Supporting Sleep and Rest in the Perinatal Population

co-sleep first trimester fourth trimester mental health perinatal sleep safe sleep second trimester sleep sleep in postpartum sleep in pregnancy sleep plan third trimester Feb 02, 2023

Dr. Alicia Power and Dr. Pip Houghton discuss sleep challenges in pregnancy and postpartum, how to screen for what might be causing difficulties, medicinal and non-medicinal options for helping patients improve their sleep, and creating a sleep plan with a support person to set the new parent up for success. They also discuss the importance of sleep for mental health, and how to create the safest space for co-sleeping with baby - to optimize rest for everyone.



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[00:00:59] Dr. Alicia Power: [00:01:00] Welcome Dr. Pip Houghton! You are joining us today from a snowy Comox Valley, up island from me on Vancouver Island. Today we're talking about supporting sleep and rest in the perinatal population. So I just wanna get started by letting you introduce yourself, telling us a little bit about the work that you do and what's brought you there. And then we'll dive into this very important conversation.

[00:01:21] Dr. Pip Houghton: Yeah, so I'm a family doctor on the North Island, currently in the Comox Valley, currently coming to you from my closet because we've had a big dump of snow. I was expecting my kids to be out of the house, but alas, they're in the house making a lot of noise. So I'm hiding out in my closet right now. I have a particular interest in passion for perinatal mental health, which came out of my own experience transitioning to postpartum, where I felt very unexpected emotions around transitioning to this big shift in my life and felt gobsmacked by some of the things that happened. And at the same time thought, I'm in medicine, [00:02:00] I'm a resident, I'm a family medicine resident. Why didn't I know about this? And then also, was able to support and witness a friend go through her own postpartum depression and journey back to wellness. And really just through supporting her and understanding what she went through it, it triggered me to learn more about perinatal mental health and that sort of become my main area of interest and focus.

[00:02:23] Dr. Alicia Power: Thank you.

[00:02:24] Dr. Pip Houghton: And in addition to that, I've got three little boys running around right outside the door of my closet. So there are four, two, and babies. So I've been around the block with babies.

[00:02:33] Dr. Alicia Power: You sure have, a couple times. Alright, so why don't we get into it. So we're gonna talk a little bit about how do we support our pregnant postpartum population in sleep and rest because we all know that's so important for coping and for mental health and for healing. And so how can we do that? Cause I know that's a huge issue that often comes up in my practice with my pregnant and postpartum patients and their support people. So let's chat a little bit about that.

[00:02:58] Dr. Pip Houghton: Yeah. So I thought [00:03:00] first let's just talk about sleep in pregnancy because sleep in pregnancy can be tough and pregnancy is exhausting at baseline, even when you are sleeping well. So I think it's important to remember that most pregnant people towards the end of their pregnancy, and actually all throughout pregnancy, your sleep architecture changes even in the first trimester but certainly becomes most noticeable in the third trimester where normal sleep patterns shift, the pregnant person is waking, often three to five times a night. And that has impacts on feelings of daytime sleepiness and general wellbeing. And, anxiet for waking at night can be having to pee. Like I remember the end of pregnancy thinking, "man, if I am up, as much as I am now with a baby, I'm gonna be exhausted" because I was waking three to five times myself to either pee or put pillows between my knees because I was uncomfortable. There's many reasons why a pregnant person might be waking at night and feeling exhausted the next day. And then, there's [00:04:00] also things like restless leg syndrome that can happen in pregnancy, and then there's insomnia and that's one of the things I wanted to touch on today is really that insomnia piece is. All things are equal, all things are stable and you're still not sleeping. How can we help you get more rest and more sleep?

[00:04:17] Dr. Alicia Power: Awesome. And as we chatted around before, there's also some other things that can decreasing having less risk and increase the risk, right? . So we're talking about some medical conditions that can come up in pregnancy.

[00:04:29] Dr. Pip Houghton: Yeah so chronic insomnia, so we're not talking, one or two nights of bad sleep. Every pregnant person is gonna have a couple nights of bad sleep. It's just, part of the game plan, unfortunately, but that chronic sleep deprivation where, you know, every night you're getting less than a couple hours of sleep for whatever reason it's not a benign issue.

