design-pregnancy-sleep-protocol

Design Pregnancy Sleep Protocol

Address pregnancy-specific sleep challenges with positioning, environment, and evidence-based interventions.

Why This Is Best Practice

Adopted by: ACOG, NHS, RCOG — all publish sleep positioning guidance after 28 weeks. Impact: Going to sleep in the supine position after 28 weeks associated with 2.54× increased stillbirth risk (Gordon et al., BJOG 2015; n=1,000 cases). Side-sleeping (SOS — Sleep On Side) adopted in NHS and ACOG recommendations as a result. Treating insomnia in pregnancy reduces postpartum depression risk by 40% (Bei et al., BMC Med 2018). Why best: Sleep changes in all three trimesters require different interventions. Blanket "try to sleep more" advice misses treatable causes.

Steps

1. After 28 weeks: Sleep On Side (SOS):
   • Left or right side — both are safe; left slightly preferred (optimizes IVC flow)
   • Place pillow between knees to reduce hip/back pressure
   • Use a U-shaped or C-shaped pregnancy pillow behind back to prevent rolling supine
   • If you wake on your back, calmly roll to your side — waking up supine is not an emergency
2. First trimester nausea/insomnia: elevate head of bed 30°; eat small snack before bed; ginger tea.
3. Third trimester heartburn: same 30° elevation; avoid eating within 2–3 hours of sleep.
4. Restless Legs Syndrome (RLS) — affects 20–26% of pregnant women:
   • Increase iron intake (check serum ferritin; target >75 mcg/L)
   • Magnesium 300 mg before bed (consult provider)
   • Leg stretches and cool compresses before bed
   • Reduce caffeine; avoid antihistamines (worsen RLS)
5. Insomnia management (CBT-I principles adapted for pregnancy):
   • Set consistent sleep/wake time; do not stay in bed awake >20 minutes
   • Reserve bed for sleep only; no screens in bed
   • Relaxation: progressive muscle relaxation, breathing exercises
6. Avoid diphenhydramine (Benadryl) for sleep — ACOG advises caution in pregnancy; doxylamine/B6 (Diclegis) is the preferred option if pharmacologic treatment needed.

Rules

• Do not sleep on your back for extended periods after 28 weeks.
• Zolpidem and other sedative-hypnotics are not approved for use in pregnancy — avoid.
• Rule out sleep apnea if snoring develops (associated with preeclampsia and GDM).

Examples

Setup: Firm mattress + C-shaped pillow behind back + pillow between knees + head elevated 2–3 inches. RLS management: Check ferritin at 28-week visit; if <50 mcg/L, discuss iron supplementation increase with OB.

Common Mistakes

• Panicking about occasional supine sleep — the risk is elevated supine sleep throughout the night, not brief repositioning.
• Ignoring RLS as "just discomfort" — iron deficiency is a treatable cause that also affects fetal development.
• Using melatonin without provider guidance — crosses placenta; evidence on fetal safety is limited.

Health Disclaimer: Sleep disorders in pregnancy may indicate underlying conditions (anemia, obstructive sleep apnea, depression). Persistent insomnia or RLS warrants evaluation by your OB-GYN or a sleep medicine specialist.