Postpartum sleep for Chinese-American mothers who experienced cesarean birth compared to vaginal birth

1. Postpartum sleep for Chinese-American mothers who experienced cesarean birth compared to vaginal birth Shih-Yu Lee RNC, PhD Byrdine F. Lewis School of Nursing Georgia State University

2. Significance of the Research Sleep is necessary for physical and psychological health. Maternal mental health is a major factor affecting the quality of parenting, which influences a child�s developmental outcomes. Objective sleep studies of mothers during the first week of postpartum recover are rare. Objective sleep studies of mothers during the first week of postpartum recover are rare. Studies of impaired sleep and fatigue in mothers with an infant cared in the ICU are rare. No report on sleep patterns of hospitalized mother after cesarean delivery. Objective sleep studies of mothers during the first week of postpartum recover are rare. Studies of impaired sleep and fatigue in mothers with an infant cared in the ICU are rare. No report on sleep patterns of hospitalized mother after cesarean delivery.

3. Sleep Regulation Schematic representation of the three major processes underlying sleep regulation. W, waking; S, sleep; N, nonREM sleep; R, REM sleep. The progressive decline of nonREM sleep intensity is represented both in the top and bottom diagrams (decline of ultradian amplitude). The increase in the duration of successive REM sleep episodes is indicated. Process S and Process C are conceptually separate processes but they are not independent. Process S, a measure of sleep need, depends on the pattern of sleeping and waking. Process C serves to maintain sleep as process S decline during the night and to maintain alertness as process S increases during the day (Borbely & Achermann, 2000). NREM sleep intensity is determined primarily by the homeostatic process, while the ratio of REM and NREM sleep depends on both homeostatic and circadian factors. Thus, mechanisms or factors that either oppose or enhance process S and/or process C can have significant effect on the timing, duration, and structure of sleep as well as daytime functioning. Schematic representation of the three major processes underlying sleep regulation. W, waking; S, sleep; N, nonREM sleep; R, REM sleep. The progressive decline of nonREM sleep intensity is represented both in the top and bottom diagrams (decline of ultradian amplitude). The increase in the duration of successive REM sleep episodes is indicated. Process S and Process C are conceptually separate processes but they are not independent. Process S, a measure of sleep need, depends on the pattern of sleeping and waking. Process C serves to maintain sleep as process S decline during the night and to maintain alertness as process S increases during the day (Borbely & Achermann, 2000). NREM sleep intensity is determined primarily by the homeostatic process, while the ratio of REM and NREM sleep depends on both homeostatic and circadian factors. Thus, mechanisms or factors that either oppose or enhance process S and/or process C can have significant effect on the timing, duration, and structure of sleep as well as daytime functioning.

