Clinical Strategies for Assessing Sleep Disturbances in Postpartum Patients

Announcer:
This is Advances in Women’s Health on ReachMD. On this episode, we’ll learn about how we can assess sleep disturbances in postpartum patients with Dr. Nicole Leistikow, who’s an Assistant Professor in the Department of Psychiatry at the University of Maryland School of Medicine and on the Education Committee for the National Curriculum in Reproductive Psychiatry. Let’s hear from her now.

Dr. Leistikow:
So assessing for sleep disturbances is a really important topic to address, and it’s an easy thing to fix and improve. It was something that I had to learn clinically in working with perinatal patients, and assessing more precisely for sleep disturbances in postpartum was not something that I was taught in medical school or residency. So when I first started taking care of postpartum patients and I would ask about sleep, I would say something generic like, “How are you sleeping?” And as I began to realize how much of a problem disrupted sleep in the postpartum was and as I started to try to find a solution to this problem, I realized I had to get much more precise in my assessment. So my question evolved to what it is today, which is detailed but still relatively simple. I ask, “What time did the baby go to sleep last night? What time did you go to sleep? And then tell me about all the disruptions—every time you woke up, what you did, and approximately what time you went back to sleep—so that I can get a history of how your night went.” And so someone might give me a history like, “The baby went to sleep around 8:00 p.m. after I fed them, and then I went to sleep around 10:00 p.m., and then the baby woke me up around 11:00, and I fed them, and I went to sleep again around midnight, and the baby woke me up again around 2:00 a.m. I fed them, and I went back to sleep around 3:00 a.m., and the baby woke me up again around 5:00 a.m. I went back to sleep around 5:30, and then we got up for the day around 7:30 a.m.” 

So what I’m doing when I’m getting this history is I’m writing down all of the sleep chunks, and I’m trying to find the windows of opportunity for improving sleep. So in the example I gave, the baby slept at 8:00 p.m., but the mom didn’t sleep until 10:00 or 11:00 p.m. So she got one hour of sleep, then slept again from midnight to 2:00 a.m., got a two-hour chunk of sleep, then slept again from 3:00 to 5:00 a.m., got another two-hour chunk of sleep, and then slept again from 5:30 to 7:00 a.m., so a final two-hour chunk of sleep. So when we add all that up, she got seven hours total, but it’s a pretty terrible experience for the mom and a significant toll on the brain.

And so the wonderful thing about taking a simple yet quite precise sleep history like this is, No. 1, it helps the patient understand partly why they’re feeling so bad when you lay it all out like that because any one of us would feel terrible if this was happening constantly with no respite. The second thing about taking a more precise sleep history is that it can suggest both the diagnosis and the intervention that we need to do. So in this example, the sleep disruption was clearly caused by infant feeding, and there was a missed opportunity where if the mom could have gone to sleep right after when the baby went to sleep and then if someone else could have taken that first feeding that happened around 11:00 p.m., there was a window of opportunity for her to sleep from approximately 8:30 p.m. until approximately 1:30 or 2:00 a.m., which would have been around a five-hour chunk of sleep, and it would have met my standard for that four-to-five-hour chunk that likely makes a significant difference in postpartum mental health, even if the mother was then waking up every two hours after that.

Sometimes taking a more precise, postpartum sleep history will reveal other diagnoses or problems as well. One of the things I tell patients to watch out for in postpartum is if they are unable to sleep when they have the opportunity to sleep because insomnia could be a risk factor for an indication of high anxiety, possible bipolar disorder, or postpartum psychosis. So if the patient is telling me that they’re not being woken up by the infant to feed but it’s that they’re too anxious or too amped up to sleep, then I’m going to start asking other questions to determine whether we have a diagnosis of anxiety versus bipolar disorder or postpartum psychosis and whether we need to intervene with a medication to get them sleeping or with a behavior change, or if there’s a psychiatric emergency here as it would be in the case of postpartum psychosis.

Announcer:
That was Dr. Nicole Leistikow sharing strategies for assessing sleep disturbances in postpartum patients. To access this and other episodes in our series, visit Advances in Women’s Health on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!