I’m 3 months pregnant. I’m having trouble sleeping and waking up feeling tired. Is this normal? Is there anything I can do?

Q. Why is sleep important in pregnancy?

A. Sleep is restorative to the body and mind and is a very important part of day-to-day health. This is even more important when going through the health and life changes associated with pregnancy. Sleep has a key role in maintaining a healthy immune system (body’s ability to fight infections), processing memories and emotions, keeping the mind sharp, and maintaining good energy levels.

During pregnancy, good sleep can provide benefits to the developing fetus and helps to reduce potential complications of pregnancy, summarized below. Maintaining good sleep practices in pregnancy can also help to prepare for the challenges of early parenthood.

Q. How much sleep do you need in pregnancy?

A. Nearly all adults need at least 7-9 hours of sleep, and there is some evidence that women need more sleep than men. It is not known if even more sleep is specifically needed during pregnancy.

Q. What happens to sleep in pregnancy and why do you feel so tired?

A. According to studies, 78-97% of people indicate that sleep is more disrupted during pregnancy than other times in their life.

There are many reasons for this as there are physical, hormonal, and psychological changes that can affect sleep:

Physical changes:

• as the uterus grows, the pressure on the bladder results in frequent urination that can wake people from sleep

• the growing uterus increases the pressure in the abdomen which decreases the space that the lungs can expand. This leads to shallower but quicker breathing, which can worsen pre-existing conditions like sleep apnea (a sleep disorder with repeated stops and starts of breathing during sleep)

• the increased abdominal pressure due to the growing uterus, as well as hormonal changes, may cause or worsen conditions like reflux (heartburn) which can be worse at night and interrupt sleep

• swelling in the upper airway can increase nasal congestion and can cause snoring

• back and pelvis discomfort and leg cramps can interrupt sleep, especially in the third trimester

• fetal movements can cause awakenings and discomfort in the night, especially in the third trimester

Hormonal changes:

• higher levels of progesterone and human chorionic gonadotropin (HCG) can increase body temperature and change circadian rhythms (body’s internal clock). These changes can disrupt sleep at night and cause daytime tiredness, which tends to be more prominent in the first trimester and usually improves in the second trimester

• oxytocin, a hormone which usually increases in the third trimester, can cause fragmented sleep

• estrogen cycles, especially in the third trimester, can worsen restless legs and cause nasal congestion leading to snoring. It also disrupts and decreases REM (dreaming) sleep – an important sleep stage

Psychological changes: Expectant parents begin to prepare for childbirth, parenting, and the upcoming major life changes. These, and any other stressors in day-to-day life, can impair sleep.

Other changes throughout pregnancy: In the third trimester, sleep stages become affected; people experience less deep sleep and less REM (dreaming) sleep.

Q. What does it mean to have “poor sleep”?

A. Poor sleep generally refers to the sensation that sleep is not restorative, making the person feel tired during the day. Poor sleep occurs when:

• there is a low quality of sleep. Low quality sleep may be experienced by frequent awakenings at night, or simply waking feeling tired

• there is a low quantity of sleep. Which means one is not getting enough sleep (i.e. sleep loss, sleep deprivation)

Research studies define sleep loss as sleeping less than 5-7 hours per night; although this may vary from person to person depending on their personal sleep needs.  Someone who needs 9 hours of sleep per night will be more sleep deprived from a 6-hour night than someone who needs 7 hours of sleep.  If you do not know how much sleep you need, think about how you sleep on weekends or on a long vacation. If you sleep in consistently, this may suggest that your weekly sleep is too short and that you are sleep deprived.

Q. Who is at risk of developing poor sleep in pregnancy?

A. Some of the factors that may increase one’s risk of poor sleep and sleep disorders in pregnancy are:

• history of anxiety or trauma

• crowded living environment with noisy or shared bedrooms

• irregular sleep habits (such as shift work or poor sleep hygiene)

• overweight or obesity

• smoking

• heart conditions 

• neurological conditions such as multiple sclerosis or peripheral neuropathy

• breathing conditions such as asthma

• anemia and/or low iron

Q. What sleep conditions are more likely to develop or worsen in pregnancy?

A. Many sleep disorders can develop or worsen in pregnancy. The most common being snoring, obstructive sleep apnea (OSA), restless legs syndrome, insomnia, and excessive daytime sleepiness (sleepiness which gets in the way of day-to-day activities). You can read more about these sleep conditions on the Health Topic Page.

Q. Can poor sleep affect the chances of getting pregnant?

A. There is evidence that poor sleep and irregular sleep schedules, such as shift work, may be associated with difficulties conceiving. More studies are needed to understand if there is a link between poor sleep and difficulties conceiving.

Q. Can poor sleep increase the chance of a miscarriage?

A. There may be an association between poor sleep and miscarriage. This has mostly been reported in women who worked night shifts. More studies are needed to understand if there is a link between poor sleep and miscarriages.

Q. Can poor sleep increase the chance of a birth defect?

A. Most pregnancies result in healthy babies, but there are chances of complications and unexpected outcomes. These chances are called baseline risks. In Canada, the baseline risk of major birth defects is 3-5%. This means that 3-5 out of 100 babies born in the general population in Canada will be born with a major birth defect. Studies have shown that children born to mothers with obstructive sleep apnea may be at a higher risk of major birth defects, however the available information does not suggest that poor sleep on its own increases the chance for birth defects.

Q. Can poor sleep increase the risk of other harmful pregnancy outcomes?

A. Poor sleep has been shown to have several effects on the pregnant individual and on the developing fetus.This has been demonstrated both for sleep loss (i.e. not getting enough sleep), and for poor quality sleep.

