Abstract
Background:
Sleep and physical activity are key postpartum recovery domains. We compared inpatient postpartum sleep and activity following vaginal and scheduled cesarean deliveries using wrist based actigraphy.
Methods:
This prospective, single center cohort study used actigraphy worn throughout hospitalization to explore differences in inpatient postpartum sleep and activity.
Results:
Of 78 patients enrolled, 61 were fully analyzed. Sleep was poor in both groups, (median sleep-bout duration 3.6 h). Sleep efficiency, total sleep time, wake after sleep onset were similar between groups. Average sleep movement index (5.4 vs. 7.2) and sleep fragmentation index (5.6 vs. 19.0) were lower after vaginal than cesarean delivery, but neither difference survived correction for multiple comparisons. Cesarean patients recorded significantly greater sedentary and light activity on days 0–2, these differences remained after correction for multiple comparison.
Conclusion:
Inpatient sleep was poor in both delivery modes. Sleep restlessness indices were lower after vaginal delivery but non-significant following multiple comparison; greater early sedentary and light activity was greater following cesarean delivery and persisted following correction. The clinical meaningfulness of these exploratory differences are unknown and require confirmation in adequately powered studies.
Keywords: Actigraphy, Activity, Cesarean delivery, Postpartum recovery, Sleep
Introduction
Adequate sleep is critical to mental and physical health and impacts maternal-infant bonding.1 Sleep is a key domain of postpartum recovery,2,3 and sleep disorders are common after childbirth.4 Disturbed sleep and post-delivery pain are bidirectionally related5,6 yet objectively collected inpatient sleep data after childbirth are limited.
Early postoperative mobilization is associated with improved maternal outcomes and is an integral component of enhanced recovery protocols.7–9 However, data comparing delivery modes beyond the first 24 h are lacking.10 Wrist-based actigraphy is a validated and objective way to measure activity11 and sleep/wake cycles, correlating well with polysomnography across consecutive days.12 Previous studies have reported inpatient actigraphy after scheduled cesarean delivery alone13,14 The present study extends this by comparing two delivery modes across the entire inpatient stay.
We aimed to compare inpatient postpartum sleep and activity following vaginal or scheduled cesarean delivery and to assess the feasibility of continuous monitoring, hypothesizing that metrics associated with better sleep and physical activity would favor vaginal delivery.
Methods
Following institutional review board approval and registration (NCT05065203), we conducted a single-center cohort study following STROBE guidelines15 at an academic tertiary center. Patients planning vaginal or scheduled cesarean delivery were prospectively enrolled on admission between October 2021 and November 2022, consecutively by research-staff availability. Each wore an ActiGraph GT9X Link device (ActiGraph, Pensacola, FL, USA on the non-dominant wrist from before delivery until their discharge, initialized with sex, height and weight, age, and hand dominance. Demographic, obstetric, anesthetic, and neonatal variables were collected via REDCap.
Inclusion criteria were ≥ 18 years and a live pregnancy planned for vaginal or scheduled cesarean delivery. Exclusion criteria were assisted vaginal delivery, weekend or critical care admission, inability to comprehend English, known sleep disorder, pre-admission opioid or steroid use; or significant autoimmune, neurological, or neurodevelopmental disorders. All patients were cared for in private rooms with ensuite bathrooms, with birth partners encouraged to stay overnight. Cesarean patients received a standardized multimodal regimen under our Enhanced Recovery After Cesarean (ERAC) institutional protocol; patients undergoing a vaginal delivery received scheduled acetaminophen and ibuprofen, with opioids reserved for severe pain. Vital signs were typically monitored every 4 h for the first 24 h after vaginal delivery, but every 15–30 min for the first 2 h after cesarean delivery before reverting to 4-hourly.
Sleep metrics included efficiency, total sleep time (TST; mean duration of algorithm-detected sleep bouts), wake after sleep onset (WASO) number and length of awakenings, activity counts, sleep movement index, the fragmentation index, and the sleep fragmentation index. Sleep periods were identified using the Tudor-Locke algorithm with default settings, which analyses the full recording and returns all qualifying rest intervals rather than a single interval per 24 h; all reported sleep metrics are therefore means across the intervals detected for each participant, and secondary and daytime rest intervals were captured rather than excluded. The three restlessness indices have previously been defined.16 The sleep movement index is the percentage of epochs with y-axis counts greater than zero during the sleep period. The fragmentation index is the percentage of one-minute periods of sleep relative to all periods of sleep during the sleep period. The sleep fragmentation index is the arithmetic sum of these two indices and provides an estimate of restlessness; it is therefore not independent of its components. Physical activity was classified as sedentary, light, or moderate. Non-wear time was detected by the device algorithm and confirmed by manual ActiLife review with cross-referencing to clinical notes; participants with <24 h valid wear time were excluded. Measured variables and definitions are found in Supplementary Table 1.
