When I became pregnant with my first child, I did everything I could to prepare—from research on cribs, bottles, breastfeeding, you name it. Having suffered miscarriages in the past, I was very concerned and anxious about SIDS. I made sure that my daughter’s crib had nothing but the mattress and sheet. I even contemplated buying one of those boards that detects movement and alerts you when a baby stops moving.

Once my daughter was born, she slept in the bassinet in our bedroom. I was still recovering from my cesarean, so my husband was there to help put her in and take her out of her bassinet when it was time to nurse. I was very good about following the safe sleep guidelines, but we would sometimes take naps together while I nursed on my side. I knew in the back of my mind it wasn’t the best option, but we were both able to get rest.

Fast forward 2 years, and my son is born. Again, I was cautious as I prepared for a new baby: I purchased a firm mattress and was sure not to have any toys, bumpers, or blankets in his crib. I told myself I was going to be much better with following safe sleep guidelines than I was with my daughter.

He, too, was born via cesarean, and in the beginning I was very good about not allowing him in bed and always putting him back in his bassinet. When he was about 3 months old, it became harder and harder to follow the guidelines. My son wasn’t sleeping at night, he refused any kind of pacifier (I tried six different brands), and the only thing that soothed him was nursing.

Baby Maxwell in his sleepsuit

Around this time, I returned to my full-time job. I found it easier to nurse him while lying down and returning to sleep. He also seemed to sleep better when he was next to me. I knew it wasn’t right, but I just wanted him to sleep—and I wanted to sleep myself. I tried swaddling, sleep suits, white noise… everything. It’s not supposed to be this hard the second time around, I thought. I’d already been through this; they say the second kid is easier!

When he was about 8 months old, I woke up to a boom and a baby screaming: He had fallen out of the bed, and I felt like the world’s worst mother. Luckily he was ok, but it could have been worse. He could have really gotten injured, or worse, I could have lost him. I knew the rules, I knew that babies were supposed to sleep in their own space, but I ignored them because I wanted my baby to sleep during the night and I was exhausted.

After my son’s fall, I knew something had to change; my son could no longer sleep in my bed at night. I decided to move his crib from our room into another room, and I gave the pacifier another shot. While sleep training hasn’t been successful, he is now taking a pacifier. Instead of bringing him into my bed when he wakes up at night, I offer him his pacifier if it’s before 3 a.m. If he wakes up again, I stay in his room to nurse him and then place him back in his crib. In addition, I had to make the decision to go to sleep earlier to ensure that I got my rest, too.

This got me thinking: What are some ways to help moms follow safe sleep practices after the baby is home? I enlisted the help of nurse Sharon Hitchcock, DNP, RN-C and some fellow moms.

Sharon is an obstetrics nurse and teaches at the University of Arizona. She is quite passionate about the topic of SIDS and safe infant sleep as she now knows why most of these deaths occur and, more importantly, how to prevent them (at least most of them).

She routinely talks about the American Academy of Pediatrics (AAP) safe sleep recommendations to students as well as parents and nurses. She’s also gotten a recent taste of some of the struggles, as she’s the happy grandma of a 9-month-old!

Naomi is mom of 9-month-old Samuel and became a safe sleep advocate long before having her baby. Heidi is almost finished with nursing school and has two kids, 3-month-old Eli and 4-year-old Sophia. Melanie, a mom of three, teaches obstetrics at the University of Arizona and is a childbirth educator at the local hospitals.

I shared with them my struggles of following safe sleep practices with my son and asked several questions about how parents can better follow safe sleep guidelines. Here’s what they had to say:

1. Night feedings can be exhausting, especially when breastfeeding. What are some best practices to help resist the urge to nurse while lying down?  

NAOMI: I resisted the urge to nurse while lying down simply because I didn’t want to bring the baby into bed with me. There were some times when I nursed while sitting up in bed, but I also nursed in a rocking chair in my son’s room, just next to his crib, so I could immediately put him back to bed when he finished eating. I’m a light sleeper and didn’t worry much about falling asleep while feeding him, but I’ve heard it’s a good idea to use a timer, like the one on your phone, if you’re worried about falling asleep.