4. Functions of Sleep Restore energy, immune function, insulin and glucose metabolism. Replenish neuroendocrine system. secretion of growth hormone. secretion of cortisol. secretion of prolactin. Process new information/learning. Memory, Learning and Social Processes � Sleep enables the brain to encode new information and store it properly. REM sleep activates the parts of the brain that control learning. The parts of the brain that control emotions, decision-making and social interactions slow down dramatically during sleep, allowing optimal performance when awake. Nervous System � Some sleep experts suggest that neurons used during the day repair themselves during sleep. When we experience sleep deprivation, neurons become unable to perform effectively and the nervous system is impaired. Immune System � Similarly, sleep also enables the immune system to function effectively. During deep sleep, the body�s cells increase production while proteins break down at a slower rate. Without proper sleep, the immune system becomes weak and the body becomes more vulnerable to infection and disease. Growth and Development � Children need much more sleep than adults. Growth hormones are released during sleep, so sleep is vital to proper physical and mental development. The effects (positive and negative) of sleep for babies and children are magnified. Tired children are often cranky, fussy and become easily frustrated and difficult. It is often easier for adults to interpret and remedy the effects of tiredness in children than for them to listen to their body�s own signals for more rest. Interleukin-6 (IL-6) is associated with excessive daytime sleepiness. Immune molecules alter sleep architecture. Many cytokines affect sleep, each individually in different ways (e.g. IL-1, -2, -15, -18, TNF, Interferon). Different combinations of cytokines expressed during infection may have different overall effects on sleep. Prolactin is a single-chain protein hormone closely related to growth hormone. It is secreted by so-called lactotrophs in the anterior pituitary. It is also synthesized and secreted by a broad range of other cells in the body, most prominently various immune cells, the brain and the decidua of the pregnant uterus. Prolactin stimulates breast development and milk production in women. There is no known normal function of prolactin in men. Memory, Learning and Social Processes � Sleep enables the brain to encode new information and store it properly. REM sleep activates the parts of the brain that control learning. The parts of the brain that control emotions, decision-making and social interactions slow down dramatically during sleep, allowing optimal performance when awake. Nervous System � Some sleep experts suggest that neurons used during the day repair themselves during sleep. When we experience sleep deprivation, neurons become unable to perform effectively and the nervous system is impaired. Immune System � Similarly, sleep also enables the immune system to function effectively. During deep sleep, the body�s cells increase production while proteins break down at a slower rate. Without proper sleep, the immune system becomes weak and the body becomes more vulnerable to infection and disease. Growth and Development � Children need much more sleep than adults. Growth hormones are released during sleep, so sleep is vital to proper physical and mental development. The effects (positive and negative) of sleep for babies and children are magnified. Tired children are often cranky, fussy and become easily frustrated and difficult. It is often easier for adults to interpret and remedy the effects of tiredness in children than for them to listen to their body�s own signals for more rest. Interleukin-6 (IL-6) is associated with excessive daytime sleepiness. Immune molecules alter sleep architecture. Many cytokines affect sleep, each individually in different ways (e.g. IL-1, -2, -15, -18, TNF, Interferon). Different combinations of cytokines expressed during infection may have different overall effects on sleep. Prolactin is a single-chain protein hormone closely related to growth hormone. It is secreted by so-called lactotrophs in the anterior pituitary. It is also synthesized and secreted by a broad range of other cells in the body, most prominently various immune cells, the brain and the decidua of the pregnant uterus. Prolactin stimulates breast development and milk production in women. There is no known normal function of prolactin in men.

6. Summary of Relevant Research Sleep disturbance is common in mothers of healthy newborn (Gay, Lee, & Lee, 2003; Shinkoda et al., 1999). Impaired sleep is part of diminished well-being during the postpartum period (Lee, 2003; Hiscock & Wake, 2001). Fatigue is a major concern during the postpartum period, and it was more severe for those who had a cesarean delivery (Maloni & Park, 2005). The characteristics of postpartum sleep include less TST and more wake time. The characteristics of postpartum sleep include less TST and more wake time.

7. Purpose of the Study To describe the nature of sleep and fatigue for mothers during the first week of postpartum recovery while their infants remained in ICU. Explore differences in sleep and fatigue during the first postpartum week between women after cesarean delivery while still hospitalized compared to woman after vaginal delivery and discharged to home.

8. Conceptual Model of Impaired Sleep Sleep Deprivation Sleep Disruption Inadequate amount of sleep Fragmented sleep due to: due to: Delayed bedtime Environmental noxious Early wake time Caffeine Multiple roles Stress/Anxiety Circadian phase Health conditions desynchronosis Developmental adaptations Adverse Health Outcomes Physiological Cognitive/behavioral Emotional Social (K. Lee, 2003) Impairs daytime function Traffic accidents Difficulty concentration, memory problems Less able to enjoy social activities High risk for depression, anxiety, and problems with substance abuse Potential for impaired immunity, impaired stress response, metabolic disturbances (insulin resistance) Impairs daytime function Traffic accidents Difficulty concentration, memory problems Less able to enjoy social activities High risk for depression, anxiety, and problems with substance abuse Potential for impaired immunity, impaired stress response, metabolic disturbances (insulin resistance)

9. Research Design Cross-sectional descriptive design. Convenience sampling. Settings: Neonatal ICU in three teaching hospitals in San Francisco area.