This was an exploratory analysis of a convenience sample size, in line with previous studies.13 Statistical analyses use STATA (V 18.0, College Station, TX). Normally distributed continuous variables were compared using the t-test and presented as mean ± standard deviation (SD); non-normally distributed continuous variables were compared using the Mann-Whitney U test and presented as median with interquartile range [IQR]. Categorical variables were compared using Fisher’s exact test. ActiGraph’s data analysis platform (ActiLife v6.13.3) was used for feature extraction with Tudor-Locke sleep-detection and Cole-Kripke sleep/wake algorithms.17,18 The Benjamini-Hochberg procedure (false discovery rate 0.05) was applied separately to: the nine pre-specified sleep-metric comparisons, and all twenty recorded activity comparisons (sedentary, light, moderate, vigorous and very vigorous activity on postpartum days 0–3).
Results
Of 136 patients approached, 78 were enrolled and 17 excluded (9 patients underwent intrapartum cesarean delivery, 1 withdrew and 7 had insufficient data), resulting in 61 patients. Patients’ demographic data are reported in Table 1. The cesarean cohort had higher body mass index (BMI), was more frequently multiparous, having had previous cesarean delivery and greater blood loss. There were no differences in Apgar scores, neonatal intensive care admission, transfusion, or breastfeeding at hospital discharge.
Table 1.
Demographic, obstetric, anesthetic and neonatal care characteristics of patients. Values are mean (SD), median (IQR [range]) or number n (percentage).
| Vaginal delivery (n = 28) |
Cesarean delivery (n = 33) |
P value | |
|---|---|---|---|
|
| |||
| Demographics | |||
| Maternal age; (years) | 33.8 ± 5.6 | 36.0 ± 5.5 | 0.13 |
| BMI (kg/m2) median (IQR [range]) | 26.3 (25.0–30.2[20.7–40.4]) | 29.4 (27.0–32.9[24.0–39.0]) | 0.008 |
| Self-reported racial group | 0.34 | ||
| Asian, n | 12 (42.9%) | 7 (21.2%) | |
| Black or African American, n | 1 (3.6%) | 0 (0%) | |
| Native American, n | 0 (0%) | 1 (3.0%) | |
| White, n | 10 (35.7%) | 15 (45.5%) | |
| None of the above or unknown, n | 4 (14.3%) | 8 (24.2%) | |
| Other, n | 1 (3.6%) | 2 (6.1%) | |
| Self-reported Hispanic or Latina | 4 (14.3%) | 8 (24.2%) | 0.52 |
| Highest level of education | 0.63 | ||
| High school graduate, n | 1 (3.6%) | 1 (3.0%) | |
| Some college/associate degree, n | 3 (10.7%) | 8 (24.2%) | |
| College degree, n | 5 (17.9%) | 4 (12.1%) | |
| Postgraduate, n | 19 (67.9%) | 20 (60.6%) | |
| Household income per annum | 0.54 | ||
| < $25,000 | 1 (3.6%) | 0 (0%) | |
| $25,001-$50,000 | 1 (3.6%) | 5 (15.2%) | |
| $50,001-$100,000 | 1 (3.6%) | 2 (6.1%) | |
| $100,001-$150,000 | 3 (10.7%) | 3 (9.1%) | |
| > $150,000 | 22(78.6%) | 22 (66.7%) | |
| Not known | 0 (0%) | 1(3.0%) | |
| Obstetric characteristics | |||
| Parity | <0.0001 | ||
| Nulliparous, n | 18 (64.3%) | 6 (18.2%) | |
| Multiparous, n | 10 (35.7%) | 27 (81.8%) | |
| Gestational age (weeks) | 39.8 (2.2%) | 38.8 (0.9%) | 0.002 |
| Previous cesarean delivery, n | 0 (0%) | 22(66.7%) | <0.0001 |
| Quantitative blood loss | <0.0001 | ||
| ≤500 mL | 25 (89.3%) | 10 (30.3%) | |
| 500–1500 mL | 3 (10.7%) | 22 (66.7%) | |
| > 1500 mL | 0 (0%) | 1 (3.0%) | |
| ASA physical status prior to delivery | 0.62 | ||
| 2, n | 27 (96.4%) | 30 (90.9%) | |
| 3, n | 1 (3.6%) | 3 (9.1%) | |
| Anesthesia technique | <0.0001 | ||
| Epidural, n | 28 (100%) | 0 (0%) | |
| Spinal, n | 0 (0%) | 20 (60.6%) | |
| Combined spinal epidural, n | 0 (0%) | 12 (36.4%) | |
| General anesthesia | 0 (0%) | 1 (3.0%) | |
| Neonatal (missing n = 2) | |||
| Neonatal intensive care, n | 0 (0%) | 1 (3.0%) | 1.0 |
| Apgar score at 5 min | 9 (9–9[8–9]) | 9 (9–9[7–9]) | 0.068 |
ASA: American Society of Anesthesiologists; BMI: body mass index; IQR: inter quartile range; SD: standard deviation; n: number. Values presented as mean ± standard deviation unless otherwise indicated.