HEIDI: I was aware of the risks of breastfeeding while lying down from my OB classes in nursing school and had heard the horror stories of parents falling asleep with their infants and accidently suffocating them during their sleep. This was enough to make me take precautions the majority of the time that I was breastfeeding at night. I would feed him in my bed, sitting up, with him in the cross cradle position. I would set alarms just in case I did fall asleep with him, as studies have shown that the longer you are asleep with your infant, the greater the risk of SIDS. If mothers are truly so exhausted that they feel like they need to lie down while nursing, they should remove all pillows and blankets from around the baby and set alarms that will wake them should they fall asleep

2. What are some ways to keep baby warm at night without using blankets?

NAOMI: Our son was born at the end of November, just when it really started to cool down here in southern Arizona. We kept the room warm and comfortable, and he wore footed pajamas.

HEIDI: For both of my children, I used sleep sacks that are available to buy online or in any baby store. They have worked well for me both times. I made sure the house was kept warm enough that they would be comfortable throughout the night.

MELANIE: It is recommended to keep the bedroom at a temperature that is comfortable for a lightly clothed adult. Overheating a baby is very dangerous, as they cannot just push the covers off.

3. The risk of SIDS goes down once a baby turns 6 months—is it okay to bed-share then?

HEIDI: No. The baby can still roll over and suffocate on the softer mattress, pillows, and thick blankets that we have. In addition to the suffocation risks, I believe that getting the baby into a routine of sleeping in their parents’ bed will be one that is hard to break. Neither of my children have been able to sleep in my bed with me, mostly due to my concern for their safety. I am a hard sleeper and would not wake up if I rolled onto them. I also always wanted them to be able to sleep in their own rooms, once old enough.

MELANIE: It is true that most SIDS deaths occur before 6 months, but the infant is still at risk for SIDS until 12 months of age, and adult beds are not designed for infants. Most babies are rolling over by 6 months, and adult beds are usually too soft and have too many blankets and pillows. The other risks include the parents rolling onto the infant or the infant falling out of the bed.

4. My baby has reflux and spits up during the night. Can I place a wedge or pillow in his crib?

HEIDI: No. This is another thing that infants could suffocate on if they rolled over. My son spits up a lot, too, but thankfully I knew from my OB class that it was safer for him to be on his back when he sleeps than on his stomach or wedged if he spits up. A baby is less likely to choke when on their back if they spit up because their airway sits above their esophagus (the tube going to their stomach), making it easier for the fluid to stay away from the airway and easier to swallow.

MELANIE: The AAP recommends that infants are always placed on their backs and not on their sides. Infants are quite good at protecting their airways while on their backs (unless they have a swallowing impairment, which your doctor would tell you). The U.S. FDA has stated that infant sleep positioners are not recommended as there have been several cases of infant deaths from the use of side positioners after the baby rolled to the stomach position or when their face got wedged into the positioner. Keeping the infant upright on a parent’s shoulder for 20–30 minutes after a feeding can decrease reflux.

SHARON: Some parents may think it’s a good idea to elevate the head of the crib to help with the reflux. However, multiple studies have shown this does not help and actually puts the baby at risk for sliding down to the foot of the bed and getting into an unsafe sleeping position.

5. If I nurse while lying down, should I remove everything from my bed in case we fall asleep?  

NAOMI: This is what the newest recommendations advise you to do. Make sure all the blankets, pillows, etc., are moved out of the way, so that in the event you fall asleep, the bed will be a little bit safer.

HEIDI: Absolutely. This is the safest practice if you must nurse while lying down. This is what I did. I also asked my husband to adjust his pillow, and if possible, stay awake with me to ensure that I didn’t fall asleep with the baby. We aren’t perfect, though, and there were a couple of times where we dozed off with him, but fortunately I had alarms set to wake me within 15 minutes of beginning nursing. Once I knew he was full and had a clean diaper on, I set him back down in his crib and went to sleep.

