The Complete GP’s Guide to Postpartum Insomnia

The first year of motherhood took me by surprise. I’d gone through life thinking I found most things fairly manageable, that I could cope with most of what got thrown at me. Then all of a sudden, there I was with a baby, thinking this is really, really hard.

Sleep was a big part of that. I’d done night shifts as a doctor, so I thought I knew what running on very little looked like. The difference is that a stretch of night shifts has an ending. You can see it, and you just have to get to it. With a baby, it feels like this will never end. Of course it does. It just doesn’t feel that way at three in the morning in week six.

What I want to do here is separate two things that are often bundled together because they need different answers. Being woken by a baby is one problem. Not being able to sleep when you finally do get the chance is a different one, and it has a name: postpartum insomnia.

The baby is down, the house is quiet, and you still can’t drop off. Or it’s the afternoon, you’ve got a window with a chance to nap, and sleep just won’t come.

Being woken by the baby is the other problem, and the two run together. Your chances of sleeping are cut short because the baby wants to be awake, and then the sleep you could have had doesn’t arrive either. It’s a double whammy.

It’s also worth saying plainly that some of this is just the period of life you’re in. With most sleep problems, I can offer strategies. When you’ve got a waking child, there’s a limit to what any of those strategies can do, and pretending otherwise isn’t helpful.

In those first few months, broken sleep and exhaustion are extremely common, but that doesn’t mean every symptom should automatically be attributed to having a baby. It can take more than one good night’s sleep to recover from prolonged sleep deprivation. If you’re persistently exhausted, struggling to function or experiencing other symptoms, it’s worth speaking to your GP rather than assuming it’s simply part of new motherhood.

Your hormones are falling fast

After giving birth, levels of oestrogen and progesterone fall rapidly. This dramatic hormonal shift can contribute to disrupted sleep, night sweats and changes in mood. Some of these symptoms can feel remarkably similar to those experienced during perimenopause or menopause, although the underlying hormonal circumstances are different.

If you’ve been reading about menopause symptoms and thinking they sound oddly familiar, that’s why. It’s the same direction of travel, just over weeks rather than years.

You’re in a very different psychological space

After giving birth, you might be dealing with changes to your mood or anxiety, even if it isn’t postnatal depression. You may have had a traumatic birth and be living with the consequences of that. You may be mourning your old life, which many women feel guilty about. You can love your baby completely and still miss the life you had, and both of those things can be true at once. It’s a genuinely enormous shift, particularly with a first baby.

You’re listening even in your sleep

Hypervigilance comes up constantly after becoming a parent, and almost always from mums rather than dads. Some part of you stays on duty all night, so every sniffle, every sound and every absence of sound registers.

A degree of this is completely normal, and it’s why you wake when the baby needs you. It becomes worth raising with your midwife, health visitor or GP when it’s the reason you’re not sleeping at all, or when it tips over into something that frightens you, which I’ll come to.

The baby blues

The baby blues typically arrive three to five days after giving birth. They’re a very common response to the change in hormones and the sleep deprivation, and the NHS notes they usually go within two weeks of the birth. For a lot of women, the first couple of days feel like cloud nine, and then it hits.

It looks like bursting into tears, snapping at the people you love, feeling exhausted but unable to sleep, feeling worried, and baby brain in a big way.

I was told in advance that on about day five, I’d just burst into tears. When it happened, I was in the shower doing exactly that, and because somebody had warned me, I recognised it. Oh, here it is. This is the thing I was told to look out for. Knowing it was coming made an enormous difference, which is the main reason I’m spelling it out here.

The baby blues usually settle without medical treatment, but that doesn’t mean you should simply have to struggle through them. Rest, reassurance and practical support from the people around you can make an enormous difference. If symptoms are severe, worsening or lasting beyond two weeks, it’s important to seek professional advice.

Postnatal depression

If low mood, anxiety or sleep difficulties are persisting beyond the first couple of weeks, or are becoming more severe, please ask for help. Postnatal depression can develop at any point during the first year after giving birth, and sometimes begins during pregnancy. It’s common and treatable, but recovery varies considerably from person to person. With appropriate support and treatment, most women improve, although some take longer than others.

