by Thea Willcocks, former Pregnancy Massage practitioner at Bristol Massage Therapy
This article, and the previous How to Get a Good Night’s Sleep article, have been created from Thea’s dissertation which formed part of her coursework for her Massage in Pregnancy Diploma from Well Mother.
In my previous post, we’ve investigated what constitutes a Good Night’s Sleep and what things we can do to help ensure we give ourselves the best chance of getting the sleep we need. This post investigates how pregnancy and sleep are related, how sleep patterns might change during pregnancy, and what more we can do to get as much rest as possible.
Changes that may affect sleep during pregnancy
During the First Trimester women generally feel the need to sleep more and feel fatigued during the day as levels of progesterone starts to surge. Extra fluids in the body due to changes in the cardiovascular system and increased renal plasma flow, cause an increased need to get up at night to urinate and may also make it hard to get comfortable. Breast tenderness and tingling at about 4-6 weeks may also make the woman feel uncomfortable at night. It is also common to be suffering from nausea and to be experiencing vomiting, although this may ease at night to some extent.
Feelings of uncertainty and anxiety about the baby's well-being or the future may be preventing the mother from getting back to sleep when they awake at night, or preventing sleep in the first place. They may also be feeling more vulnerable and cautious in general.
During the Second Trimester, sleep can improve as symptoms such as nausea and fatigue reduce and energy levels become more stable. This is a period of transition between major hormonal changes and the major physical changes. Later during this period, the woman will possibly start to feel the need to slow down with her body giving clear indications of this. Some digestive issues may begin as decreased motility of the GI [gastrointestinal tract] tract may lead to heartburn and constipation. The mother will also start to feel hungry as protein and carbohydrate requirements exacerbate which may increase wakefulness.
There is significant weight gain and changes to the body's appearance which may cause some women distress and waking thoughts as they adapt to their changing shape. This is also when women start to stick to a side lying position at night, often on the left as advised by the medical profession and this can cause increased discomfort at night.
During the Third Trimester, women often have fewer periods of deep sleep and more wakefulness during the night. They will be experiencing major physiological changes, and resulting discomfort due to changes in posture caused by the growing bump. In addition, the increased elasticity of connective and collagen tissue, may cause more mobility in joints, stress on ligaments and muscles in the lower back which can lead to further discomfort making it even harder to get comfortable. The hips and lower back are often areas that complain, especially from significant periods of time spent in the side lying position. Also the supporting arm and shoulder and between and beneath the breasts can start to feel uncomfortable without support.
A growing uterus displaces the mother’s stomach and intestines, putting pressure on the digestive system possible causing or exacerbating symptoms such as heart burn. The bladder is also under increased pressure due to the growing uterus. Feeling baby's movement may, for some women, increase periods of wakefulness and also where the baby lies during the night can put pressure on nerves, in particularly the sciatic nerve. Some women also experience restless leg syndrome. Later on in pregnancy, anxiety due to fragmented sleep and thoughts about giving birth and life once the baby arrives may also be playing a part.
When wakefulness turns into awake ... "Flight and Fight", the effect of anxiety and stress on sleep ...
Survival is dependent on wakefulness, which is why you can be ready to take flight in a fraction of a second. Whereas, in contrast it takes 15 minutes for the normal sleeper to fall asleep. If we are struggling to fall asleep due to worry or discomfort we can inadvertently tap into our evolutionary past and stimulate our 'fight and flight' response making it even harder to fall asleep. Moreover, the more sleep deprivation we experience the more we effect our internal homeostasis which can further remove us from the desired sleep.
During sleep not only is the hypothalamus [a portion of our brain] activated to release certain hormones but so is our nervous system. During sleep the sympathetic nervous system (SNS) activity, which is linked to the release of cortisol and other stress related hormones, is generally decreased while the parasympathetic nervous system (PNS), which is related to rest and recovery is increased. Sleep loss is associated with an elevation in sympathoragal balance, with higher sympathetic and lower parasympathetic tone. The endocrine [hormone] organs are sensitive to this sympathoragal balance. Studies have shown those suffering from sleep deprivation to demonstrate an increased level of the stress hormone cortisol during the early evening. Cortisol along with adrenaline is part of the body's 'flight or fight' response readying the body for action, not for sleep!