6. Sometimes the baby falls asleep on my chest. It’s recommended that babies sleep on their backs, but since he’s on my chest is it okay?

HEIDI: I believe so, as long as you are rested enough that there is no risk of you falling asleep and you are able to monitor the baby while he is asleep on his tummy. I did this a lot with both of my children during the day and think it is the perfect opportunity for skin-to-skin time.

SHARON: Make sure you can see your baby’s face (to make sure it is not covered or does not become wedged into your breasts) and you are awake and attentive to him.

7. The only way to get my baby to sleep is if I nurse him; when I go to transfer him into his own bed, he wakes up and cries. Is it okay to let him cry it out?

NAOMI: This is a hard topic. There are so many opinions out there, and it’s hard not to get discouraged by all the articles in my Facebook newsfeed that highlight how awful it is to let your baby “cry it out.” It became important for me to consider our circumstances and the fact that every baby is different. I didn’t use the formal “cry-it-out” method for sleep training, but there were, and still are, so many times when I have to let my son cry for a while before he’ll give in and go to sleep. He’s fed. His diaper is clean. He has burped. He’s still crying. He’s not comforted by me holding him close. I’m starting to go a little crazy, and my left ear is ringing from his screams. I know he’s exhausted. What he needs is sleep. It’s okay to place him in his crib and walk away. It’s OKAY to let him cry. I had to learn this early on. It’s made a huge difference.

MELANIE: Crying is a baby’s language and the only way they have to communicate. They cry because they are hungry, tired, uncomfortable, and sometimes just because they are fussy and need to get rid of excess energy. If they have burped and their diaper is clean, you can try to console them with rhythmic noise, music, or gently stroking their head. If the baby is tired, they will usually fall asleep quickly.

Safe sleep is harder than it appears, at least for some of the recommendations. This is an extraordinarily complex topic, and we know it’s hard. In order to keep your baby  as safe as possible, learn  the recommendations, start them at birth, do the best you can, and know that you are not alone in your struggle.

Do you have safe sleep tips/advice you want to share with parents? Share them at www.awhonn.org/SafeSleepTips

Resources

• American Academy of Pediatrics Safe Sleep Recommendations – 2016
• American Academy of Pediatrics Safe Sleep Website
• Healthy Mom&Baby article: What’s New with Infant Safe Sleep
• More health4mom.org resources on safe sleep

References

American Academy of Pediatrics. (2016). SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics, 138(5), 1–12. doi:10.1542/peds.2016-2938

Centers for Disease Control and Prevention. (2017). Sudden unexpected infant death and sudden infant death syndrome. Retrieved from https://www.cdc.gov/sids/data.htm

Gradisar, M., Jackson, K., Spurrier, N. J., Gibson, J., Whitman, J., Williams, A. S., . . . Kennaway, D. J. (2016). Behavioral interventions for infant sleep problems: A randomized controlled trial. Pediatrics, 137(6), 1–10. doi:10.1542/peds.2015-1486

Hitchcock, S. C. (2017). An update on safe infant sleep. Nursing for Women’s Health, 21(4), 307–311. doi:10.1016/j.nwh.2017.06.007

Moon, R. Y., & Task Force on Sudden Infant Death Syndrome (2016). SIDS and other sleep-related infant deaths: Evidence base for 2016 updated recommendations for a safe infant sleep environment. Pediatrics, 138(5), e1–e29. doi.org:10.1542/peds.2016-2940

Storrs, C. (2016). It’s OK to let your baby cry himself to sleep, study finds. Retrieved from http://www.cnn.com/2016/05/24/health/cry-it-out-sleep-training-ok/index.html

Courtney Duggan is a digital marketing manager in the Washington, D.C. area and is a mother of 2.

According to the U.S. Department of Health, one in four girls and one in five boys will be sexually abused before they turn 18. One in five women and one in 71 men will be raped at some point in their lives. This is in many ways a silent epidemic. Sometimes victims don’t disclose their abuse to their care providers. The reasons vary, and can range from  ongoing suffering of the traumatic effects of the abuse and  avoiding  reliving it, to a continuing sense of shame that victims  may have never come to grips with.

