WOMEN & SLEEP: Adventures in Sleep for the Pregnant Woman, Postpartum Edition

See Also:
Adventures in Sleep
for the Pregnant Woman, Part One:
The First Trimester
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Adventures in Sleep
for the Pregnant Woman, Part Two:
The Second Trimester
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Adventures in Sleep
for the Pregnant Woman, Part Three:
The Third Trimester

So you think you can sleep now that junior is born?

Not likely. Three things can prevent a new mama from enjoying sound sleep for quite a few more months:

1. Nighttime Awakenings
2. Postpartum Discomfort
3. Postpartum Insomnia

Let's take a closer look.

Baby needs nursing at 2 am. Most new parents "get" that, on an intellectual level. However, on a deeper level, they may grossly underestimate just how much these nighttime feedings and snuggles will cut into their sleep time and how long this period of sleeplessness can last.

Newborn babies may take anywhere from three to nine months to settle into their sleep architecture. Most people aren't prepared to endure yet enough nine months of poor sleep after having just gone through nine months previously dealing with sleep problems.

Getting insufficient sleep does take its toll on new parents, both physically and emotionally. It's important to take this sleep deprivation seriously; while making lighthearted jokes about not getting enough sleep is common in our culture, the fact is that anyone with ongoing sleep deprivation is setting themselves up for all kinds of health and safety issues.

The National Sleep Foundation points to the following as the risks one assumes by not getting enough sleep:

1. Increased risk of car accidents caused by impaired judgment or drowsy driving
2. Increase in body mass index — after the baby, an increased appetite can be due to the needs of nursing, which uses calories, but if you are continuing to eat more calories than you burn and feel hungry all the time despite adequate calories, this can be caused by hormonal imbalances due to sleep deprivation
3. Increased risk for cardiovascular problems and for developing diabetes
4. Increased risk for long-term depression, substance abuse and mood disorders
5. Cognitive declines and reduced ability to manage executive functions like decision-making
6. Higher risk for illness

Solutions? Obviously the answer is to get your sleep, but how to achieve this may be tricky, especially for single, working mother households. But napping whenever possible is always a good option (especially while baby is sleeping). Hiring someone like a doula to help with nighttime awakenings or to be there for you and baby in the afternoon while you nap can make all the difference. Your spouse, best friend, or relative can also be good for handling feedings and simple babysitting so you can get the rest you need.

If you are at work, ask for napping opportunities during the day while you get through this stage of your new family life.

Finally, while the baby monitor has become the ubiquitous tool for 21st century parents who wish to check in on their babies, it can also be a trouble-some sleep thief. A mother can hear a crying baby from far, far away; it's hard-wired in her brain to do so, and some recent scientific studies back this up. If you are nearing the stage when junior may be just crying for comfort but not for hunger, it may be time to turn off the monitor video and sound and just get some sleep, perhaps moving toward the "crying it out" stage that many pediatricians advocate for teaching infants self-soothing. 

Postpartum discomfort mirrors many of the same prenatal problems a mother encountered prior to labor and delivery. There's the insistence on continued reflux, nighttime leg cramps, hormone changes that sweep over you and leave you feeling nauseated, tenderness in the breasts or the pelvic region due to surgical procedures or natural tearing from delivery. You may be weaning yourself off painkillers after a major abdominal surgery, or you may be passing large blood clots because you are trying to do too much in the early weeks after childbirth.

Solutions? In a nutshell, take care of your aches and pains with the help of your physician, and practice good sleep hygiene. Treat yourself to warm baths, even warm milk at bedtime. Eat healthy foods, try to exercise at a level that is appropriate to your postnatal condition (mothers experiencing Cesarean births will have different requirements from those who delivered vaginally), practice relaxation techniques such as yogic breathing or listening to soft music. All efforts to achieve relaxation also tend to assuage aches and pains and give you a better sense of overall well-being. Keep in mind that the more sleep you get, the less you will be bothered by transitory or residual pain in the postnatal term. Pain perception increases when sleep is insufficient.