[00:04:48] There's real risks associated with insomnia in the general population and the pregnant population. For pregnant patients, we're looking at an increased risk of gestational diabetes. There's [00:05:00] an increased risk of hypertension in pregnancy. There's an increased risk of preterm birth. And certainly there is an increased risk of mood and anxiety disorders and also just a general impact on your cognitive abilities during the day. We know that when we're sleep deprived, our brain doesn't function very well, and so we can feel foggy and slow that could impact work. Certainly impacts our general sense of wellbeing. So this is important. This is an important thing to talk about.

[00:05:27] Dr. Alicia Power: Yeah, and I think we also need to think about other reasons that might be causing insomnia as well. I think we often forget, I know I do to screen for sleep apnea and people who are really struggling with lack of sleep. And everything swells in pregnancy, including our airways. So you just at a higher risk of sleep apnea. So make sure that's in the back of your mind and you're screening for that as appropriate if you do have patients coming in or clients coming in with kind of that chronic, I feel like I'm sleeping, but I'm always tired during the day. I mean, they might just be growing a baby, but it might be more than that. And if you can help support them a little bit around that. And so what other questions are [00:06:00] we thinking about when we're screening people for sleep?

[00:06:05] Dr. Pip Houghton: Yeah. For me, coming from a mental health perspective, sleep and mood are so intimately related. So if we've reached a point in our patient assessment where we have discovered that the patient is not sleeping we wanna dive more into that. Why aren't they sleeping? Is it, is it comfort? Can we help to support them in getting more comfortable? Are there some strategies we can use to, to fix their posture or how they're lying? And can physio help? Is it their bladder? I don't know that we can do a ton about their bladder, to be honest.

[00:06:33] Dr. Alicia Power: We can decrease fluids later at night. We can decrease caffeine, bladder irritants.

[00:06:39] Dr. Pip Houghton: But you know, it's, some things are gonna be trickier to change. But the big one for me is, are you lying awake at night because you're worried? Is there anxiety happening? A lot of the time insomnia and anxiety and depression are so intimately linked. Sleep disorders in general or so intimately linked with our mental health. So [00:07:00] for me, a patient sharing that, yeah I'm not sleeping and I don't know why. That's a big red flag to start, diving into some mental health assessments. And we're not gonna go down the rabbit hole of how to assess mental health today, but just keeping that in mind that we should not be accepting, oh, you're pregnant, so you're not sleeping as a normal aspect of pregnancy. We need to ask a little bit more about why they're not sleeping and get to the bottom of it and see if we can help them sleep a bit.

[00:07:28] Dr. Alicia Power: Yeah. And then adding in that sleep apnea screen as well, or if they're partners there asking about snoring and waking and that type of stuff. So all really important. So we've chatted about different reasons for sleep challenges in pregnancy, especially as you come to more that third trimester where there's just so much more. Let's talk a little bit about kind of management options. So if we've ruled out the more medical side of things, ie. the sleep apnea, those pieces of the puzzle. Where can we go from here?

Management Options

[00:07:53] Dr. Pip Houghton: Yeah. So if someone in pregnancy is not sleeping we wanna offer them as much support as we can in getting [00:08:00] comfortable. Sometimes that's physiotherapy. But you know, our basic management for insomnia and pregnancy is gonna be the same in the general population for the most part. So we wanna talk to our patients about sleep hygiene. Millennials in particular are terrible with sleep hygiene, right? We're all on our phones lying in bed, and then we shut our phone off, roll over, and hope to go to sleep. We all know that this is not gonna be helpful for sleep or anyone who's struggling with insomnia. So really having a pointed conversation around sleep hygiene, avoiding screens before bed, keeping the bedroom cool, keeping lights low before bed so that we're allowing our melatonin to function the way it's meant to. When you are getting up at night to pee, don't flick all the lights on to find the bathroom. Put a teeny little nightlight in there so you can find your way and get back to bed without exposing yourself to all those bright lights. It seems obvious, but avoidance of caffeinated products, even in eight, the eight hours before you want to be sleeping because of the halflife of caffeine. And avoiding those bladder irritants like you mentioned so that we're [00:09:00] limiting that bladder problem overnight. And then, easy stuff like getting enough exercise during the day and certainly exercising in pregnancy can be challenging and uncomfortable and in some patients may not be appropriate. But can we get them moving even just a little bit, ideally first thing in the morning to get our circadian rhythms functioning optimally? Can we do that exercise outside first thing in the morning in daylight or can we get a bright light exposure first thing in the morning to really try and stimulate the melatonin production the way we need it.