How can massage help with both the physical and emotional effects of pregnancy and lack of sleep?
Safe and intentioned touch such as relaxing massage stimulates the parasympathetic nervous system, countering the effects of the sympathetic nervous system activated by a lack of sleep. Regular pregnancy massage treatment can encourage improvements in the balance of automatic nervous system functioning and also encourage the client to feel safe to experience repeated wakefulness between sleep cycles without consciously needing to wake up or stay awake.
By stimulating the parasympathetic nervous system throughout a massage, the therapist also gives the client a much needed period of rest that may be lacking at home, allowing much of the beneficial functioning of the parasympathetic system to be initiated during the session. The massage therapist can work to relieve chronic patterns of tension in the muscles resulting from both the physical changes occurring during pregnancy and from possible elevation in SNS activity. Massage can also encourage more awareness of how the client feels in their body, and through encouraging better muscular tone and balance within the body communicate a different physical patterning to the brain.
Massage is also a time for reflection and can provide a non-judgemental space to process all the changes during this period, offering both physical and emotional comfort with understanding and compassion. The therapist can also encourage new approaches to the body, through specifically tailored exercises to help relieve symptoms as well as advice on posture and sleeping positions. Some of this advice will correlate with NHS guidelines such as; using pillows, memory foam toppers and bolsters for support and encouraging regular gentle exercise. They may also refer the client to other bodywork professionals as a source of support. This may include pregnancy focused chiropractic or physio work and pregnancy tailored exercise classes such as pregnancy yoga or swimming - do take a look at WaterBumps.
Other advice may be related to diet and eating patterns or environment, such as not over eating and avoiding sugary foods too close to bedtime, creating a sleep promoting environment that is cool, dark and quiet and having a gentle sleep focused bedtime routine that may include warm herbal drinks. Foods rich in the amino acid Tryptophan are said to promote sleep if combined with high GI (glycemic) carbohydrates which allow the high protein Tryptophan to access the brain, an example of this combination would be pumpkin seeds and yogurt.
A massage therapist specialising in pregnancy massage can also help the client to be prepared for wakefulness as one of the body's natural responses to pregnancy and as preparation for early motherhood. Gentle breathing exercises and visualisation can also be used to help the client connect with how they are feeling and process the change.
Beyond this, working regularly with the client, the therapist will be listening to how the client is responding to this advice and modify it appropriately, so it reflects their lifestyle and personality, as well as offering often a much needed sympathetic ear. All the advice in the world will not improve sleep if a client struggles to appropriate it and indeed may make the situation worse if they then add this to their list of worries keeping them awake.
"As with many lifestyle habits the key point is you intention" ~ The Sleep Book
Listen to Your Body’s Needs ...
Client A was really struggling with feeling like she had to sleep on her left side, as she had heard this was the optimal position for her baby's health. She was growing more and more uncomfortable in this position at night, but too worried to move as she thought she might be doing something wrong. The NHS does advise left lying to provided optimal blood flow to the placenta, but as the placenta can implant anywhere in the uterus this is more of a general rule and will not necessarily be the case for every individual.
Client A was encouraged to discuss what she felt she wanted to do instinctively, which was to change sides regularly and with some supportive words of encouragement began to follow this instinct. The client also started using a memory foam topper to reduce the pressure on the bottom hip. Over time Client A felt much more able to listen to her own body. Through receiving regular massage over the hips, tops of legs and sacrum, and by observing how the tension was forming through her static position and making small adjustments to sleeping arrangements, the client began to feel more in tune with her body and gain some relief at night.