Postpartum Insomnia may occur along the spectrum of Postpartum Depression (PPD) or the so-called "baby blues." It's quite common to experience emotional shifts following childbirth. Hormone changes lead to mood swings, fatigue and problems sleeping at night. Insufficient sleep then leads to memory problems, brain "fog," emotional sensitivity, even the desire to stop being a new mother. Whether the insomnia following childbirth is caused by PPD, or whether the PPD is caused by insufficient sleep is less important: what's critical here is that it can be serious and needs treatment.

Solutions? Get support at home for tasks that can be handed off to others (like spouses, relatives, neighbors, friends, or for-hire doula services). Use that time to sleep and recharge yourself. Take a morning off; even a couple of hours to yourself can be immensely rejuvenating. If depressive symptoms continue, don't hesitate to seek help from your doctor. PPD is not a sign of weakness or something to be ashamed of; much of it is caused by unstable hormone peaks and valleys and can be addressed with therapy, medication, or a combination of both. Your baby needs you to be a whole mother, and that includes emotional stability in the definition of "whole."

Final thought:
Getting good sleep isn't a luxury for the few. It shouldn't be a checkmark on one's bucket list of things you'd like to encounter some day, but as an all-out priority in your life. Not sleeping compromises both the health of you and your child. It is worth doing everything in your power to ensure you relieve yourself of the problems that sleep deprivation can bring.

Introducing May's theme at SHC: Women & Sleep

Women have specific sleep issues which are related to their physiology. While any woman may experience (just like any man) any of the typical disorders of sleep as outlined by the International Classification of Sleep Disorders reference, they can also have sleep problems that are directly related to menstrual cycles, pregnancy, postpartum motherhood, menopause and those disorders related specifically to female reproduction.

For May, SHC focuses on sleep problems specific to women throughout the lifespan, as well as common sleep disorders that women may be surprised to learn are not limited to their male counterparts. SHC will also discuss how lifestyle choices and demands may impact sleep quality and quantity and why this reality for women may be different than for men.

To get a jump on the topic, you can visit SHC's comprehensive page on Women's Health here.

Expert Testimony || Sleep Deprivation

Mark Rosekind,
National Traffic Safety Board,
 under President Obama

"Not getting enough sleep impairs our work performance, increases the risk for injuries and makes it more difficult to get along with others. Without sufficient sleep it is more difficult to concentrate, make careful decisions and follow instructions, we are more likely to make mistakes or errors, and are more prone to being impatient and lethargic. Our attention, memory and reaction time are all affected. But while we may recognize these symptoms, we do not always associate them as being symptoms of sleep loss."--Mark Rosekind, National Traffic Safety Board

SLEEP Rx || Mother's Little Helper: Things you should know

Worry and stress are as ubiquitous to the parenting landscape as stepping on Legos, cleaning out Cheerios from the backseat of the car, and dealing with seemingly endless bouts of insomnia and sleep deprivation.

Some parents find they are overwhelmed with the burdens of managing family life, especially if they are working part- or full-time, volunteering in the community, or caring for elderly parents as well. Exhausted is perhaps too lightweight a term to describe what it can feel like trying to stay on top of all the tasks that today's parenting lifestyles demand.

Getting enough sleep is perhaps the best way to manage these kinds of day-to-day stresses. But sleep takes time, and in today's time-pressed society, it's the first thing sacrificed to keep up with the demands of raising kids. Perhaps cutting back on commitments or getting more outside help is one solution? This probably won't happen until the opportunity to "enhance" our performance with drugs becomes less socially acceptable.

This is not a new problem. Back in the old days, overwhelmed parents might have taken a nip at the cooking sherry to get through the nerves of the day. Even a cigarette or a pot of coffee could help with exhaustion.