[00:09:29] And, if sleep hygiene isn't working well or it's already being optimized or the patient thinks it's being optimized some other options are CBT Insomnia programs, and I love these CBTI programs are great. So there's some awesome free apps online if you just pop into the app store and look up CBTI. There's tons of great options in there. And these programs help to target the unhelpful thoughts that we have around sleep that can then trigger feelings of anxiety around sleep, that [00:10:00] then can trigger unhelpful behaviors around sleep that sort of cycle us down this poor sleep habit. And even in patients who tell us that they're not struggling with anxious thoughts if they're trying to fall asleep, CBTI is still super helpful. Sometimes we don't realize what's going on in our mind when we're trying to fall asleep.

[00:10:18] Dr. Alicia Power: Yeah. And then my favorite thing that I love is those apps. Those bedtime story apps. I know they're great. I used to use them. I use Calm, but there's a few out there and they're just great. I use them mostly started using them when I was on call. Cause I'd always just be, I'm not a super anxious person, but my brain would be like, who's gonna call? What's gonna happen? And then I just started using them every night and I've never listened to a whole one. No, that's not a lie. I have a couple times, but not very often. And so what we'll do Pip for people who don't necessarily, aren't super familiar with sleep hygiene we'll we've got a great, just cheat sheet on sleep hygiene. And then we'll put a couple of these great free resources so that people can pass it out to patients. So we'll link that in, in the show notes below and you can just get a download. We'll fill it out, you can send us an email and we'll get, we'll give it to you and then you can use [00:11:00] it to send it out to your patients.

[00:11:02] Dr. Pip Houghton: Yeah, and the bedtime stories are great because a lot of the time, the reason we're not sleeping, like you mentioned, like being on call, is we're anticipating being woken up by something so that anticipatory stress is keeping us awake. So if we're third trimester pregnancy and we know we're gonna be woken up five times to pee, or because our back hurts, or whatever or Braxton Hicks or whatever it is that's waking you up. If you're anticipating not having a good sleep, your thoughts are gonna be cycling around that anticipation. So these stories are a really lovely distraction and often they're read by someone who has this lovely, soothing voice and, with Audible and this is not a sponsored post, this I just enjoy audible. You can set it so that the volume slowly peters out over a period of time so that you can fall asleep as it gets softer and it turns itself off. Which is a lovely way to distract your thoughts as you're trying to fall asleep.

[00:11:53] Dr. Alicia Power: Yeah. And you're talking about that setting up your room environment for sleep. So cool, dark. It's the same thing that we want for those newborns [00:12:00] when they're three to four months. So if you can start implementing it now, then you're gonna already be ahead of the game when that baby comes as well. And we talk about that in our newborn sleep course that we have on our other platform, our She Found Motherhood platform. So that's great. And the other thing that I've learned about recently is getting a red light for the bathroom or as a nightlight. Because it doesn't have those blue waves, which are the ones that mess with your brain and sleep. And so also telling patients when they have a nursery that they're changing diapers in getting a red light as well, so you're not then having to turn the light off. Cause it's hard to change a dirty diaper in the dark. So we do need a little bit of light, but those red lights have a different wavelength. So that can be a handy tip for patients as well.

[00:12:38] Dr. Pip Houghton: Yeah, great tip. Yeah, thanks for that one.

[00:12:40] Dr. Alicia Power: So what if people have some restless legs? What are we talking about there?

Restless Leg Syndrome

[00:12:44] Dr. Pip Houghton: Yeah, so restless legs in pregnancy. So we wanna screen for iron deficiency and treat as indicated, third trimester pregnancy, iron deficiency is gonna be there. And then the other thing that can help is magnesium supplementation. And Alicia, you probably know better than I, my understanding is we don't need to be [00:13:00] screening for a magnesium deficiency. We can just supplement with the magnesium supplement if the patient's experiencing restless legs. So important to just ask some questions around that. And, restless legs at night can be triggered by daytime fatigue or not enough rest. And certainly in our pregnant population who's expecting a baby, they're often trying to get a as much done as possible during the day so that they're ready for baby. They might be tying things up at work, they might be doing errands, setting up nursery, laundry, huge to-do list. And so they may not be taking enough rest during the day to allow, their body to go to bed. And we know that rest and sleep begets sleep. We don't want to be going to bed totally depleted. So talking to our patients about rest.