What are some possible signs of sexual abuse?

According to When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women, having a constellation of these symptoms can indicate a history of abuse. Having one or more of the following should trigger a red flag and considerations for a woman’s  care during childbirth:

• Not able to feel fetal movement. Some women have “numbed” that part of the body
• Hyperemesis gravidarum
• Chronic pelvic pain
• Missed prenatal appointments
• Panic with vaginal exams
• Extreme anxiety with IV starts
• Disassociation that manifests as if she’s going into a trance

Many of these symptoms can understandably occur in women who don’t have a history of sexual abuse, but when a woman has two or more, it’s reasonable to suspect that such a history is possible. These symptoms can stem from PTSD, which is triggered by a woman’s perception of loss-of-control, as well as the physical sensations that occur during pelvic exams, labor, and birth. By rushing through procedures, and not allowing the woman time to process (if possible), understand, and consent to what is happening to her body, we can inadvertently trigger a posttraumatic reaction.

Admittedly, the discussion of sexual abuse is a tough topic for those on either end of the conversation. We often just touch on the subject while reviewing women’s admission histories, and then move on. Fortunately, we don’t need the admission of abuse to employ strategies developed for survivors. It’s actually much more common for caregivers to pick up on non-verbal cues and then tailor their care. A real tragedy is the guilt and shame survivors can feel after giving birth. So, like we would do for any woman,  it’s best to acknowledge the struggle of labor and birth, the strength a woman demonstrated, and the effort and precious reward she  achieved.

What are interventions that nurses and other caregivers can provide?

• Explain as much as you can in advance, for example “If we run into an emergent situation there might be unfamiliar nurses coming in to help. I know this can cause anxiety, but I want to prepare you ahead of time in case it happens.”
• Always start with asking permission. From starting an IV to turning on the overhead lights, make sure to obtain permission before doing any procedures or making changes to the environment
• Go slowly with everything you do–this can be helpful in relation to a woman’s  fear of losing control. Fast movements can be triggers. This is especially important when uncovering a woman or assisting her with positioning.
• Limit vaginal exams. These are especially traumatic and should be minimized. If a woman is having difficulty in relaxing enough to complete an exam, try making an agreement about when and why you can perform one. If a woman understands that the exams are being performed only when necessary, and with her consent, her anxiety is often more controllable during exams.
• Minimize people in her room. She might have issues with nursing students or residents, especially if they are male. Obtain her permission before any new staff come into the room, unless there’s an emergent situation.

What are things not to say?

• Intrusive interest-prying for details or descriptions of the abuse
• Minimizing the abuse: “Well, that’s over now.”
• Exaggerated concern
• Shock or disgust
• Pity

What are good things to say?

• “I can imagine that was very hard to share that with me. It takes a lot of courage to talk about and I respect you for doing that.”
• “Sometimes talking about these episodes can trigger strong feelings. How are you feeling right now?”
• And, it’s always essential to assess the woman’s current well-being “Do you feel unsafe in any aspect of your life?”

Not all survivors of sexual abuse have difficulty with pregnancy or childbirth, for some it can be empowering. For those who do struggle, recognize that we have a powerful opportunity to help them. We can communicate therapeutically to help  change the woman’s focus from feeling out-of-control.  We can employ care practices to avoid the woman feeling re-traumatizatized.  And we can set the stage to promote healing and bonding with the newborn. In many instances it’s our tacit recognition and respectful and supportive care that facilitates healing, more than any words we could utter or medicines we could administer.

Where can I learn more?

• When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women
• Simkin, Penny and Phyllis H. Klaus. Seattle: Classic Day, 2011. Print.

What are resources for my patients?

• National Sexual Abuse Hotline: 1800-656-HOPE
• RAINN: Rape, Abuse, Incest National Network, www.rainn.org

Tasha Poslaniec has been a registered nurse for 17 years. She has been working in obstetrics for over a decade and is currently a Perinatal Quality Review Nurse and Childbirth Educator.