Sleep duration
Inpatient sleep was poor in both cohorts. Median [IQR] TST for all patients was 3.6 h [1.6–5.6], with no difference between cohorts.
Sleep continuity
Median [IQR] sleep efficiency and WASO for all patients were 95.4% [91.6–99.2] and 12.8 min [2.3–23.2]. There were no differences between cohorts in sleep efficiency, WASO, or the number or length of awakenings.
Sleep restlessness
The metrics in this domain are components of a single dependent construct rather than independent findings, the sleep fragmentation index being the sum of the movement and fragmentation indices.
The sleep movement index and sleep fragmentation index were lower (better) in the vaginal than the cesarean cohort: sleep movement index 5.4 [2.5–11.7] vs. 7.2 [4.3–21.8] and sleep fragmentation index 5.6 [2.5–17.6] vs. 19.0 [4.8–39.2], both of borderline statistical significance (raw P = 0.046 and p = 0.04). Neither survived Benjamini-Hochberg correction across the nine sleep metrics (q = 0.21 for both) (Fig. 1). Fig. 2 reports the differences by day.
Fig. 1.
Actigraph sleep parameters following vaginal delivery (SVD) and scheduled cesarean delivery (CD). Box plots show unadjusted significant distribution differences of average sleep movement and fragmentation index. No sleep-metric difference remained statistically significant after Benjamini–Hochberg correction. Median observation shown as bold line, box showing the lower and upper quartiles, whiskers representing observations outside the 5–95 percentile range, and diamonds showing outliers. ns = non significant.
Fig. 2.
Inpatient actigraph sleep data over time between vaginal (SVD) and scheduled cesarean deliveries (CD) Box plots show significant distribution differences of sleep fragmentation index and sleep movement index on day 1 postpartum. Asterisks denote unadjusted P < 0.05. Median observation shown as bold line, box showing the lower and upper quartiles, whiskers representing observations outside the 5–95 percentile range, and diamonds showing outliers. ns = non-significant
Patients undergoing cesarean delivery recorded greater sedentary and light activity on days 0–2 (Fig. 3a). After Benjamini-Hochberg correction across the twenty activity comparisons, between-group differences remained significant for sedentary activity (adjusted p = 0.026, 0.019 and 0.001 on days 0, 1 and 2 respectively) and light activity (adjusted P = 0.019, 0.003 and 0.002 on days 0, 1 and 2); no other activity comparison remained significant (all adjusted P ≥ 0.11). For all patients combined, sedentary time fell from day 1 to day 2 with a corresponding rise in light and moderate activity (Fig. 3b).
Fig. 3.
