Giving birth to laughter?

Dear readers, 

During my internship, I’m often asked about the differences between Belgian and Slovenian midwifery practice. In this blog, I will shed some light on one of the major differences. It is no secret that giving birth is generally not something to be laughed with. Most women who enter the labour ward are somehow frightened by the expected labour pain, not in the least because of horror stories told by their mother or friends. The cry for pain relief is probably one of their loudest. The Belgian and the Slovenian answer to it, vary considerably. In Slovenia, there is space for some laughter in the labour room! But is that laughter the best medicine for labour pain?

Pain relief

In Belgium, pain relief in the labour ward generally boils down to either epidural anesthesia or nothing. 70% of the Flemish women who gave birth in 2014 received epidural anesthesia. Recently, the Flemish Professional Association of Midwives (VBOV) announced that it will start exploring the admission of laughing gas. So far, only one Flemish hospital has introduced laughing gas in the labour room (A.Z. St. Blasius Dendermonde).

Contrary to Belgium, in Slovenia four options for pain relief are available: laughing gas, two sorts of opioids (remifentanil and pethidine) and epidural (spinal) anesthesia. Where epidural is the golden standard for labour pain relief in Belgium, in Slovenia its use has only begun to rise in recent times and is still far from established practice. All options have their pros and cons, which I will not discuss here. I will however discuss the most commonly used method of pain relief in Slovenia: laughing gas. 

Laughing gas

Laughing gas is a simple anaesthetic agent that has been in use in medical settings for two centuries now. It made its entrance in obstetric care in the 1930s because of its anxiolytic and analgesic effect. It is a mixture of nitrous oxide (N20) and oxygen, and in the obstetric context usually contains 50 percent of each.

Advantages

Laughing gas is seen as a analgesic that does not intrude in the course of the birth since it doesn’t intervene with the release of oxytocine, the hormone that is the key to progress in labour. Laughing gas works rapidly and its effects expire quickly once administration is stopped. Furthermore, its availability expands the number of options for pain relief during labor and it might add to women's feeling of being in control since they can administer it themselves (though solid research data seem to be lacking on the latter). When used for a limited period of time during labour, laughing gas is considered to be safe for both mother and child.

Disadvantages 

Laughing gas is seen as a generally less effective painkiller than neuraxial anesthetics. Also, when compared to women who received no analgesics or a placebo, women who received laughing gas more often suffered from nausea, vomiting, dizziness and drowsiness. Furthermore, laughing gas cannot be administered when contra-indications such as hemodynamic instability or impaired oxygenation exist. Caution is necessary if a woman simultaneously receives other sedative medication.

www.labourpains.com

Effect on health care workers

There are also questions about the effect of laughing gas on health care workers. In animal experiments, under a number of conditions a teratogen effect was found, but in humans, the picture is less clear. Furthermore, laughing gas might be a cause of disruption of the vitamin B12-metabolism. Based on the outcomes of the animal tests one author urges reservation when using laughing gas, and advises to only use it under strict indications (that, he claims, do exist).

Because of the lack of conclusive scientific evidence about possible congenital disorders caused by laughing gas, the Dutch Association for Anesthesia and the Dutch Association for Obstetrics and Gynecology urge to not expose pregnant staff to (high doses) of nitrous oxide (especially not in the first term).

Debate about laughing gas in the labour ward

In 2004, the Dutch Health Care Inspection (IGZ) advised hospitals to restrict the use of laughing gas in labor wards “as much as possible” and to “preferably” end its use. The debate that followed led to strict rules for the use of inhalable analgesics in Dutch labour wards: thorough ventilation of rooms, an exhaustion system in the room and a ‘scavenging system’ fitted to every mask (measures, by the way, that are not imposed on the labour ward here in Slovenia). The Royal Dutch Association of Midwives (KNOV) adds annual checkups of staff exposed to laughing gas, a risk assessment and evaluation, training and a protocol to this list. Nevertheless, the KNOV considers the IGZ’s discouragement of the use of laughing gas to be based upon methodologically doubtful research.

My impressions

As a Belgian student, working with laughing gas was a quite new experience to me. The impression might exist that nitrous oxide gets all women to laugh their way through labour, like in this YouTube video:

However, this is not really my experience so far. Rather, women in serious labour are holding on to their mask as to their lifeline, gulping gas during contractions. Some start to say funny things or laugh a bit, but most of the time the women concentrate on making it through the contraction. From their reports, the gas only seems to take away the top of the pain. Even with the gas, labour is hardly a laughing matter.

I wonder whether some sort of placebo effect can be ascribed to the use of the mask. Since the women are administering the gas to themselves, they seem focused on their own breathing, which is in general very important during labour. This focus on a steady, deep breathing might add to the relief by drawing the women’s attention away from the actual pain. Thorough research into this matter and the actual effect of laughing gas seems to be lacking. 