[00:13:43] Dr. Alicia Power: And as you've recently reminded yourself, having, it's even worse when you have a child at home, a toddler at home, because there's no time to rest, right? So I bet this third trimester was probably more exhausting for you than the first, third trimester that you went through because you had two, Oh yeah. Little ones at home that you were trying to wrangle as [00:14:00] well, right?

[00:14:00] Dr. Pip Houghton: Yeah. Absolutely.

[00:14:01] Dr. Alicia Power: Yeah. Okay. So let's talk a little bit about medication. So if we've ruled out the medical reasons so restless legs, sleep apnea, depression, anxiety, all go together, but, what are our options in terms of if we really need our patients, really needs a bit more support? What are we talking about from a medication point of view?


[00:14:17] Dr. Pip Houghton: Yeah, so I think it's important not to be fearful of considering medication as an option if the patient is truly not sleeping and it's really impacting their function or how they're feeling because we don't want someone going into postpartum excessively depleted if we can help it. So of course we want to try and do this without medication if we can, but sometimes, even a day or two of medication to just get them regulated in the sleep cycle again can help. So you've, if people have listened to me speak on medication in pregnancy and postpartum before it, the important thing to remember is that there is no medication that is 100% risk free. But you know, the condition of insomnia and [00:15:00] pregnancy is not 100% risk free either. So we want to have an informed discussion with our patients about the benefits of treating insomnia with medication. If they're really suffering, they don't have to suffer.

[00:15:13] So some medication options we can consider and discuss with our patients. Something as simple as, diphenhydramine or Benadryl and antihistamine safe in pregnancy you know, chronic and excessive use can potentially create a bit of a withdrawal process in the newborn, but we're talking a lot of Benadryl. As much as a quarter tablet at bedtime can be enough to get someone off to sleep, even for a day or two to get them enough rest so that they reset their sleep cycle. We're talking 12.5 milligrams of Benadryl. So certainly that's an option over the counter. We don't want to be chucking these medications at our patients and then saying, "Hey, good luck. See you at your next prenatal in four weeks." We want to be making sure that we're following up with them closely after we've suggested a medication for sleep. [00:16:00] Pop them in for another visit in a week to check in and see how they're sleeping after trialing that medication. And another important piece here is that sometimes the patients knowing that they have medication as an option, even if they don't take it is enough to get them sleeping just so that they know they have that backup plan if they have another bad night, it takes out some of that anticipatory stress and I've had it happen more than once where I've offered medication to a patient and they've started sleeping just fine without even taking it.

[00:16:28] Dr. Alicia Power: Yeah, so true. I've done this exact same thing. People just ask for, can I just have 10 pills more in my non-pregnant population, but still, and then they don't use them, but they just knowing that they have something that if they're desperate they can go to is super reassuring. Yeah. And takes away that anxiety.

[00:16:44] Right? Totally. Yeah. Yeah. Yeah. Okay, so Benadryl over the counter. What about prescription options?

[00:16:50] Dr. Pip Houghton: Yeah, so Mirtazapine is an option. And so Mirtazapine we use for sleep outside of pregnancy. And I think the important thing to remember with Mirtazapine is that paradoxically, [00:17:00] mirtazapine works best for sleep at the lower doses. The dose range, anything between 7.5 and, 45 milligrams can work for sleep. But really, reminding ourselves and reminding our patients that the lowest dose, so that half tab of your 15 milligram tabs is gonna be where we want to start for sleep. And sometimes this does require patient education because our patients often have the perception that a higher dose means it's more effective. And that's not always the case. And we do know that. The higher the dose, the higher risk of side effects. So we always want to be working with the lowest dose that is effective for the patient. So that we're, treating the condition, but minimizing side effects.

[00:17:38] Dr. Alicia Power: Luckily in pregnancy most people wanna take the lowest dose possible, right?

[00:17:41] Dr. Pip Houghton: Absolutely. Yeah. Yeah. The nice thing with mirtazapine is it is an anxiolytic as well, so if there's an anxiety component going on it, it may help with those symptoms as well. Thing to keep in mind with this drug in pregnancy is that it can cause weight gain in some people. So in our patients who were [00:18:00] already watching for maternal obesity or gestational diabetes or who we may be monitoring for large for gestational age infant, we might just wanna be considerate of whether or not that's the most appropriate medication for them because we don't wanna add unnecessary weight gain if they're already at risk. So you know if that's an option. I find that it does work well for patients who need it.

