey where you are responsible for the health and well-being of a new human.
There is a complete episode on stress during pregnancy with tips to manage stress. Any method you can utilize to minimize stress can mitigate the adverse effects stress can have on your sleep. Remember, this phase of your life is temporary. If you are dealing with physical discomforts, those will eventually go away. If you have anxiety about your birth, you will ultimately be on the other side of that event. It can be helpful to realize that there will be a point in the future when this issue goes away or that you will not be bothered by it.
We think of REM (rapid eye movement) as the dream state of sleep. The majority of your dreams occur in REM, but you can have dreams at any stage of sleep. Advances in our understanding of REM sleep and dreaming are mainly due to technology in brain imaging. During REM sleep, there is increased activity in various regions of your brain. This includes the visual-spatial regions, motor cortex, hippocampus (learning and memory), and the emotional centers of your brain.
Dreaming has been proposed as overnight therapy. During REM sleep is the only time when our brain is entirely devoid of the anxiety-triggering molecule noradrenaline. Dr. Matt Walker argues this allows us to re-process upsetting memories in a safer, calmer environment. There is also evidence that dreaming improves creative problem-solving.
Vivid dreams are common during pregnancy. This could be due to increased stress and anxiety during pregnancy and the anticipation of being a parent. Many symptoms during pregnancy can disrupt your sleep throughout the night, and some of those disruptions will be during a REM cycle. You are more likely to recall a dream when you wake up in a REM cycle.
You can read about decoding your dreams online, but there isn’t any science behind this. It isn’t uncommon to have dreams that make no sense or nightmares relating to your baby. Your pregnancy and baby are likely dominating your life right now. It makes sense to think about these in your subconscious and your sleep. See this episode for more research on dreams during pregnancy. The research does show that nightmares are linked to daytime stress. Anything you can do to decrease your stress can help with nightmares and, of course, has positive impacts on other areas of your life and health as well.
Difficulty Getting Comfortable
79% of pregnant mothers report difficulty finding a comfortable position. As your body goes through changes during your pregnancy, the comfortable positions and how you support your body in those positions may need to evolve.
You most likely sleep in the position you do out of habit. If you are pregnant and typically sleep on your stomach, you will find it difficult to continue past the first trimester as your belly grows. There are also downsides to sleeping on your back. One is that it can make sleep-disordered breathing worse. Another is during pregnancy, as your uterus grows, it puts more pressure on your intestines and your vena cava. Additional pressure on your intestines means that you could make digestion less efficient. Your vena cava is the main artery that carries unoxygenated blood from the lower half of your body back to your heart. If there is a lot of pressure on this vein, it could decrease the flow of blood, which will ultimately reduce your oxygen and oxygen getting to your baby.
Sleeping on your side maximizes blood flow. Some downsides to side sleeping are pain in your shoulder, hips, or your back if your spine is not aligned when you sleep. If you have to pick a side, your left side is ideal because it promotes blood flow and digestion. Your vena cava is to the right of your spine. Sleeping on the left side puts less pressure on this vein. This means the deoxygenated blood from the lower half of your body can flow easier to your heart to be replenished with oxygen. When you are pregnant, this also means your baby has access to more oxygen.
There has been a lot of research on sleeping positions and the effects on outcomes like stillbirth. See this episode on sleeping positions for an examination of the evidence.
If you are having trouble getting comfortable, pillows can make a significant difference. Pillows designed for pregnancy give you support in key areas. Supporting your bump will take some pressure off from the weight of your belly. Supporting your back can make you more comfortable. Putting a pillow between your knees can take some pressure off your hips and help align your spine. The pregnancy pillows from Boppy give you a lot of options, from a small wedge to a total body pillow. Boppy even makes a side sleeper pillow with two pillows connected with a stretchy fabric panel to accommodate your growing bump. This way, you have support on both your back and your belly, without a bulky pillow under your body. (You can save 15% off Boppy.com with the promo code PREGPOD15). You may need to experiment with different positions and support to find the most comfortable position to sleep and stay asleep.