My experience is also that the use of laughing gas doesn’t enhance the mobility of the women (which I consider to be very important for the progress of labour), since the effect often seems to lead to their staying in bed. I also have some questions about how consciously they experience their labour when using the gas, and the psychological effect this has. 

Personally, I don't feel too comfortable working without ventilation measures, like we do in Slovenia. Out of precautiousness, I would endorse the ventilation measures described above, in the interest of the newborn, the partner attending the labour and the medical staff present. I don't have a clear cut answer to the question whether we should advocate the introduction of laughing gas to Belgian labour rooms. Somehow, I have the impression that intensive one-on-one coaching by a midwife, back massage, guidance in using the correct breathing techniques (maybe the administration of some extra oxygen), the use of different positions, et cetera might be as effective. This makes me wonder what the added value of laughing gas really is. I am looking forward to more evidence-based insights on this.  

Literature used:

Brief Hoofdinspecteur Inspectie voor de Gezondheidszorg (IGZ) (2004). Kenmerk IGZ/FMT/GB-04-31749. Den Haag: IGZ.

Collins, M., Starr, S., Bishop, J. & Baysinger, C. (2012) Nitrous Oxide for Labor Analgesia: Expanding Analgesic Options for Women in the United States. Rev Obstet Gynecol 5(3/4): e126-e131 doi: 10.3909/riog0190

Devlieger, R., Martens, E., Martens, G., Van Mol, C. & Cammu, H. (2015) Perinatale Activiteiten in Vlaanderen 2014. Brussel, SPE. Found on the internet:

http://www.zorg-en-gezondheid.be/sites/default/files/atoms/files/SPE_jaarrapport%202014.pdf

Klomp, T., Van Poppel, M., Jones, L., Di Nisio, M., Lagro-Janssen, A. (2012) Inhaled analgesia for relieving pain during labour. Cochrane Database of Systematic Reviews. Found on the internet:

http://www.cochrane.org/CD009351/PREG_inhaled-analgesia-for-relieving-pain-during-labour

Knape, J. (2006) Lachgas niet onveilig, maar wel steeds minder nodig. Ned Tijdschr Geneeskd 150(19): 1053-1054

KNOV (2009) Adviesrapport – Het gebruik van Relivopan in de eerstelijns verloskunde. Utrecht: KNOV werkgroep ‘Etonox’. Found on the internet:

http://www.knov.nl/fms/file/knov.nl/knov_downloads/911/file/KNOV.adviesrapport_Relivopan_eerstelijns_verloskunde_november_2009.pdf?download_category=overig

Nederlandse Vereniging voor Anesthesiologie [NVA] en Nederlandse Vereniging voor Obstetrie en Gynaecologie [NVOG] (2008) Richtlijn medicamenteuze pijnbehandeling tijdens de bevalling. Found on the internet:

http://www.nvog.nl/upload/files/definitief-richtlijn-pijnbehandeling-bij-de-partus_def-091208.pdf

Rooks, J. (2011) Safety and Risks of Nitrous Oxide Labour Analgesics: A Review J Midwifery Womens Health 56(6): 557-565. Found on the internet:

http://www.porterinstrument.com/~porterin/dentalcontent/app/webroot/files/datasheets/Safety-and-Risks-of-Nitrous-Oxide-Labor-Analgesia-JMWH-[2011].pdf

Schyns-van den Berg, A., Engel, N., Marcus, M. & Beenakkers, I. (2010) Partus en pijn hoeven nergens hand in hand. Medisch Contact 65(50): 2716-2721

VBOV (2015). Lachgas tijdens de bevalling, een optie in België? Press release by the Flemish Professional Association of Midwifes. Found on the internet:

http://www.vroedvrouwen.be/nl/vroedvrouwen_in_de_media

Wellness

Hello everyone!

As you may have noticed, from the beginning, there has been somewhat of a delay in my blogging. Besides the normal process of adapting to a new situation, my first weeks in Ljubljana were sometimes a bit hard. The main reason was that I have not been feeling well, in particular because of a persisting hypertension. Luckily, my colleagues proved to be very helpful and concerned. When they noticed I wasn’t feeling well, they immediately referred me to the emergency department.

So, entirely unplanned, I got to see the Slovenian health care system from the patient’s perspective. It proved to be an interesting experience. The first thing I noticed, was the very efficient way I was treated. No waiting lists for appointments, I was quickly attended to and the approach was very constructive in working towards finding causes and solutions. The specialists spoke good English and were very helpful.

Next week, I hope to round up the last examinations and discuss the results with the internist, who gave me apart from medication some usefull advices to make my situation as comfortable as possible in the meanwhile. Those advices basically boiled down on trying to keep my stress level as low as possible by not doing extra work for school outside of working hours, to enjoy the good Slovenian life by going for hikes and outings, enjoying the amazing Slovenian foodculture, going for a good massage and even… getting a local boyfriend. Being a good patient, I have already started to work through this unexpected bucket list. So let me update you on the progress sofar...