But we've moved on from there in the 21st century. Valium ("Mother's Little Helper") became the housewife's drug of choice in the 1960s as more women entered the workforce or became single parents. Since then, other prescription medicines have become a socially normalized way for parents to find the energy or decompression they need to get through the day.

Opiates like OxyContin or Vicodin, sedatives (think Xanax), even stimulates like Adderall or Ritalin are Mother's latest Little Helpers. Even energy drinks, used purposefully in excess, have become the new amped up alternative to old-fashioned coffee drinking.

How does this kind of "behavior modification" during the day influence sleep?

Too many anti-anxiety or pain-relieving prescription medications (sedatives and opiates) during the day can seriously throw the body's sleep drive off kilter at night, leading to insomnia, which leads to excessive daytime sleepiness. You can see what a terribly endless loop of poor sleep habits might emerge.

Whether used to depress the central nervous system or to manage pain, sedatives and opiates also disrupt sleep architecture, interfere with critical REM sleep and the deeper non-REM stages where all healing and release of human growth hormone occur (read more).

These drugs are not meant to be used on a daily basis, but that doesn't stop a lot of people form using them regularly. And that means the chance of becoming dependent on them is high. If parents opt to stop using these drugs, they can throw their bodies into a terrible state of withdrawal that will further mess with their sleep staging. Also, risky drug interactions (including with alcohol or marijuana) are further reason to avoid using these anti-anxiety or pain management meds off label.

In addition, consider this: many people have sleep breathing issues they are not aware of; taking these meds can be extremely dangerous for them because, while they sleep, the upper airway may become so relaxed that severe sleep apnea and respiratory distress can be a direct result.

Too many stimulants, by the very nature of what they do, will lead to wakefulness at night as well. If one is advised to not have caffeine products after 5pm, just imagine how hard it will be for users of stimulants taken in the late afternoon to fall asleep at a decent hour? Suddenly the kids are in bed, the house is clean, the bills are paid, and it's now 3am and Mom still can't sleep.

Ongoing sleep deprivation from regular stimulant use is guaranteed to show up later in countless dangerous ways: motor vehicle accidents, major errors in judgment during times of stress, the exacerbation of other underlying health conditions and other problems which can only serve to make family life even harder--for everyone.

Parents in 2014 need to rethink sleep as a critical best practice for relieving anxiety and stress. Sleep, exercise and meditation together can work to give the body ample opportunities to detox, heal and manage the daily stresses of parenthood. A strong, well-rested mind and body are always going to manage the challenges of life better than a mind and body which relies on enhancing drugs to achieve artificial energy or relaxation.

Sleep Hygiene Tip of the Week || Capture your worries first

"Girl suffering from anxiety" by MikaelF.
CC BY-SA 3.0 

Who hasn't had racing thoughts at one time or another? It's a perfectly human experience to go to bed with a lot weighing on your mind. Life can be very challenging, and stress from change, from fear and from events beyond our control can leave us sorting out what we can or should do next, often without arriving at any obvious answers. Ideally, we learn to cope with our dilemmas and return to better nights of sleep as solutions are applied and problems are ameliorated.

However, if you have racing thoughts every single night when you go to bed, and they aren't spawned by singular events of change or stress, but belong to a category of more generalized worry, then you might actually need to figure out why you are experiencing this. Racing thoughts at bedtime can cut into the very important physiological process of sleep, leading to serious consequences down the line.

What are racing thoughts, exactly?

Racing thoughts are one way our body and brain present anxiety, which we all understand variously as worrying, nerves or unease about things in life that are uncertain.

Anxiety has an influence not only on how much we think about recurring concerns--"How will my daughter do on the flight by herself?" or "When will I get that raise?", in example--but how we frame our concerns. Anxiety doesn't typically pose thoughts positively; therefore, racing thoughts often acquire a negative tone which increases with obsessive returns to the thoughts themselves. Anxiety can lead our minds to repeat these negative thoughts with such negativity that they often become magnified. What might be smaller problems in the beginning can become psychologically insurmountable if racing thoughts aren't held in check. These thoughts can be extremely distracting or seemingly benign (like the same musical phrase repeating itself over and over in your head), but if you can't control them, you will find yourself growing even more anxious! It can become a vicious circle.

