Coping with sleep loss. (Continuing Education)(Cover Story).

Recently, I provided labor support for about seventeen hours to an inspiring, young, first-time mother named Laura. In other types of work, a seventeen hour shift might seem nearly impossible, but as I was heading home at 4:30 in the morning, I found myself thankful that the length of time I was with Laura felt so manageable.

During the past several years, the length of time that I have been with each of my birth clients, during her actual labor, has averaged nearly twenty-four hours. Sometimes my "shift" has been about twelve hours or less, but it has not been uncommon to be with a woman for thirty-six or even forty-eight hours.

Some of the job hazards of being a labor assistant include the demands of being on call, the stress of witnessing difficult births, low pay, long hours, and sleep deprivation. I have personally found this last concern to be the most challenging. Sleep loss is not simply an inconvenience that comes with the job; its effects can be agonizing for labor assistants, as well as for the birthing family.

Many labor assistants find that the extraordinary joys of working with women in birth outweigh the challenges. At the same time, it is important to reduce the hazards to the labor assistant, for her own well-being and that of her clients.

Following are strategies that can help manage or minimize sleep deprivation.

Helping Laboring Women Sleep

Laboring women often need rest or sleep after bedtime, or at other points in a long labor At these times, labor assistants can offer guidance about when it is appropriate for the mother to take a break, and when she may need sleep.

To help a mother sleep during her labor, position her on her side or partially reclining in bed. In a hospital or birth center setting, get sheets and blankets from the linen supply room and help her to cover up and get settled in. Turn off all lights in the room, leaving on a light in the bathroom or entryway as a nightlight. Close drapes and blinds.

Tell nurses and other providers that the mother will be getting some sleep, and make sure they will be able to leave her undisturbed for about an hour. Let other family members know that the mother will be resting, and remind them as needed, so that they do not continue their conversations while she sleeps.

Once the mother is settled into bed, she may feel less comfortable during several contractions, especially if she had previously been upright or active. Massage can be used on specific areas of the body to help her relax into the reclining position. For back discomfort, try a soft pressure against her sacrum, or press down gently on her upper hip during contractions if she is lying on her side. A more generalized massage stroke for relaxation is to give her a long, sweeping stroke with your palm, along either side of her spine.

Women are often surprised to learn they can sleep in labor. If the environment in the room is conducive, and they are sleepy; they will doze off. Physically and mentally, women often benefit from the chance to do so, and to replenish themselves for more of the work ahead. As contractions continue, the woman may be awakened by each one. Encourage her to breathe slowly or normally through them, while helping her to stay reclining so that she can doze off again when the contraction ends.

Another place that the laboring mother can sleep is in a rocking chair or padded chair, if one is available. Surround her with pillows for support, then make adjustments to the room for darkness and quiet.

Caregivers might offer narcotics to a laboring woman so that she may sleep, known as Therapeutic Rest. This may produce a deeper sleep, while also carrying the risk of side-effects to mother and baby. If her labor is otherwise normal, offer to help the mother with nonpharmacological methods of getting rest.

Sometimes caregivers may describe the laboring woman's condition as one of "exhaustion." This can be discouraging to hear. Many times, however, she is simply sleepy or sleep-deprived. Try to remind her of this if her labor is otherwise normal. It is possible to help women rest and restore themselves for the remainder of the process. True medical exhaustion is rare.

Women usually have incredible strength and stamina to carry them through the marathon of labor. Remind the woman's caregivers, as well, that she may simply be in need of sleep, and that her body has probably not exhausted itself. You can help everyone involved to remember that women are capable of persevering through a normal labor, even when long.

Spouses and Loved Ones 

When assisting a woman whose labor progresses past bedtime (or, as a general guideline, past midnight), it is important that everyone in the room get rest. If the woman is accompanied by a spouse or loved ones, the loved ones' excitement may seem to build around this time of night. They might be aware that tiredness is creeping in, but they often dig in their heels and search for ways to stay awake.

After bedtime, firmly encourage the woman's loved ones to sleep. I usually suggest trading off with them, encouraging the spouse to sleep for an hour while I provide labor support. Then it is my turn to sleep for an hour.

As a general standard of care, a laboring woman should not be left alone while her supporters sleep. After bedtime though, unless the woman is close to pushing or experiencing unusual difficulty, I think it is essential that labor assistants and spouses take turns sleeping. If the birth is not imminent at bedtime, it is likely that everyone will be awake and working hard at dawn. Trying to stay awake several hours past bedtime is enough to create the arduous symptoms of sleep deprivation: loss of ability to concentrate, difficulty with judgment, anxiety, and increased feelings of distress.

We know that relaxation reduces the levels of stress hormones and cortisol in laboring women. The same is true for support people. It will serve the laboring mother much better if her supporters have had a chance to replenish themselves. And an hour of rest, or even a half hour, is sometimes all that is needed.

Where Should You Sleep?

When it is necessary for you to take a nap, where should you do so? In a hospital or birth center setting, look for a reclining chair that unfolds into a bed for visitors. There may also be a folding cot available for visitors. Ask a staff member for one of these if it is not already in the room. Help the woman's spouse or loved ones find a location where they can provide her with labor support during your nap.