Going to the Bathroom
Another reason you may be waking up in the middle of the night is that you have to get up and go to the bathroom. In one study, 83% of pregnant mothers had a sleep disturbed by frequent urination. You have increased fluid requirements during pregnancy, and the hormonal and physical changes cause you to urinate more frequently. While you should not decrease your fluid intake, you can ensure you are staying hydrated throughout the day, and you can stack your water more heavily earlier in the day.
When you do have to get up and go to the bathroom in the middle of the night, you want to avoid viewing bright lights. Viewing bright lights in the evening signals to your brain that it is time to wake up. This can make it more difficult to fall back asleep and disrupt your circadian clock. Ideally, you can make it to the bathroom without turning on a light. You can also put a nightlight in your bathroom or a hallway so you can easily find your way without turning on bright lights. You may consider using a nightlight with a red bulb to minimize exposure to blue light.
Heartburn is pain or a burning sensation in the upper part of your digestive tract. Acid goes from your stomach into your esophagus and irritates the lining of your esophagus. This is also sometimes referred to as acid indigestion or acid reflux. There are a few mechanisms thought to contribute to heartburn during pregnancy. Progesterone relaxes the smooth muscles in your digestive tract, which includes your esophagus. The lower esophageal sphincter, the valve between your stomach and your esophagus, is displaced into your thoracic cavity, which is your chest, allowing more food and acid to pass into your esophagus from your stomach. Your growing uterus can also increase pressure on your stomach, making heartburn worse. Plus, to deliver more nutrients to your baby, your digestion is slowed.
The first line of defense for heartburn is to make diet or lifestyle modifications. You can eat smaller meals. Avoid fatty foods, spicy or greasy foods. The first step in digesting food is in your mouth. The more you chew your food and allow your saliva to help with the digestion process, the less work your stomach will have to do. Chewing gum can help you produce more saliva, which can help neutralize stomach acid. Drinking in between meals, rather than consuming a lot of fluids with a meal, may also be helpful. If you are having issues with heartburn at night, in addition to not eating right before bed, you can elevate your head, chest, or upper body when you sleep.
If these suggestions are not relieving your heartburn, the second line of defense is to talk to your doctor or midwife about taking medication. There are many over-the-counter or prescription medications for heartburn. There is a separate in-depth episode on heartburn that examines the research on the safety of medications like antacids, H2 blockers, and PPIs (proton pump inhibitors) during pregnancy. As with any medication, you always want to run it by your doctor or midwife first, even if it is available over-the-counter.
Sleep Disordered Breathing
Sleep-disordered breathing refers to breathing alterations during sleep, ranging from snoring to complete cessation of breathing and sleep apnea. There is evidence that symptoms of sleep-disordered breathing are associated with a higher likelihood of pregnancy-induced hypertension and preeclampsia, gestational diabetes, and unplanned cesareans. One study found 19% of pregnant mothers had sleep-disordered breathing.
The prevalence of snoring is higher in pregnant women, mainly due to the estrogenic effect on the nasal mucosa. Loud snoring in the third trimester has an estimated prevalence between 14-45%. Nasal congestion, sometimes classified as pregnancy rhinitis, is a common symptom in pregnancy and can lead to snoring.
While snoring may be more bothersome for your partner than for you, some research links snoring to adverse pregnancy outcomes. One study found maternal snoring during pregnancy is a risk factor for adverse effects, including cesarean delivery and small for gestational age babies. A study found that snoring in pregnancy was associated with increased daytime sleepiness, but only for women who did not snore before becoming pregnant.
Snoring is more common in people with a higher BMI. As a long-term strategy, losing weight may improve snoring in overweight individuals. For relief in the short term, you can avoid sleeping on your back. Nasal strips worn on the outside of your nose may help keep nasal passages open and reduce snoring.