10. Instruments (English/Chinese version) Sleep diary Numerical Rating Scale-Fatigue (Lee, 1992) General Sleep Disturbance Scale (Lee et al., 1991) Wrist actigraph non-invasive motion monitor

12. Sample Characteristics- mothers All 21 mothers reported that they were breast-feeding their infants. However, because of the infant�s medical condition only one mother in the CD group was able to breast-feed her baby and the other mothers were pumping and storing their breast mild. During the data collection period, only one mother from the CD group got up during the night to pump. There were no significant differences in demographic variables between the two groups. All 21 mothers reported that they were breast-feeding their infants. However, because of the infant�s medical condition only one mother in the CD group was able to breast-feed her baby and the other mothers were pumping and storing their breast mild. During the data collection period, only one mother from the CD group got up during the night to pump. There were no significant differences in demographic variables between the two groups.

13. Sample Characteristics- Infants

14. Results for Objective Sleep Data TST was significantly less than the TST indicated by mothers (477, SD= 46) and fathers (457, SD= 56)) to be requires to restore their energy. This is the first study to objectively document that sleep is considerably worse for hospitalized women after cesarean births compared to the same time frame for women discharged and sleeping at home after vaginal deliveries. The higher percentage of day sleep among the cesarean birth mother may resulted from sleep debt from night time. TST was significantly less than the TST indicated by mothers (477, SD= 46) and fathers (457, SD= 56)) to be requires to restore their energy. This is the first study to objectively document that sleep is considerably worse for hospitalized women after cesarean births compared to the same time frame for women discharged and sleeping at home after vaginal deliveries. The higher percentage of day sleep among the cesarean birth mother may resulted from sleep debt from night time.

15. Actigraphy Example This is one of the study participants from my dissertation project who had an new born infant hospitalized in ICU and she only slept about 3 hrs (183 minutes) and her WASO was 52.61%This is one of the study participants from my dissertation project who had an new born infant hospitalized in ICU and she only slept about 3 hrs (183 minutes) and her WASO was 52.61%

16. Results for Subjective Sleep Data The higher level of morning fatigue in the CD group may be a result of awakening more during the night and getting less total sleep due to surgical recovery as well as postpartum recovery. Previous studies show that mothers of medically fragile infants are at risk for depression during the first year of the infant�s life, and maternal depression affects infant growth and development. Sleep problem is one of the earliest sign of depression. The higher level of morning fatigue in the CD group may be a result of awakening more during the night and getting less total sleep due to surgical recovery as well as postpartum recovery. Previous studies show that mothers of medically fragile infants are at risk for depression during the first year of the infant�s life, and maternal depression affects infant growth and development. Sleep problem is one of the earliest sign of depression.

17. Correlation between fatigue and sleep variables

18. Conclusion Cesarean birth mother had significantly shorter TST compared to vaginal birth mother. Cesarean birth mothers had significantly more fragmented sleep and wake time during the night. Cesarean birth mother had significantly higher daytime sleep. Both groups of mothers reported similar levels of overall sleep disturbances, poor sleep quality, and daytime sleepiness. Cesarean birth mothers experienced higher morning fatigue and lower evening fatigue. CD mother slept two hours less than VD mothers. Daytime sleep 10% on CD mothers, 3% on VD mothers. Sleep loss may lead to poor physical and cognitive function, and both are needed for the mother to participate in caretaking during the infant�s hospitalization and subsequent hospital discharge. Providing optimal parenting to medically ill infant may be jeopardized by a mother�s lack of sleep. Maternal mental health is a major factor affecting the quality of parenting, which impacts children�s developmental outcomes. Mother reported night awake due to need to use the bathroom, uterine cramping. Onlyy one CD other indicated that her sleep was interrupted by hospital staff interventions. CD mother slept two hours less than VD mothers. Daytime sleep 10% on CD mothers, 3% on VD mothers. Sleep loss may lead to poor physical and cognitive function, and both are needed for the mother to participate in caretaking during the infant�s hospitalization and subsequent hospital discharge. Providing optimal parenting to medically ill infant may be jeopardized by a mother�s lack of sleep. Maternal mental health is a major factor affecting the quality of parenting, which impacts children�s developmental outcomes. Mother reported night awake due to need to use the bathroom, uterine cramping. Onlyy one CD other indicated that her sleep was interrupted by hospital staff interventions.