3a. Actigraph measured physical activity during inpatient stay for both vaginal delivery (SVD) and scheduled cesarean delivery (CD) expressed as sedentary, light and moderate activity. Asterisks denote unadjusted P values; after Benjamini–Hochberg correction across the twenty activity comparisons, only differences in sedentary and light activity on days 0–2 remained significant. The number of participants contributing to each full day was 29, 28, 26, 20 and 6 for scheduled cesarean delivery (days 1–5) and 27, 26, 17 and 2 for vaginal delivery (days 1–4). Median observation shown as bold line, box showing the lower and upper quartiles, whiskers representing observations outside the 5–95 percentile range, and diamonds showing outliers. ns = non-significant
3b. Actigraph measured physical activity of entire cohort (combined vaginal and elective cesarean deliveries) during inpatient stay expressed as sedentary, light and moderate activity. Asterisks denote unadjusted P values The number of participants contributing to each full day was 56, 54, 43, 22, 6, 2 and 2 (days 1–7). Median observation shown as bold line, box showing the lower and upper quartiles, whiskers representing observations outside the 5–95 percentile range, and diamonds showing outliers. ns = non significant
Discussion
The main findings from this exploratory study are that inpatient postpartum sleep was poor in both spontaneous vaginal and cesarean delivery cohorts, with a median TST of 3.6 h; this figure represents the average duration of algorithm-detected sleep bouts rather than total sleep per day, therefore not directly comparable with daily sleep recommendations.19 Further, it is also lower than 6.7 h reported in a longitudinal peripartum trajectory study of patients undergoing scheduled cesarean delivery recording from day −7 to day +28, of which only day 1–2 is inpatient; the difference principally reflects setting and sleep-period definition rather than a like-for-like comparison.14 We observed higher sleep fragmentation and sleep movement indices, and greater early sedentary activity, following scheduled cesarean delivery. To our knowledge this is the first study to compare postpartum sleep and activity for the duration of inpatient hospitalization between vaginal and cesarean delivery cohorts using an objective measure.
Increased sedentary activity is a known risk factor for thromboembolic disease,20,21 although whether the observed differences here carry any such risk is unknown. Although differences of borderline statistical significance were observed in both the sleep movement and fragmentation indices after scheduled cesarean delivery, these are not independent, given that the fragmentation index incorporates movement data. The higher sleep fragmentation after cesarean delivery is most consistent with more frequent early nursing contact. Vital signs were recorded every 15–30 min for the first 2 h after cesarean delivery, vs. 4-hourly after vaginal delivery, and those receiving intrathecal morphine underwent additional respiratory monitoring every 2 h for 12 h in line with Society for Obstetric Anesthesia and Perinatology (SOAP) recommendations.22 Each contact represents a potential arousal that would be expected to increase movement and fragmentation indices. Intrathecal morphine was likely associated with differences in monitoring rather than its direct sedative effects. Greater sedentary and light activity following cesarean in the first 48 h did not translate into increased vigorous activity, which remained minimal in both groups. The lower overall activity observed in the vaginal delivery cohort may relate to perineal pain or differences in early mobilization patterns and warrants further investigation. In contrast to earlier step-count studies reporting reduced ambulation after cesarean delivery, patients in the cesarean group showed higher wrist-based activity counts, likely reflecting the difference between step-based ambulation and wrist actigraphy, which additionally captures non-ambulatory movement,10,23 and show these differences persist throughout the postpartum hospitalization. Wearable technology can therefore objectively and longitudinally assess postpartum sleep and activity.
Sleep fragmentation, an estimate of the restlessness during sleep, may impact perceived quality of sleep and the subjective feeling of restfulness after waking and may have relevance to postpartum mental health. Disrupted sleep has been associated with mood disturbance and proposed as a contributor to postpartum depression.1
Whether the differences observed here translate into meaningful psychiatric morbidity is unknown and is a priority for future investigation. The importance of protecting rest as part of enhanced recovery is recognized in professional guidance,24 and prior work has examined by delivery mode and type of anesthesia.25 Further, studies have utilized actigraphy in pregnant patients to explore the relationship between sleep, anxiety and blood pressure,26 and to compare sleep in inpatient versus outpatient obstetric settings.13
The clinical meaningfulness of our findings remains uncertain, as there are no established minimal clinically important differences for actigraphy-derived indices in the postpartum population. Future work should incorporate subjective sleep measures, examine the influence of peripartum drugs and monitoring frequency, and evaluate whether strategies that protect inpatient sleep, including minimizing unnecessary overnight interruptions, improve recovery.