Studies have found that sleeping less than 5-7 hours per night during pregnancy increases the risk of:

• pregnancy induced hypertension (high blood pressure)

• preeclampsia (pregnancy-related high blood pressure condition)

• gestational diabetes

• placental abruption (when the placenta separates from the wall of the womb before birth)

• pre-term birth (birth before 37 weeks of pregnancy)

However, it is not clear if these outcomes were caused by the disrupted sleep cycle, other risk factors, or the combination of both.

Q. Can poor sleep affect labour and childbirth?

A. Women who sleep less than 6 hours per night during the last month of pregnancy are more likely to experience longer labour and have a higher risk of caesarean birth (c-section), even if the person does not feel tired.Poor sleep also increases pain sensitivity, and it has been shown that women with shorter sleep duration are more likely to report increased pain during labour.

Q. Can poor sleep in pregnancy affect the child’s health after birth?

A. A study reported that children who are born to mothers who slept less than 6 hours per day during pregnancy were more likely to be overweight and have higher blood pressure.

Q. What is the recommended sleep position in pregnancy?

A. As the pregnancy grows, sleeping on the back can cause the uterus to press on blood vessels which may lower blood pressure and may reduce the blood flow to the placenta and the growing baby. For this reason, sleeping on the side, particularly on the left side, is the suggested sleeping position after 28 weeks of pregnancy.

Sleeping on the back can increase the risk of developing OSA and worsen symptoms or severity of OSA. OSA can have effects on pregnancy. You can read more about these effects in our health topic on Snoring and Obstructive Sleep Apnea in Pregnancy.

Q. How to improve sleep in pregnancy?

A. Talk to a healthcare provider if you have any concerns about your sleep. Some strategies that can help improve sleep are:

• Keeping a regular schedule with a consistent bedtime and wake-up time that do not differ by more than an hour day-to-day.

• Waking up to bright light in the morning, whether by opening the blinds or by using a high luminosity light.

• Increasing nighttime sleep. Almost everyone requires minimum 7 hours of sleep per night. During pregnancy, aim for at least 7.5-8 hours of sleep, although some may need even more.

• Having a wind down routine for at least an hour before bedtime, such as a hygiene routine followed by reading a book or meditation. These routines can help settle the mind and signal it is time for bed.

• Avoiding screens one hour before bedtime. This allows the body to begin producing natural hormones like melatonin that signal it is time for bed.

• Keeping a notebook at the bedside table, to write down thoughts and reminders, can be helpful if worries and planning are keeping one awake.

• Taking a warm shower or bath may promote sleep.

• Avoiding stimulating substances such as caffeine, especially after noon.

• If you require a nap during the day, limit it to no more than 30 minutes and try not to nap after 3pm. You can find more information on napping here.

• Keeping active can improve sleep quality. Talk to your healthcare provider before increasing your activity level during pregnancy. You can find more information in Exercise during pregnancy.

• Limiting fluid intake 2 hours before bed to reduce nighttime washroom trips.

• Limiting meals and snacks before bed. Eating too close to bed can increase heartburn and discomfort during the night. Aim to have the last meal of the day at least 4 hours, and small snacks at least 2 hours, before bed.

• Try making yourself as comfortable as possible. Pregnancy pillows can promote side sleeping position, and an extra pillow between the knees or at the low back can help with comfort.

Q. When to talk to a healthcare provider about sleep?

A. It can be challenging to know if one’s sleep changes are due to pregnancy or a sign of an underlying medical or psychological condition.Talk to a healthcare provider about any concerns you have. Additionally, it is suggested talking with a healthcare provider if:

• You are sleeping too much (>9 hours per day) or too little (<6 hours).

• You are so tired during the day that you cannot complete necessary day-to-day tasks or are falling asleep during the day.

• You are excessively tired, despite getting at least 8-9 hours of sleep per night.

• You are snoring heavily, gasping awake, or someone tells you that you stop breathing in your sleep.

• You experience discomfort in your legs and a strong urge to move your legs, especially if this interrupts your sleep.

Q. What happens to sleep postpartum?

A. There are many physical and hormonal changes that happen after you give birth. With the added challenge of managing the sleep cycles of a new baby, getting good sleep may be hard. Sleep postpartum will not be discussed in detail here, but sleep is just as important after giving birth as in pregnancy.  Many of the strategies mentioned above to improve sleep during pregnancy can help with sleep afterwards.

Q. Is it okay to take medications for sleep during pregnancy?

A. In general, it is best to address sleep with habit and lifestyle changes. In fact, several studies (in non-pregnant women) specifically show that lifestyle changes such as regular exercise outperform sleeping medications. There are some cases when sleeping medications are required. Whether or not a sleeping medication is indicated, and its safety during pregnancy, should be discussed with a healthcare provider on an individual basis.

Q. Are dreams and nightmares more common during pregnancy?

A. Some patients report that dreams become more vivid or more emotional during pregnancy. Dreaming occurs during REM sleep, which is disrupted particularly during the third trimester, contributing to changes in dreaming. Dreaming is a highly emotional state, and the changes that occur during pregnancy may also contribute to dream content.  People who have a pre-pregnancy history of mental health concerns such as depression or trauma may be particularly prone to dream changes, especially disturbing or emotional dreams.  Dreaming itself should not be a cause for concern, but if the dreams are troubling to the person, it should be discussed with a healthcare provider.

Q. Where to get more information?

A. Resources for Patients

Sleep On It Canada: Becoming parents and the lack of sleep

Sink into Sleep

MGH CENTER for Women’s Mental Health: Sleep Resource Hub

Sleepio App