She also writes about nursing and childbirth and has been published in the Huffington Post and the American Journal of Nursing. Pain control in childbirth has long been a topic of study and research for her.

1. No one wants you to have the birth you want more than we do. Except maybe you, of course… We want to support you to stay healthy and have a healthy baby. If you end up with an unexpected birth experience, we mourn the loss of the idealized birth with you, and are here to help the experience you have be the best possible.
2. Most providers will not stay with you during labor. Many times when a woman is admitted, she’ll ask when her provider is coming. Providers have busy offices to keep up with and demanding surgical schedules. Your nurse will be the one that stays by your side. Your provider will check in on you frequently and we give them continuous updates throughout your labor.
3. We will not remember what your stretch marks looked like, how much cellulite you had, or what your vagina looked like once we walk out of your room. Guaranteed.
4. Labor is painful. Everyone thinks their labor is different than everyone else’s, that no one could have labor pains as bad as yours. But the truth is, labor hurts for (almost) everyone. The best thing you can do is take prenatal education classes so you know what to expect. A lot of fear and pain comes from the anxiety of not knowing.
5. Educate yourself on the benefits of breastfeeding. By now, everyone should know that there are a million and one reasons to breastfeed. There is so much evidence out there that supports all of the benefits of breastfeeding. No one comes to the hospital with a plan to breastfeed thinking that they may not be successful. So educate yourself prior to having your baby. Know what the most common problems are, success strategies and what to expect the first few weeks. Commit yourself to breastfeeding your baby!
6. Designate someone as your photographer. Your partner will be caught up in the moment. They’ll probably forget all about the camera. Before you go into labor, designate someone as your personal photographer or hire a professional birth photographer. You will not remember the way your partner looked at you. You may not remember how your partner looked at your baby for the first time. You want to make sure you’re able to look back and remember all of the little details you may later forget.
7. Talk to your provider. Your doctor and your midwife work for you . It’s a privilege that you’re allowing them to be a part of the birth of your baby. Don’t forget that. Discuss in advance things you would like, and ask questions. You want to know early in your pregnancy if you picked a provider who you aren’t comfortable with so you can change providers if you need to. No question is too silly. Trust me; they’ve heard it all before!
8. Don’t be afraid to speak up. Frequently, women are admitted to the hospital and they feel as if they have no say in the care that is provided. But you can speak up! You have the right to ask questions, to get those questions answered, and you have the right to say no.
9. Don’t get induced unless you have a medical reason. Even if your back hurts, and you have trouble sleeping at night, and you’re going to the bathroom 500 times a day, remember that your baby is baking in there! Every minute matters. So find methods to distract you if you’re very uncomfortable, and aim to go the full 40!
10. Take it all in and cherish the moments. Every day, nurses take care of women who can’t get pregnant, who can’t stay pregnant and we care for women who will not get to take their baby home after delivery. Having a healthy baby is a lifelong, priceless gift. Cherish every moment, because before you know it, the toddler playing with your car keys will be the 16 year old asking to borrow your car.

Part One of a Three part series on Intimate Partner Violence

The women in this post have volunteered to speak for abused women who are afraid to talk or can’t talk.

Give voice to women who are facing Intimate Partner Violence. Learn more about it and what you can to do help.

There are no boundaries to intimate partner violence.

Even pregnancy does not protect the woman from abuse.

How does IPV impact the mother’s health during pregnancy, the birth process, and her recovery?  How does the abuse affect the health and well-being of her unborn child?  How does the mother provide for her newborn under the shadow of abuse?

The next post in our three part IPV series: Intimate Partner Violence during Pregnancy will address these questions.

Want to learn more now? Find out more about IPV and what you can to do help.

Ann Bianchi, PhD, RN
Ann L. Bianchi is an Associate Professor, College of Nursing , The University of Alabama in Huntsville, Huntsville Alabama.