The major strengths of this study are the use of a validated actigraphy device and established algorithms to objectively obtain sleep and activity metrics, a demographically and obstetrically diverse population, and continuous postpartum data collection until discharge with few patients lost to follow-up. Limitations include recruitment from a single academic medical center, English speaking patients, with recruitment dependent on research-staff availability, limiting generalizability. Importantly, included patients may have not been truly representative of other populations inside and outside the United States in terms of education and socio-economic group, as known differences reported in postpartum recovery and length of stay.27 The groups differed in some of their baseline characteristics, and these were not adjusted for. Full covariate adjustment was not robustly supportable at this sample size; the cohorts differed in BMI, parity, previous cesarean delivery and blood loss, and residual confounding cannot be excluded. The Tudor-Locke algorithm was developed and validated using waist-worn accelerometry in a non-pregnant population, and its application to wrist-worn recordings in postpartum adults is unvalidated; its assumption of consolidated rest is poorly matched to the fragmented sleep of the postnatal ward. These findings represent observational associations; in particular, blood loss differed substantially and is partly intrinsic to delivery mode, so the greater early sedentary activity after cesarean delivery may reflect combined effects this study was not powered to separate. Averaging metrics across a variable-length stay may also bias results. We did not collect data on pre-existing drug use other than steroids or opioids, perineal trauma or episiotomy, or social support during the postpartum stay. Attrition bias cannot be excluded; patients undergoing intrapartum cesarean delivery, excluded by design, may represent a clinically distinct group warranting dedicated investigation. We acknowledge that most postpartum recovery occurs in the outpatient setting, and therefore future studies are required to evaluate sleep and physical recovery metrics beyond hospitalization in these patient populations.
In conclusion, inpatient postpartum sleep was poor across both delivery modes, with no difference in total sleep time, efficiency or WASO. Sleep restlessness indices were lower after vaginal delivery but were not significant following correction for multiple comparison across the sleep metrics; greater early sedentary and light activity after cesarean delivery remained significant after correction across activity comparisons. Whether differences of this magnitude are clinically meaningful for postpartum recovery is unknown, as no minimal clinically important differences exist for actigraphy-derived indices in this population. These exploratory, unadjusted associations require confirmation in adequately powered studies. Continuous inpatient actigraphy was feasible. Future adequately powered studies should adjust for confounders, incorporate subjective sleep measures, examine the influence of peripartum drugs such as intrathecal morphine and of monitoring frequency, and evaluate whether targeted interventions improve these metrics and relate to psychiatric morbidity.
Supplementary Material
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijoa.2026.105274.
Footnotes
Declaration of competing interest
The views expressed are those entirely of the authors.
Data may be requested by contacting the corresponding author. JOC is supported by the NIHR Central London Patient Safety Research Collaboration. Dr. P. Sultan is the recipient of the following grants from the US National Institutes of Health, unrelated to the submitted work: Principal Investigator, “Early Intervention for Postpartum PTSD: Comparing Written Exposure and Capnometry-Guided Breathing Therapy” (1R01AT013866–01); Principal Investigator, “Development and Validation of a PROMIS-based Measure to Assess Postpartum Sleep” (5R01HL166253–02); and Co-Investigator, Stanford PRIHSM (PReventing Inequities in Hemorrhage-related Severe Maternal Morbidity) (5U54HD113142–03). Dr. P. Sultan is an Editorial Board member of the International Journal of Obstetric Anesthesia. The remaining authors declare no competing interests. No other funding or competing interests declared.
CRediT authorship contribution statement
J.E. O’Carroll: Writing – review & editing, Writing – original draft, Validation, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. A. Yarmosh: Writing – review & editing, Formal analysis, Data curation. K. Ando: Writing – review & editing, Data curation. M.J. Im: Writing – review & editing, Data curation, Conceptualization. C.-H. Shu: Writing – review & editing, Methodology, Formal analysis. N. Aghaeepour: Writing – review & editing, Investigation, Formal analysis. M. Druzin: Writing – review & editing, Methodology, Funding acquisition, Formal analysis. D.M. Panelli: Writing – review & editing, Methodology, Investigation, Formal analysis. B. Carvalho: Writing – review & editing, Writing – original draft, Supervision, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization. P. Sultan: Writing – review & editing, Writing – original draft, Validation, Supervision, Methodology, Investigation, Funding acquisition, Conceptualization.
Ethics declaration
Written informed consent to take part in the study and to publish the article has been obtained from all participants or their legal representatives. The privacy rights of participants have been observed.
This study was performed in compliance with relevant laws, regulatory frameworks and guidelines where the research took place.
This study was approved by the Stanford University Institutional Review Board
(Approval No. 60762)
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