Daytime presentation of anxiety through the presence of racing thoughts can be troublesome enough and worth looking into if you just can't seem to ditch this kind of behavior and it distracts you from activities of daily life. However, when racing thoughts have a negative impact on your nighttime sleep over an extended period of time, it's imperative that you figure out why and try to correct the problem. If your thoughts prevent you from sleeping, make it hard to focus, bring up subjects that you find shameful, or otherwise cause you ongoing distress, you need to be concerned.

A disastrous side effect of untreated nighttime anxiety is sleep deprivation, otherwise known as insufficient sleep. Insufficient sleep, over time, will lead to many dangerous consequences, including the likelihood of being in a fatal car accident, chronic damage to the cardiovascular system, the development of type II diabetes and increased risks for stroke and the development of obesity.

Racing thoughts may also be symptomatic of an anxiety disorder, such as bipolar disorder, ADHD, panic attacks, generalized anxiety disorder, obsessive compulsive disorder and, yes, sleep insufficiency caused by other means. It's definitely worthwhile to check with your doctor if you have repeated nights of racing thoughts for more than a few days here or there, as well as for other symptoms that point to any of these potentially underlying conditions.

If you have racing thoughts from time to time, but do not think they are connected to any hidden emotional health concerns, you may wish to consider various relaxation techniques at bedtime.

One of the most empowering ways to conquer racing thoughts at bedtime is to write down your worries at night before going to bed. This nonpharmaceutical treatment for anxiety can be your first line of defense against chronic anxiety, in fact.

It's simple. Keep a pen and notebook at your bedside. When you climb into bed at the end of the day, write down your worrisome thoughts in this notebook. It's so simple it seems like it could be a useless task, but the fact is, your brain "frets" because it wants to avoid forgetting important things. Sometimes "important things" are a grocery list or the names of the people you work with at your new job. Then again, "important things" might also be tasks you need to complete on a deadline or a series of emotionally intense encounters you have recently experienced with a loved one. Whatever your "important things" are, it's up to you to define them as the sources of your racing thoughts.

By writing them down, you are literally capturing your anxiety on the page. (Think of the page as their cage.) In doing so, you also then more clearly identify the sources of your stress. If all your thoughts point to one source, or to multiple sources, their presence in this "cage" gives you something concrete to work with later. Now your brain can relax and let these thoughts go, at least temporarily, while you sleep  because it knows your concerns are now safely captured elsewhere. And then you can then feel better knowing your thoughts will be there to address the next day after you've had some quality time to sleep on your problems. You might even have a dream or two which offers a solution!

Not only that, but your "cage" of "important things" can be an excellent basis for forming an action plan during your waking hours, which can be very positive and empowering.

You can even write your worries down, then turn to a back page in your notebook, where you have written the following: "I don't need to think about this right now. I can look for solutions when I wake up tomorrow," and repeat that as a kind of mantra until you can relax and fall asleep. Often, this positive affirmation is all you need to let your racing thoughts go.

Ultimately, by practicing this nightly, you should find satisfaction in having created an avenue for solving your problems, enough so that you can find calm at bedtime and re-train your thoughts on the more pleasant subjects that you turn to in order to encourage peace and sleep.

Sleep Hygiene Tip of the Week || Just say No to phones and beds

It's a common habit (we see it in the sleep lab all the time): people take their phones to bed with them, often tucking them under their pillows or next to them on the bedding.

People, don't do this. Four good reasons:

1. You could catch your linens on fire. Cell phones have been known to melt or otherwise catch on fire because of a faulty battery. They can also overheat if left in a functional mode. This is advice from the category of Good Common Sense: if you need to have your cell phone nearby, then at least put it on a firm surface. Read more: "What's causing your cellphone to get so hot?"