Sleep apnea is snoring, followed by gasping or choking because your airway collapses. Sleep apnea raises the risk for cardiovascular issues, including high blood pressure, heart attack, heart disease, and stroke. In pregnancy, sleep apnea not only disrupts your sleep it can decrease the amount of oxygen going to your baby. Research shows pregnant women with sleep apnea are at increased risk for having low birth weight, preterm, and small for gestational age infants, cesarean section, and preeclampsia.
Like snoring, sleep apnea is more common in individuals who are overweight. If you are overweight or obese, decreasing your weight to a healthy level may improve sleep apnea in the long term. Elevating the head end of your bed or using pillows to prop up your head and upper body can help.
If you think you may have sleep apnea, please bring it up with your doctor or midwife to discuss your treatment options. The most effective treatment for sleep apnea is a CPAP (continuous positive airway pressure) machine. This is a mask that covers your nose or your nose and mouth. A CPAP mask increases air pressure in your throat so that your airway does not collapse when you breathe in. There are some downsides to this apparatus, primarily that it can be uncomfortable. Instead of a CPAP, you may also be able to utilize a mouthpiece that holds your jaw and tongue in a position to minimize sleep apnea. See this study for more in-depth information on sleep-disordered breathing during pregnancy.
Restless Leg Syndrome
Restless leg syndrome is a neurological disorder that presents as bothersome sensations in your legs that are relieved when you move them. Restless leg syndrome is twice as common in women than men and 2-3 times more common among pregnant women than in the non-pregnant population. About 24% of expecting mothers experience restless leg syndrome. These sensations tend to be more common at night and are most common in the third trimester of pregnancy.
There are four major hormones, estrogens, progesterone, prolactin, and thyroid hormone, that may play a role in restless leg syndrome during pregnancy, but this is not fully understood. Restless leg syndrome increases with low folate and iron levels, so make sure you are taking your prenatal vitamin that contains these nutrients. Restless leg syndrome will improve and even disappear after you have your baby. If you have difficulty with restless leg syndrome, please bring it up with your doctor or midwife. There are medications used to treat this condition if other non-invasive methods are ineffective. You can read more in-depth information about restless legs syndrome and pregnancy in this review.
Leg cramps are when the muscles in your foot or calf contract involuntarily. This sensation is often painful and almost always seems to happen in the middle of the night. Leg cramps are most common in the third trimester.
A Cochrane Review examined research on supplements to improve leg cramps during pregnancy. The researchers found magnesium supplements may reduce how often women experienced leg cramps compared with placebo or no treatment. A small trial showed vitamin B may be helpful. Unfortunately, no trials considered muscle stretching, massage, relaxation, or heat therapy.
There is no downside to stretching your calves before bed. Downward dog is an excellent stretch for your legs and calves. You may consider the Sleepy Lotion from 8 Sheep, formulated to help pregnant moms sleep better. The lotion has six organic ingredients, including magnesium. (Save 10% with the promo code PREGNANCYPODCAST.) You can try a bath with Epsom salt, which naturally contains magnesium. If you are getting woken up by leg cramps, stretching can help. You will find out very quickly which way to stretch your leg to give yourself some relief.
Your Baby is Moving
Some expecting mothers may have difficulty sleeping because their baby is moving. All the moving you do during the day rocks your baby to sleep. When you are ready to go to bed, they may be moving around like crazy. Typically, if your baby is active in your belly, it doesn’t last very long. While it can be annoying to have your sleep disrupted, do your best to enjoy the movements. If you are far enough along in your pregnancy to feel movement from the outside of your belly, let your partner know so they can experience it too.
Insomnia is a vague term that describes a lot of sleep challenges. Insomnia occurs when you have frequent disturbances to your sleep, resulting in decreased quantity and often the quality of your sleep. This can include trouble falling asleep, waking up in the middle of the night, and trouble going back to sleep. A lot of the specific issues discussed in this article contribute to insomnia. For a general overview of the research on this topic, see this review.