[00:18:23] Dr. Alicia Power: Great. Yeah. And then I think you were gonna chat a little bit about Trazodone as well.

[00:18:28] Dr. Pip Houghton: Yeah. And then, so Trazodone, similarly to Mirtazapine, we wanna be starting at the lowest dose, so even a half, half tab. It comes in 50 milligram tabs, so half 25 milligrams at bedtime. Appears safe in pregnancy. It does have quite a significant dosing range that is considered safe in pregnancy. So you can bump it up if you need to, but I typically find 25 to 50 milligrams at bedtime seems to be enough for people. And it does still have that anxiolytic effect as well, so can help if there's anxiety or mood components to their sleep issues and tends to be well [00:19:00] tolerated. Keeping in mind all of these medications are meant to make our patients sleep, so they likely will feel some sedation in the morning.

[00:19:10] Dr. Alicia Power: Yeah, and like you said earlier, sometimes it only takes a little bit to help us reset and not have those negative connotations with going to bed, right? If we've experienced that insomnia not sleeping, then when we go to bed, we expect that insomnia and that not sleeping and then that just precipitates the issue. Whereas if we can reinforce going to bed with a reasonable sleep for a few nights sometimes, then that in and of itself can just be therapeutic.

[00:19:33] Dr. Pip Houghton: Yeah. And when we're not sleeping, our stress hormones, our cortisol and adrenaline is running rampant to keep us awake during the day. So if we're going to bed, trying to fight, that system, night after night it's gonna make it harder and harder to sleep as nights go on. So just interrupting that for a night or two can be really therapeutic. The other thing is if you suspect anxiety is a is an issue in the sleep, we wanna make sure that anxiety is [00:20:00] being adequately managed and that's a topic for another day, but just being mindful of that.

[00:20:04] Dr. Alicia Power: Yeah. Awesome. So we've chatted a little bit about the pregnant population. Let's shift gears and talk a little bit about that postpartum period. Now you've got a newborn at home, hopefully. And so that adds its own challenges, but let's chat a little bit about that postpartum period.

[00:20:18] Dr. Pip Houghton: Yeah. The biggest source of sleep deprivation postpartum is the newborn. We can't do very much about the newborn. Babies sleep in all varieties of patterns in the early weeks, which I know you speak to in, in your course. They sleep a lot, but often in short chunks. And when you factor in the time it takes to breastfeed change and settle a baby, sometimes it's, you get them down.

[00:20:43] It's gonna be about an hour before you're up again doing it all over. So really that night after night is going to contribute to a lot of sleep deprivation. And as providers, I think one of the most important things we can do for new families and [00:21:00] expectant families is manage expectations before baby comes. So a lot of the stress families feel around sleep deprivation is because they went into the newborn season with unrealistic expect. And it's not your, it's not anyone's fault. There is all kinds of garbage on the internet around how, at six weeks your baby should sleep for six hours uninterrupted, and at eight weeks it should be eight hours. You know who's telling us, who's telling the baby this? The baby's not getting that memo, baby did not get that memo. Yeah, there's, there are no shoulds when it comes to newborn sleep. The newborn is going to sleep the way the newborn sleeps and we need to support families in managing that. So I speak a lot to setting up a sleep strategy within your household so that we can manage those early days of sleep deprivation while supporting each other in getting enough rest. And that will look different in every family unit, depending on what is required [00:22:00] within the family. But as providers, I think we can give our patients a huge gift by talking to them about this before baby arrives. So how are you going to support each other with night work? How are you going to support each other during the day so that you're getting adequate rest? It's very hard for a parent to rest during the day when they also have the baby monitor on hand, right? Like it's, sleep when the baby sleeps is really hard when you're trying to listen for the monitor to see if baby's crying. So if we're supporting our spouse or our partner in getting daytime rest, we really want to support them in going into a quiet room with the lights off, no monitor and no cell phone, so that they're truly able to rest. And this is an important conversation to have with their patients before baby comes because in some families that may not be the expectation. The expectation may be parent who stays home with baby does all of the night work and all of the sleep work and parent who works out of the [00:23:00] home sleeps through the night. And you know that in some families may be appropriate, in most families, that's gonna result in one person being burnt out and very tired.