2. It might be even Better Common Sense to not have your phone in the same room with you at all while you sleep. Why? Every time you get a text or a call, even if the sound is turned off, the screen flashes on, and in doing so, it emits blue spectrum light. Your body can still perceive blue spectrum light even if your eyes are shut, due to photoreceptor cells that are contained in your skin. Blue spectrum light has been shown to delay or block the production of the sleep-promoting hormone, melatonin, in the pineal gland. If your body is not getting adequate melatonin, it cannot effectively achieve sleep onset. So... perhaps turning the phone off entirely would make more sense, or at least turning it face down with the sound off would be the alternative if you just couldn't stand to not have your phone with you. Learn more: The melanocyte photosensory system in the human skin.

3. Though the jury is still out on this point, you might consider the fact that cellphones to emit a small amount of electromagnetic radiation (EMR). Sleeping with a constant stream of EMR emissions next to your head or even next to your bed may be yet one more reason to not have your phone in the same room with you at all while you sleep. Check out this detailed discussion at the David Suzuki Foundation, which does not take a position on the debate surrounding EMR and cell phone use.

4. Finally, having a cell phone in bed with your, or even next to you, means you are more likely to answer it, no? You are woken up by a text or a call... how much self control do you have? If you receive important calls at night because you are on call or in management or for some other legitimate reason, that's one thing. Using your cell phone as an alarm is common and, probably, harmless if you keep your phone plugged in away from your head. But we have seen patients in the sleep lab who are just having conversations with people in different time zones at that time. Patients who are taking calls from people who have no business calling at that time of night (meaning: people who are practicing very poor sleep hygiene and have no respect for other people's lifestyles). Patients who reach for their phones to check the time in the middle of the night, though there is no healthy reason to check the time in the middle of the night (it will not make you go back to sleep more easily, that's a guarantee!) Or patients who, because they can't sleep (see number 2), turn on their phones to find something to pass the time, which further interrupts melatonin production and more grossly enhances their sleeplessness. Are you worried you might have a cell phone addiction? Check out these various entries on cell phone overuse at Huffington Post.

Bedtime is supposed to be about sleep. If you are struggling to get sufficient sleep and keep your phone at your bed because you can't resist checking out the latest Pinterest link your friend has just texted you or playing your round of a smartphone game app as soon as your opponent's notification arrives--even if it's at 2am--then you need to be thinking about what your priorities are. You cannot live well with insufficient sleep. Insufficient sleep causes car accidents, loss of sex drive, impaired judgment, reduced performance on the job, increased risk for disease (especially cardiovascular, but stroke and diabetes, as well), accelerated aging of the skin, weight gain, memory loss, cognitive deficits, and depression. It's up to you to decide if that Pinterest link arriving at 2am is worth breaking a healthy cycle of sleep for, but we suspect that you will ultimately decide it's not.

Sleep Hygiene Tip of the Week || Give Fido his own bed

Do you take a menagerie to bed with you every night?

Just how still and quiet are they? Hmmmmm?

You might laugh about the fact that pets are a major contributor to poor sleep for their human caretakers, but the truth is that people who take a lot of pets to bed with them may be making their sleeping life much more difficult than it needs to be.

Pets get up and moved around. They make sounds in their sleep. They act out their dreams sometimes. Is it any wonder that sleeping with pets might be one reason why you aren't getting a full night's sleep?

SLEEP HYGIENE TIP OF THE WEEK: It may be difficult to retrain pets to NOT sleep with you, and it may be difficult for you to fall asleep without your beloved pets at your side. However, I see patients all the time who normally sleep with pets; in the lab during a sleep study, they have to sleep without their pets. Guess what? At least half of them sleep better WITHOUT their pets. It can be done if you are resolved to make the change.