Later on in the pregnancy, the pain in the hips had eased considerably and Client A started sleeping a lot better. Then as it came to a period of wrapping things up at work and the birth came nearer Client A started to suffer from tension headaches. At this point the massage session became a space where she could reveal how she a was feeling and by sharing anxieties feel them less intensely. Receiving nurturing touch to ease physical discomfort in a held space, the client was able to recognise her own tension and let it go.
Make time for the things that help you relax ...
Client B was suffering more with issues around the shoulder and discomfort under the ribs and between the breasts. After receiving regular massage to relax the affected areas over several weeks and by discussing and implementing advice on sleeping position, which included placing some support between the breast and support behind the back, Client B found it much easier to be more open in the chest and shoulder area and was in a lot less discomfort. She also felt her posture in general was improving especially at work.
She also started to use some sleep promoting aromatherapy oil at home which she enjoyed using regularly before bed and when she awoke at night to comfort and calm her. This included a reduced concentration mix of chamomile, lavender and Mandarin essential oils.
Pregnancy as preparation
Client C found a partner session particularly beneficial as her husband wanted to understand ways to support her during the last trimester. By thinking about this time as a period of preparation for both of them as parents, they could start to view the fragmented sleep patterns as part of this process. Doing gentle exercises together and working with the exercise ball to encourage optimal fetal position gave them some tools to use during times of discomfort and also focused their attention on the next stage and how they could prepare for this together. Gentle holds on the abdomen and sacrum as well as rocking and embracing create a greater sense of connection for both parents with their baby.
Later in pregnancy some of the birth points used in Shiatsu and Acupuncture can be taught to the partner to encourage the transition from pregnancy to birth. It is important that the therapist approaches this stage gently as it is pretty nerve racking and whether this is the first pregnancy or not there is always a worry about the Unknown.
We have millions of sensors both inside and out, continually sending data to our brain and during pregnancy this internal information is increased threefold. All of this information, be it from sensors in our muscles and connective tissues relaying our position and pain levels, temperature sensors in the skin, or our ears and eyes responding to our environment, is fed back to the waking brain known as the reticular activating system. The higher the levels of information being received, the more likely it is you will have accordingly high levels of alertness and wakefulness. Things that arrive in the mind - be these physical sensations, external influences or thoughts over stimulate our Amygdala response, releasing cortisol and adrenaline when they are perceived as a threat - are causes for less sleep. When the mind regards these arrivals as the enemy and struggles to get rid of them, is when it truly goes into ‘fight or flight’ mode. Over time, this can create a pattern and a conditioned response. The important thing is to find a way to stop the struggle and accept the things you cannot change.
The Sleep Books approach indicates:
" ... the first step to having more energy is to stop struggling, let go and simply rest … remain in the present and accept things as they are ... welcome what shows up in your mind. Focus on living and you will sleep better."
So although there are many things out there telling us how both to get a good night’s sleep and how best to go about being a pregnant woman, I'd say no two persons experience is the same and moreover this experience will change several time throughout pregnancy. Rather than holding on to a strict code of behaviour we are better off responding to the moment in the best way we can, and trusting the signs that our bodies are giving us even if they seem negative at the time; they may serve a greater purpose. In the end, it is by accepting we can't get it right all the time and noticing without judgement how we are in the moment that we will start to find things a little bit easier. Massage therapy can be one tool to help support this process of recognition and acceptance in a responsive and practical way.
"Embrace absolutely everything in its constant flux and Transformation." ~ The Path, Michal Puett
My thanks to all those wonderful women who agreed to be my case studies during my coursework, especially those who have agreed to be included in this article.
Meadows, G. (2014) The Sleep Book: How to Sleep Well Every Night
Thomas Y. Get A Good Night’s Sleep: 7 Practical Steps (courtesy of The Sleep Council)
Schwenger P (2012) At the Borders of Sleep
Puett M & Gross-Loh C (2016) The Path: A New Way to Think About Everything
Yates S (2010) Pregnancy and Childbirth: A Holistic Approach to Massage and Bodywork
NHS Website - Tiredness in Pregnancy Wikipedia - Sleep HelpGuide.Org - The Biology of Sleep