Postpartum Anxiety

[00:23:09] Dr. Alicia Power: Yes. And challenging relationships from that point forward. Yeah, exactly. Exactly. Totally. Totally. Exactly. Let's talk a little bit about postpartum anxiety and intrusive thoughts as well, because that's one of those things. So sometimes we actually have the opportunity to sleep postpartum, or patients have the opportunity because they've done your strategies and they've got good sleep plan and the partner is, taking care of the baby, but then they're in this quiet space with the ability to sleep and they just can't sleep.

[00:23:32] Dr. Pip Houghton: Yeah. So this is one of the questions I make sure I ask postpartum patients is when the baby is sleeping, when you have another adult in the home who's tending to baby, are you able to sleep? And if not, why not? And intrusive thoughts are often one of the sources of, usually the postpartum parent, the birthing parent, not sleeping. And it's so for those listening who are unfamiliar with intrusive thoughts these are thoughts that are [00:24:00] pervasive. Distressing images or streams of thought, usually around harm coming to baby and safe sleep is a significant trigger. So an example of this would be a thought that your baby is going to die from SIDS every time you go to sleep. And so this may result in behaviors like constantly checking baby or not trusting another person or adult to supervise baby while they're sleeping, which obviously is then gonna make it very difficult for the person who's having the thoughts to rest. So if intrusive thoughts are a big trigger for not sleeping, we wanna help our patients identify that. And a lot of the time our patients don't know what intrusive thoughts are. They may be having the thoughts and feeling a lot of shame that those thoughts are there. So one of the therapeutic things is to just identify that, oh, that sounds like an intrusive thought. 90% of postpartum people have intrusive thoughts. Those thoughts don't mean a bad thing is gonna happen. Thoughts are not facts. We don't need to believe our thoughts and help, you know, to offer them some coping skills so that [00:25:00] those thoughts aren't keeping them awake at night. Coping skills can be as simple as distraction: bedtime stories, like we mentioned before, great distraction. If intrusive thoughts are becoming really significant and the person is really not sleeping then we need to consider is this an anxiety disorder that's causing these thoughts and does the anxiety need to be treated?

[00:25:18] Dr. Alicia Power: Awesome. So how can we chat about those? We've chatted a little bit about helping to support sleep and some strategies around that. Kind of having a good plan with your partner or support person or hiring a night doula every few nights or whatever it is, having a friend come into your house and kind of help care for your baby so that you can sleep. What are some other things that we can be educating our patients on, because we know that some people, those first few months, it's so hard, and those babies really do need a lot of support to sleep, right? Mm-hmm, they're used to being in you, being rocked, being wooed, being cuddled, all of those things, right? And now they're outside of you. But that doesn't mean that they're not also transitioning, so they often need a lot of sleep. And we all talk about safe sleep strategies and babies not sleeping in the same space, but [00:26:00] the reality is, sometimes we just need to survive. So can we quickly chat around how you counsel your patients around that?

[00:26:08] Dr. Pip Houghton: Yeah. So before we dive into that I'm gonna put it out there that the safest place for baby to sleep is in their own sleeping space on their back. We know that to be true. So I'm gonna put that out there. The second thing I'm gonna say is that data suggests though, this is very difficult to study that up to 90% of breastfeeding people will at some point fall asleep with their infant, either by choice or by accident. So that's a lot of people. And we in medicine have done a very good job of hammering home safe sleep to the point where it terrifies our patients. We have not done a very good job informing our patients on safe co-sleeping, whether they choose to do it intentionally or not. So for me, I think it's really [00:27:00] important that all new families understand that yes you may be making the choice to have baby sleep in their own sleep space.

[00:27:09] But also you may find yourself in a situation where you accidentally fall asleep with baby. And so if that's going to happen, we want to make sure we're prepared. So things we want to avoid doing with baby is falling asleep on a couch or a lounge chair. Babies are much more likely to suffocate if they slip down the side of a couch and are squished between a sleep deprived adult in a lounge chair. So when you're breastfeeding a baby at night and you know that you're very tired, choose a firm sleep space that doesn't have an excessive amount of blankets, but doesn't have a ton of pillows, so that if you fall asleep, while nursing baby is much less likely to be suffocated by soft objects. This is harm reduction, right? We do harm reduction in all other aspects of medicine. We're not saying that this is the safest choice, but if this were to happen, the [00:28:00] safer way for it to happen is to minimize harms.