If you are introducing a new pet to your household, make it a priority to train them to sleep in their own bed, even in a separate room. And don't forget, not only might you be suffering from poor sleep due to your pets' sleeping behaviors, but you may also be very active or noisy in sleep, keeping them awake as well!

Insomnia Central || Is there a connnection between insomnia and suicide?

"Alarm Clock - Photo Sketch" by Jeff Turner, 2009

The Behavioral Sleep Medicine Program at Penn State released new findings at a recent SLEEP 2014 meeting of Associated Professional Sleep Societies which suggested that most suicides take place between the hours of midnight and 6 a.m. 

The findings, following two student suicides in the university's 2014 Spring semester and three others within the previous year, confirms that those who cannot sleep at this time of night are often putting themselves at greater risk for suicidal thought patterns and behaviors. 

Psychiatry professor and program director Michael Perlis explains: “[J]ust being awake at night may in and of itself be a risk factor for suicide.”

According to the study's findings, suicide rates increase at a rate of over 16 percent after midnight, peaking between 2 and 3 a.m.. Suicide rates decrease to just over 2 percent after 6 a.m. These findings contradict earlier studies that have concluded that suicides primarily occur during the daylight hours. Perlis and his team explained that the higher percentage of late night suicides happens while fewer people are awake, showing a more concentrated probability for those who are awake to participate in suicidal activity.

Source: "Penn research team finds that suicides most commonly occur at night." Husain, Z. The Daily Pennsylvanian, June 11, 2014.

Sleep Hygiene Tip of the Week || Keep a sleep diary and track your ZZZs

Comedian Tracy Morgan in 2009,
photo by David Shankbone.

You have probably heard about the recent vehicular crash along the Jersey Turnpike which critically injured comedian Tracy Morgan, put two of his friends in the hospital, and took the life of his fellow comedian, James "Uncle Jimmy Mack" McNair. What you might not know is that the accident may have been caused by a drowsy driver. 

Morgan's limousine bus was struck from behind by a truck whose driver allegedly failed to notice the slowed traffic in front of him. Investigations into the accident suggest he may not having slept at all for more than 24 hours prior to the time of the accident. The truck driver has been charged with death by auto and four counts of assault by auto and his bail was set at $50,000.

How does drowsy driving happen? It's simple. If you don't get enough sleep every night, you generate a "debt of lost sleep" over time which can lead to cumulative cognitive problems that can be compared to the same kinds of impairments affecting people who are legally drunk. Ironically, driving drowsy, in New Jersey, is considered a crime comparable to drunk driving.

Drowsy driving can happen to anybody... including you. People who are at higher risk for drowsy driving include teenagers, new parents, the elderly... anybody who doesn't get their full night's rest, night after night.

If you have a relatively normal sleep schedule, you can suffer from sleep deprivation (aka insufficient sleep) by simply not getting solid sleep at night. This can increase the likelihood that you will drive drowsy.

However, if you have an unusual work or life schedule, in which you find it difficult to find and stay in a reliable sleep pattern, such as what can happen with 9-1-1 dispatchers, long-haul truck drivers and nurses on rotation, your risks for sleep deprivation increase dramatically.

SLEEP HYGIENE TIP OF THE WEEK: If you find you are sleepy during the day, while at work or in your car, it could be useful and illuminating to keep a sleep diary, noting bed and rise times each day and any naps, periods of insomnia or other pertinent information to help you better understand your sleep habits. Generally speaking, most human beings need slightly longer than 8 hours of sleep per night, every night of the week. If, after keeping your sleep diary for a full two weeks, you find your amounts of sleep don't add up to 50-60 hours per week, this should give you pause to consider how you might be accumulating an undesirable amount of sleep debt.

You might then be able to sneak in added sleep via naps or earlier bed times or later rise times in order to recuperate your lost sleep. By doing so, you can avoid the very serious consequence of drowsy driving as described here, as well as other long-term cognitive problems that can arise from chronic sleep deprivation.