One study found 57% of pregnant women had symptoms of insomnia. A meta-analysis found the overall prevalence of insomnia in the third trimester of pregnancy was 42.4%. A doctor diagnoses insomnia using questionnaires, like the Pittsburgh Sleep Quality Index or self-reported sleep history. We have examined the impact of poor or insufficient sleep in pregnancy and insomnia can contribute to the risks.
As with any sleep issues, the first line of defense is to make changes to diet, lifestyle, and environment. Behavioral therapy and cognitive behavioral therapy can treat insomnia. If you are still struggling with insomnia, your doctor may discuss taking a medication.
Music or guided meditations can be powerful tools to help you relax and improve your sleep. There is research demonstrating that background music can help children sleep. There is evidence showing soothing music can improve sleep in adults. There is also a study showing music can decrease the time it takes to fall asleep. Listening to music reduces stress, triggers dopamine release, and induces relaxation.
Dr. Andrew Huberman recommends the research-supported protocols on the Reveri app for sleep disturbances, insomnia, or sleep anxiety. Reveri is currently available on iPhones and will be rolling out on Android in the future. Dr. Huberman suggests doing the Reveri sleep self-hypnosis three times a week at any time of day. It’s only 10-15 min long and will help you rewire your nervous system to be able to relax faster.
Dr. Huberman also recommends if you wake up in the middle of the night and you can’t fall back asleep, consider doing an NSDR (non-sleep deep rest) protocol when you wake up. Enter “NSDR” into YouTube, and the top 3-4 options have different voices and durations. Or simply do a “Yoga Nidra” protocol (enter “yoga Nidra” to YouTube).
I am a big fan of the Endel app. This app has personalized soundscapes to help you focus, relax, and sleep, backed by neuroscience. This is an app I have been using for over a year. I use the sleep sounds for myself often and the sleep soundscape for my children. Usually, when I am working at my computer, you will find me listening to one of the focus soundscapes. You can try Endel free for 30 days.
4.5% of pregnant women admit to the use of sleep medication. Many drugs can treat sleep disorders and insomnia, including benzodiazepines and hypnotics. There are known risks or limited evidence associated with some of these medications. Please discuss all of the risks and benefits of taking any sleep medication with your doctor. If you think about taking an over-the-counter sleep aid, you should always run it by your doctor or midwife first. This intervention is the last line of defense after attempting other methods to improve your sleep.
A decision to take any medication involves weighing the discomfort the medication aims to treat with the potential risks of the medication. This may be a difficult choice and one that your care provider can help you navigate.
Supplementing with Melatonin
Melatonin is a hormone that plays a critical role in your circadian clock and is a driver of sleep. The increasing over-the-counter availability and marketing of exogenous melatonin as a safe sleep aid has increased its popularity in recent years. There are several important cautions Dr. Matt Walker raises about using melatonin.
You need to know that melatonin will help you fall asleep, but it does not help you stay asleep. There may be more of an application for using melatonin in acute situations. It may have more application when traveling to other time zones to combat jet lag rather than using it as a nightly sleep aid. The American Academy of Sleep Medicine does not recommend using melatonin to treat sleep onset or sleep maintenance insomnia.
Secondly, there are concerns about the label accuracy of melatonin supplements. A study that examined melatonin content found 29% of the supplements tested had melatonin content within 10% of the labeled amount. The other 71% of tested melatonin supplements contained 83% less than stated on the label, up to 478% more than the label. This study highlights the importance of making sure you are getting supplements from a high-quality, trusted source. If you are considering melatonin, Thorne is my go-to source. (You can use this link from Dr. Andrew Huberman to get 20% off your Thorne purchase.)