19. Conclusion Mothers had less nocturnal TST experienced higher morning fatigue severity. Higher morning fatigue was related to high total day sleep time. Mothers with high morning fatigue severity reported more sleep disturbance, lower sleep quality, and more daytime sleepiness and poorer daytime function. Morning fatigue was similar between two groups however, the CD mother slept over 10% during day time and the VD mother only sleep about 3% during day time. This might related to VD mothers need to come to hospital to visit baby or they have been longer time exposure to sunlight. Morning fatigue was similar between two groups however, the CD mother slept over 10% during day time and the VD mother only sleep about 3% during day time. This might related to VD mothers need to come to hospital to visit baby or they have been longer time exposure to sunlight.

20. Implications for Clinical Practice: Sleep assessment Questions to ask- Longer than 30 minutes to fall asleep on 3 or more nights/week. Awakenings during the night more than 2 nights/week. Falling asleep during the day without deliberate effort. Use anything to assist sleep. Provide information to improve mother�s sleep Researchers have called attention to management of sleep during early postpartum recovery to improve childbering women�s quality of life, research focused on sleep and fatigue in mothers with a critically ill infant is rare. The standard of care for parents with a hospitalized infant includes providing information and supportive coping strategies. However, information to improve their sleep remains a neglected area that may be critical for helping new mothers cope more effectively with short- and long-term stress related to their vulnerable infant�s recovery and growth and development. Researchers have called attention to management of sleep during early postpartum recovery to improve childbering women�s quality of life, research focused on sleep and fatigue in mothers with a critically ill infant is rare. The standard of care for parents with a hospitalized infant includes providing information and supportive coping strategies. However, information to improve their sleep remains a neglected area that may be critical for helping new mothers cope more effectively with short- and long-term stress related to their vulnerable infant�s recovery and growth and development.

21. Implications for Future Study Larger sample size and in various ethnic groups studies are needed. Methodological issues: longitudinal study The relationship between labor and delivery experience, and maternal sleep and fatigue and health outcomes need to be further examined. The sleep regulation among the mothers have a medically ill infant need to be further explored. Intervention to promote maternal sleep and lessen fatigue is needed. Intervention to promote maternal sleep and well-being is needed. This analysis was based on a small convenience sample of Chinese American mothers from one region of the United States who had stable, but hospitalized newborns. Although the findings are limited to well-educated who aged above 30 and married or living with a partner; however, it would suggest that new mothers with a hospitalized infant are in a stressful situation and vulnerable to inadequate sleep, especially those who are still hospitalized and recovering from cesarean surgical delivery. Generalizability is limited by the small sample size, the use of a convenience sample form only one ethnic group, and one geographic location Include different geographic locations, different generations, other minority ethno-cultural groups, more diverse socioeconomic groups, different health problems in different illness stage (acute & chronic) and child�s different developmental periods. This analysis was based on a small convenience sample of Chinese American mothers from one region of the United States who had stable, but hospitalized newborns. Although the findings are limited to well-educated who aged above 30 and married or living with a partner; however, it would suggest that new mothers with a hospitalized infant are in a stressful situation and vulnerable to inadequate sleep, especially those who are still hospitalized and recovering from cesarean surgical delivery. Generalizability is limited by the small sample size, the use of a convenience sample form only one ethnic group, and one geographic location Include different geographic locations, different generations, other minority ethno-cultural groups, more diverse socioeconomic groups, different health problems in different illness stage (acute & chronic) and child�s different developmental periods.

22. Acknowledgements Symptom Management Fellowship (NINR, T32 NR07088); Research Award, UCSF Graduate Division. Participants Dr. Kathryn A. Lee Dr. Sally H. Rankin Dr. Abbey Alkon Dr. Sandra J. Weiss Managers and staffs from Children�s Hospital at UCSF, SFGH, and CPMC