The thing I most want to get across is that it’s common, treatable, and not your fault. It isn’t anything you’ve done. Nobody you tell will be shocked by it. Your midwife, health visitor and GP deal with this constantly.

Postnatal anxiety

Postnatal anxiety gets far less attention than it should. Depression tends to show up as low mood, hopelessness and an inability to feel joy in things you’d normally enjoy, which we call anhedonia. Anxiety looks different. It’s hypervigilance, it’s being permanently on edge, and it’s intrusive thoughts.

Unwanted, intrusive thoughts about something bad happening to your baby are surprisingly common after giving birth. Having these thoughts doesn’t mean you want them to happen or that you’re going to act on them. However, if they’re persistent, distressing or affecting your ability to care for yourself or your baby, it’s important to seek professional support. Postnatal anxiety and obsessive-compulsive disorder can both involve intrusive thoughts, and effective treatments are available.

I think I had postnatal anxiety myself, if I’m honest. I was very on edge and very hyperactive, running around doing everything at double speed.

If any of that sounds like you, you don’t have to wait for somebody to ask or for the six-week check to come around. Ring your GP surgery and say it’s about your mental health. They should be able to see you sooner. Out of hours, 111 will help. And if you ever feel you can’t keep yourself or your baby safe, please treat that as an emergency and call 999.

Postpartum psychosis – a rare but important emergency

Postpartum psychosis is rare, but it’s a medical emergency that usually develops suddenly in the first two weeks after giving birth. Symptoms can include extreme changes in mood, confusion, hallucinations, unusual beliefs or feeling unusually energetic and needing very little sleep. This is different from ordinary insomnia or anxiety. If you or someone close to you notices these symptoms, seek urgent medical assessment the same day. If there’s an immediate risk to safety, call 999.

Pick one or two of these. A baby wakes and cries because that’s how they communicate, so that part of it stays as it is. What you can do is protect the sleep you can control and stop the rest from making you feel worse:

• Sleep when you can: Especially in the first fortnight, don’t try to plan the day around sleep. Take it where it appears.
• Say no to visitors: You’re allowed to. The hour you spend making tea for somebody is an hour you could have spent asleep.
• Protect the window when the baby is down: That stretch is the bit you have some say over, so treat it as the thing to guard rather than the time to catch up on the washing.
• Leave the clock alone: Working out how much sleep you’ve had, or how much you might still get, turns a bad night into arithmetic. Don’t look.
• Get outside in the first hour of the day: Even on a grey day, even for a few minutes with the pram. Outdoor light is far stronger than indoor lighting, and it helps reset your body clock, which pays off that evening.

Your postnatal GP check, usually offered at six to eight weeks, is an important opportunity to talk about your own physical and mental health. Your midwife and health visitor should also be checking how you’re feeling, but you don’t have to wait for a scheduled appointment if you’re struggling.

The difficulty with that appointment is that it’s two appointments, one for you and one for the baby, and in practice, both the doctor and the mum tend to focus on the baby. The baby ends up taking most of the time, and what’s left for you is usually a few quick screening questions. It’s very easy at that point to say yes, yes, I’m fine, and then ask something else about the baby.

Please try not to. Answer with more than one word, and answer as honestly and as openly as you can. That’s your opportunity, and it may be the only time anyone asks you directly.

In an ideal world, the six-week check wouldn’t be the whole of it. We should be doing much more for women at this stage than we currently do. Until that changes, use the appointment you’ve got, and don’t wait for it if you’re struggling now.

A lot of new parents don’t ring the GP first. They go online, and many of them turn to social media before anywhere else. I’d rather meet them there than pretend otherwise.

So, if that’s where you’re looking, look at who is telling you. Someone being brilliant at their own job doesn’t make them a source of sleep advice, and something working beautifully for one family doesn’t mean it’ll work for yours. Check whether the person has the credentials to give you the information, and whether what they’re giving you is evidence-based.

Opinions are fine, and you’ll get plenty of those unsolicited from family and friends. But if you want evidence-based advice, you have to go to evidence-based places. The NHS website and Tommy’s are both good. If you’re using AI to look things up, ask it for resources that carry NHS approval rather than taking the answer at face value.

It’s the standard I hold myself to as well. Even in putting this together, I’ve been checking against guidance from the NHS, the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists rather than going from memory.