While you are lying down, encourage yourself to relax, even if you can hear the mother's labor sounds. Do your best not to worry that you are missing something during the short time that you will be resting. It is important to your ability to provide good care that you rest for a short time during a long or overnight labor.

There may be another labor and delivery room that is empty for the time being. Ask the staff for permission to sleep in there. You might find a family waiting room that is not being used. Turn off the light in the waiting room, bring in blankets, and lie down on the couch. You may want to ask the midwife or doctor if they have an "on call" room, and if they would allow you to lie down there.

You may want to carry a watch or small clock with a travel alarm. Also, be sure to tell the laboring woman's care provider exactly where you are, and instruct them to get you if anything changes in the woman's labor.

Avoid leaving the room if the woman is coping with a phase of her labor that seems unusually difficult, even if her care provider is with her. Also, if her providers are considering medical interventions, stay in the room until these decisions have been made. You will avoid returning to a situation that has unexpectedly become more complicated.

As a labor assistant, staying well-nourished can help relieve tiredness to an extent. Be sure to eat a reasonably normal meal at regular intervals during a birth. Carry high-energy snacks to each birth that you attend, such as nuts, dried fruit, and protein bars, and remember to snack at least every couple of hours. Keep yourself well-hydrated. Though eating will not replace your need for sleep, it can help temporarily if the timing is not right for you to nap.

The Unusually Long Labor

What about a labor that unexpectedly continues beyond twenty-four hours in the hospital? If the woman is still in early dilation, without medical interventions, she herself may want to consider going home. It might seem like an unusual prospect after spending all that time in the hospital, but discussing this option may make sense to the woman and her care providers.

If the woman stays in the hospital, you may, as labor assistant, decide to take a short break at home. You may want to eat, shower, change clothes, comfort your children or partner, or sleep, especially if there was not a place available to sleep in the hospital.

If you are working with a backup partner, you may want to call her to cover for you if you decide to go home for a short time. If you do not have a designated backup partner, you can still place phone calls to other labor assistants in your network, and try to find someone to stand in for you until you return.

Your decision to sleep or take a break during a birth should always be based on what will best serve the laboring mother. It is necessary, not neglectful, to take care of yourself so that you can be alert and refreshed as her support person, as is using your judgment about when in the labor to do so.

Early Support at Home

If the mother is planning a hospital or birth center birth, do you provide labor support while she is still at home? The benefit of home labor support is that you can help comfort and calm the mother in early labor, allowing her to stay home longer. While she is still at home, you may be able to help with remedies for certain circumstances, such as alleviating back labor. The benefits of home support in early labor can positively influence what will happen later in the labor.

In some cases, doing home labor support can also extend the length of time that you are on your "shift" by a couple of hours or up to half the day. When labor starts late at night, you may lose out on your own sleep at the beginning of the process. If this detracts from your ability to maintain stamina once you arrive at the hospital, you may decide to take this into consideration.

If you choose not to provide home support, the laboring woman may adjust her view of what she can manage at home with loved ones. Knowing that she will need to wait until active labor to go to the hospital can have the positive effect of encouraging her to have confidence in her own coping skills.

Alternatives to home labor support include visiting the woman's home in early labor, offering your perspective on where she is in the process, teaching comfort techniques, and then leaving until her labor becomes more active.

You can give your support by phone while the woman is still at home. Encourage her to try deep breathing techniques and practice with her by telephone, as well as vocalizing together. Make sure that she is eating normally and drinking lots of fluids during early labor, to prevent problems of dehydration and losing strength that she will need later.

Give suggestions for comfort measures such as taking walks, asking her partner for massage, and showers for relaxation. Discourage baths in early labor, because they can slow down the process.

If labor is beginning late at night, encourage her to sleep! Mothers often find this to be a great challenge in early labor, because of their excitement, and because of the discomfort and unfamiliarity of the contractions. Try to impress how much she will need the rest by the time labor gets more active the following day.

You may want to suggest a strong cup of relaxing herbal tea, a glass of wine, or a warm bath (appropriate for relaxation late at night). Ask her to turn out all lights and lie down, even if she feels she won't be able to sleep. The darkness and a reclining position will at least give her body some rest.

Getting Active

After encouraging a woman to get some sleep, at home or in the hospital, help her to get active again! She may be reluctant to feel the increased discomfort that can come with changing positions, but once she is rested and awake, help her get out of bed. Remind her of the benefits of moving the labor along, and help her make this next adjustment in her birthing process.

Coping with sleep loss is a potential issue present at every birth one attends. As with other challenges which may arise in the labor process, prevention is usually the best approach.

When you meet with women and couples prenatally; talk with them about the possibility of a long birth. Explain the ways that you would help them and yourself to rest, so they will feel more prepared when the time comes.

In our role as labor support providers, the profound joys of the profession usually eclipse the drawbacks, which can be significant as well. While you take good care of women, remember to include yourself. Everyone will benefit.

--Ananda Lowe is a Labor Assistant, Assistant Director of ALACE, improvisational dancer, and mother in spirit.