[00:28:04] We can minimize harms in co-sleeping if there's only one adult in the bed, which in some families is possible, in some families is not possible. So you know are you able to put a firm mattress on the floor so that it's only the breastfeeding parent and baby on a firm mattress where there's very low risk of baby falling off, very low risk of baby rolling down a crack or getting squished somewhere. Very low risk of baby being squished between two adults. The other key thing with SID'S risk and co-sleeping is does anyone in the home smoke. If anyone in the home smokes or has smoked in pregnancy, really co-sleeping should not be a consideration for your family. We know that is the biggest risk for SIDS and suffocation. So as much as possible, and this is said without judgment, we want to make sure our smoking patients and that being tobacco and marijuana are very mindful of that risk, and they do everything possible to avoid accidental cos [00:29:00] sleeping and that we talk to our patients about that.

[00:29:01] If we are choosing to co-sleep with babies and when we're talking to our patients about co-sleeping, we also wanna make sure that they don't have any sedating substances on board. So alcohol being probably the most common one. But you know, when we're talking about using medication postpartum to help our patients to sleep, we really need to be clear and we need to document that we've been clear that we do not use sleep aids if we're planning to co-sleep with baby. The other thing is if we're using a sleeping medication for our patients to help them sleep postpartum, we really want to support them in getting adequate sleep. So we would like to avoid them being responsible for most of the night work for that reason too.

[00:29:40] Dr. Alicia Power: Indeed. And then the other thing is just making sure that you don't, yeah, I think you already said this. Not a lot of pillows, not a lot of Yeah. Comforters, et cetera around you. If you are sleeping with your partner in the same bed, then putting yourself between your partner and the baby seems to be the most protective. Cuz naturally I think we create a C-shape around our babies if we're, if we have our babies in the bed. [00:30:00] So those. And then you can get those kind of little sideline things that they can actually have their own space. Yeah, but they're in the bed. They're right next to the bed with you. So that's an another option for that kind of co-sleeping. If people are gonna do that, is to have those co-sleep right off the side of the bed so they're not gonna fall onto the floor.

[00:30:15] Dr. Pip Houghton: Yeah, so from the provider perspective, I think it's really important that first we educate our patients on the safest way for baby to sleep, which is on their back in their own space. But I think it's also really important to open the conversation around co-sleeping, because most of our patients are either choosing to do it or doing it accidentally. And if we don't create an environment where we can talk to our patients about harm reduction, then one of two things will happen: is they will continue to intentionally co-sleep, potentially in a risky setting or, they will find themselves accidentally co-sleeping and feel terrible about themselves and, feel very guilty and feel very conflicted about how to manage that moving forward. We want to be the source of information for our patients. [00:31:00] This, these tips we're talking about are called the Safe Seven for co-sleeping. You can find them readily online. Some public health units are even including this now with discharge information for our patients so that we are empowering patients to make the safest, most right decision for themselves in the moment.

[00:31:17] Dr. Alicia Power: Yeah. And we can link to a couple of the Safe Seven options if you do wanna find them so you can give them to your patients as well. Yeah. Awesome. That was a ton. Thank you Dr. Pip for that. So we chatted around sleep challenges in pregnancy and how to screen for the different reasons and non medicinal and medicinal options in terms of helping patients to improve their sleep. We also chatted around postpartum and setting up, setting yourself up for success with having a sleep plan with your partner, your support person, but also how to recognize that sleep is important and we might unintentionally fall asleep with our babies and how to create the safest space we can if that's gonna happen.

[00:31:54] So that was wonderful. If anybody is looking to connect with Pip, you can find her at [00:32:00] her website Making Mama Well, She's got incredible resources for patients. And she actually put on, didn't you put on a course for providers who are pregnant and postpartum.

[00:32:11] Dr. Pip Houghton: I did. Yeah. Physician to Parenthood. It just finished and amazing. I'm like, I got great feedback. So it was lovely working with some colleagues who are expecting their first babies. Yeah. The other thing I would add is for medication questions, a great app is the Infant Risk app. This is, again, not sponsored this is something I use all the time to check medications and pregnancy and breastfeeding. Or the Mother Risk website is another option.

[00:32:33] Dr. Alicia Power: Yeah. I agree I use the Infant Risk app and it's great. So thank you so much for joining us today Pip, it was a pleasure to chat with you and I think we can all do a better job supporting our patients and clients in their sleep journey in pregnancy and postpartum.

[00:32:46] Dr. Pip Houghton: Great being here.


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