Adapted from “Hello Sleep: The Science and Art of Overcoming Insomnia Without Medications” by Jade Wu, PhD. © 2023 by Jade Wu and reprinted with permission of St. Martin’s Publishing Group.
How Does Sleep Change During Pregnancy?
Three-quarters of pregnant people report having poor quality sleep, and about half have significant sleep problems. About 38% have clinically significant insomnia (almost four times the rate for the general adult population), and it may be even higher for some in their third trimester.‡ Some common sleep-related disturbances by trimester include:§
First Trimester
- Increased daytime sleepiness
- Increased total sleep duration
- Increased number of nighttime awakenings
- Decreased deep sleep
- Nighttime discomfort (e.g., breast pain, frequent urination)
Second Trimester
- Improved nighttime sleep compared to first trimester
- Less fatigue and daytime sleepiness compared to first trimester
- Onset or worsening of snoring, nasal congestion
- Vivid dreams
- Possible onset of restless legs syndrome
- Back and joint pain
Third Trimester
- Return of fatigue and daytime sleepiness
- Return of fragmented nighttime sleep (i.e., many awakenings)
- Decrease in deep sleep and REM sleep
- Worsening positional discomfort in bed
- Worsening back, joint, and pelvic pain
- Vivid dreams and nightmares
- Increasing risk of obstructive sleep apnea
- Increasing risk of restless legs syndrome
We may not have control over all these sleep changes, but I find that it’s helpful to understand why they happen. These clues can help us learn how to cope in the moment and how to return to good sleep after pregnancy.
Hormonal Changes
During the first trimester of pregnancy, human chorionic gonadotropin (HCG) levels approximately double every two days. Progesterone and estrogen also rise dramatically over the course of pregnancy. This mind-boggling amount of hormonal change has direct effects on sleep:
- HCG and progesterone have soporific effects, which is why pregnant people tend to experience a lot more sleepiness during the day and may need to sleep longer at night.
- Progesterone, in a cruel twist, also causes nighttime sleep fragmentation (i.e., more awakenings). This is part of the reason why pregnant people wake up more often during the night and don’t feel as rested even after long nights of sleep.
- Estrogen decreases REM sleep. It can also cause upper airway congestion that induces or worsens snoring and obstructive sleep apnea.
- Hormonal changes also cause other physical symptoms that make sleep more difficult, such as nausea, heartburn, joint discomfort, breast pain, and frequent urination.
Anatomical and Physical Changes Pregnancy can feel like an alien has taken over your body. Sometimes, it is not very kind to your sleep. You may experience:
- rapid pregnancy-related weight gain that can induce or exacerbate snoring and obstructive sleep apnea;
- abdominal and pelvic pressure that causes discomfort and pain, making it increasingly difficult to find a comfortable position at night;
- nasal congestion, which causes dry mouth, leading to drinking more water at night, and needing to urinate even more often;
- intense fetal movement at night, the baby’s favorite time to practice karate in the uterus; and
- for many, worsening iron deficiency that dramatically increases risk for restless legs syndrome, which occurs primarily in the evenings.
Psychological and Emotional Changes It isn’t just the body that undergoes a transformation. During pregnancy, you may experience emotional upheavals and psychological changes that include:
- anxiety and depressive symptoms, which are common during pregnancy and can certainly disrupt sleep; and
- “nesting” symptoms, which involves an intense drive to get ready for the baby, which can keep your mind spinning even late into the night.
How to Cope with Sleep Changes During Pregnancy
Sadly, there’s not much we can do to prevent most of these pregnancy factors that affect sleep, especially hormonal shifts and physical changes. But it’s reassuring to keep in mind that most will not last forever, and that for most people, sleep goes back to normal after pregnancy and the postpartum months. While you’re in the midst of it, here are some things you can do to cope:
- During the peaks of excessive sleepiness (first and third trimesters), plan to nap. If you’re at work and can’t nap properly, still try your best to rest during your lunch break instead of eating while working or socializing with coworkers.
- Keep your wake-up time consistent from day to day, but listen to your body’s changing needs. But over the course of your pregnancy, allow your sleep schedule to change depending on the current trimester’s needs (e.g., after an energetic second trimester you may need to allow a later rise time to get more sleep in the third trimester).
- Make sure to get plenty of bright light exposure during the day. It’s not clear exactly how you confer this benefit upon the fetus, but it’s certainly a worthwhile investment because trust me, the sooner your baby knows the difference between day and night, the less everyone will cry.
- Take snoring and signs of obstructive sleep apnea seriously. Other signs of obstructive sleep apnea include gasping/choking/snorting during sleep, waking up with a headache or dry mouth, and having high blood pressure. Risk factors include being overweight and having a larger collar size (but I’ve also worked with slim people and top athletes who have apnea, so err on the side of being cautious!). Ask for a referral to a sleep specialist as early as possible, because scheduling testing and receiving treatment can take many weeks.
- Keep up a nutritious diet and consult with a dietician specializing in pregnancy.
- Work with a prenatal physical therapist before you think you need one. This was the best thing I did for my second pregnancy.
- Establish a relationship with a mental health therapist before you need one. This is an especially good idea if you have a history of mood disorder symptoms, anticipate a difficult delivery, have little social support, or have a history of sleep problems.
“Hello Sleep: The Science and Art of Overcoming Insomnia Without Medications” by Jade Wu, Ph.D., is a practical and compassionate guide to having a better relationship with sleep and overcoming insomnia. Order it from Amazon.com, Bookshop.org, or wherever you shop for books.
‡ Ivan D. Sedov, Emily E. Cameron, Sheri Madigan, and Lianne M. Tomfohr-Madsen, “Sleep Quality During Pregnancy: A Meta-Analysis,” Sleep Medicine Reviews 38 (April 2018): 168–176.
§ Bilgay Izci Balserak, and Kathryn Aldrich Lee, “Sleep and Sleep Disorders Associated with Pregnancy,” in Principles and Practice of Sleep Medicine, ed. Meir Kryger, Thomas Roth, and William C. Dement (New York: Elsevier, 2017), 1525–39.