Melatonin and Breastfeeding
Melatonin is naturally present in breastmilk and is higher in milk at night than during the day. If you are pumping breastmilk, you may consider labeling your milk with the time of day you pumped. Ideally, you can give your baby milk in the morning that you pumped in the morning and milk at night that you pumped at night. Fluctuating melatonin levels in your breastmilk may help your baby develop more regular sleeping patterns.
LactMed is a fantastic resource for evidence on medications and breastfeeding. According to LactMed, “no data exist on the safety of maternal use of melatonin during breastfeeding. However, doses higher than those expected in breastmilk after maternal supplementation has been used safely in infants. It is unlikely that short-term use of usual doses of melatonin in the evening by a nursing mother would adversely affect her breastfed infant, although some authors recommend against its use in breastfeeding because of the lack of data and a relatively long half-life in preterm neonates”.
If you consider using melatonin in your children, keep in mind that melatonin suppresses other hormones involved in the onset of puberty. I know it would be easier to take a supplement than to modify other habits. You can make so many small changes to improve your sleep without risks or downsides.
Sleep as a New Parent
The time from getting pregnant through the first few years of your baby’s life is a huge adjustment. You will need to be flexible for these short phases you will be going through. You can expect to get less sleep and to have your sleep disrupted by your baby. You can make many evidence-based changes to improve your sleep, even if you are not getting a full eight hours.
Infants do not sleep in one long stretch overnight. Instead, they sleep in a polyphasic pattern, meaning on and off throughout the day and night. Babies are hard-wired not to sleep for long periods. Breastfed babies will sleep for shorter stretches than babies on formula because breastmilk is easily digested, and your baby needs to be fed more often. Even when examining studies on sleep for babies, researchers define sleeping through the night as 5-6 hours. They should start to fall into more of a day and night rhythm around three or four months. By one year of age, they should be sleeping for a relatively long stretch at night with two naps during the day. By age four, they should be sleeping longer at night with one daytime nap.
All you can do is prioritize sleep as much as possible within the constraints of your parenting responsibilities. This starts in pregnancy, and one study found 78% of pregnant mothers took daytime naps. Once you have your baby, the cliché “sleep when the baby sleeps” is good advice. If your baby is taking a nap, try to close your eyes, even if it is just for a short time. It can be challenging to do this in the real world because your baby’s nap times are a convenient opportunity to get other things done. Anything on your to-do list can wait.
Naps can help make up for some lost sleep during the night. In a TED talk from Dr. Matt Walker, he discusses that humans are hardwired to have a drop in alertness in the afternoon, somewhere between 1:00-4:00 pm. Naps can have benefits, but they can also disrupt sleep. Dr. Walker’s advice is to avoid naps if you struggle to sleep at night. If you are not struggling with sleep and you can regularly nap during the day, a short 20-minute nap earlier in the day is fine. A nap too late in the afternoon can make it hard to fall asleep that night. Andrew Huberman recommends limiting daytime naps to less than 90 minutes, the length of a sleep cycle, or don’t nap at all.
Neither of these recommendations considers the value of naps specific to pregnancy or being a new parent. Your body is working harder during pregnancy than during any other phase of your life. As a new parent, your sleep is constantly interrupted by your baby’s needs. If you are tired and have the opportunity to take a nap, please do.
A study of pregnant women found that the number of daytime naps has minimal impact on nocturnal sleep parameters; however, long nappers (more than 90 minutes) did exhibit modestly impaired sleep continuity and quality. While naps can be a lifesaver in pregnancy, you may consider limiting them to less than 90 minutes.
There are many devices available that can track your sleep. While these can give valuable data, some are more accurate than others. I have worn an Oura ring since 2018, and it is an invaluable tool. Like any sleep tracker, it is only valuable if you utilize the data. Seeing metrics from your sleep can be great if they confirm that you are sleeping well. If the metrics show that you are not getting quality sleep, it can be frustrating. Tracking metrics allows you to make changes and see how those changes impact your sleep.
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