1    Outings

Although I have little or no time to leave Ljubljana for outings, I have been out and about with friends, dining, having coffee, chatting, laughting and generally having a great time. Particularly colourful (and sunny!) was our visit to the Botanic Garden of Ljubljana University.

A peak experience in the most literal sense of the word was having a coffee on the top floor of Nebotičnik, or in English, 'the Skyscraper'. When they finished building in 1933, it was the tallest structure in the then Kingdom of Yugoslavia.

A city within the city, that’s how one might consider the BTC area in Ljubljana. While the little streets in the city center host many small, creative shops, people do their general shopping at the BTC, where things are big, bigger, biggest. My search for a new charger for my laptop brought me there, and it is quite an experience (though not necessarily a pleasant one).

The BTC has  one large shopping mall, and over a dozen smaller ones. Besides, there’s a hotel, as well as bars, restaurants (including Slovenia’s only Burger King), a cinema and sporting clubs. One of the office buildings, the so called Crystal Palace, is the highest building in the country. On a whole, BTC City claims to be among the largest shopping and entertainment area’s in Europe – in a country as small as Slovenia…

On sunny days, one of Ljubljana’s attractions is the river Ljubljanica. Especially during the first days of spring, with the trees blossoming forth, its banks provide lovely opportunities to relax and enjoy the good city life. In earlier ages, the river was equally important to the people living in this region, but not necessarily for recreational purposes.

Until half way into the nineteenth century, the Ljubljanica was the way to transport goods into, and from the city. Some centuries before, during the Middle Ages, the river also was a means of punishing people. Bakers who had been caught cheating with the weight of their bread, were publicly humiliated by being thrown into cold waters of the Ljubljanica from one of the bridges…

Nowadays, it is less easy to enter the river. In fact, since 2003, you need a permit to dive into it. This measure was to stop people from searching the river and its beds that are known for the archeological artefacts that can be found there. These often disappeared with their finders, much to the dismay of the official historians. 

Estimates are that up to 13.000 historical artefacts have been found over the years, from a Stone Age arrow head (35.000 – 45.000 years ago) up to stuff from the Renaissance. It is believed that the locals have long considered the river a sacred place, and perhaps offered artefacts to it a sign of mourning or thanksgiving.

The magic of Ljubljana lies in its capacity to transform the way we perceive life. Strolling along the city, you’ll suddenly find yourself feeding spring flowers to muskrats. Everything seems to look cuter here. Or is Ljubljana just triggering the birth of spring in you, the season that makes you more perceptive of life’s beauty?

The Ljubljana Castle stands proudly on Castle Hill, a site that has been occupied since 1200 BC. The present castle is not that old, however, most of it was built (or rebuilt) in the sixteenth and seventeenth century. Over the millennia, ‘Ljubljana Grad’ was, amongst other things, a fortification, a prison and a home for the poor. Currently, it is it used for all kinds of cultural events and as a wedding venue.

Above all, it is lovely place to linger for both tourists and locals. I went there with some friends, and we were rewarded for the climb up Castle Hill with a great view of Ljubljana. Too bad there are no separate tickets for the castle’s Viewing Tower. You have to buy  a ticket for all the castle’s features, which, student discount included, still costs around 5 Euros. It struck us as a bit too much just for an extra bit of view! For a moment, we were tempted to fish for the coins people throw into the castle’s wishing well and use them to buy the tickets. However, our good manners quickly overcame the temptation… or was it our lack of ingenuity? ;-)

2     Food

Peace of mind does not only come from visiting relaxing places and enjoying good company. In fact, as Igor Gaber tries to teach his fellow inhabitants of Ljubljana: peace begins on your plate. I discovered the one and only Ljubljana Loving Hut, part of an international chain of vegan fast food restaurants. Based on the idea that all creatures, whether human or animal, can live in peace with each other and the earth, they serve a range of fine vegan dishes. As I can now say from my own experience, contributing to world peace has never been so enjoyable!

Just around the corner from my place is the Centralna Postaja, or Central Station in English. As the photograph on the upper right, they serve good lunches (with salads in jars!), but that's not the only thing they do. They have their very own radio station broadcasting from the building (which you can listen to here). A great place to hang out with a good ambiance, especially on warm spring evenings.

3     Massage

I even found the time to go for a proper massage at a wellness club the doctor had advised. Since I had no intention of ending up in some dubious place, I decided to stick to her advice, which turned out to be very good. It was in fact my first ever ‘official’ massage, but probably not my last. This 80 minute Thai massage really helped to reduce my stress level. Funny enough, I felt the effect even more the day after, when I noticed an increased energy level.

Leaving the place, I decided to prolong this little moment for myself, by having a Irish coffee at the dreamy riverside on a gentle night at the Solist Bar. Perhaps for the first time in my life, I am thoroughly enjoying flying solo.

4       Local boyfriend

As a student in the medical field I know that treatment fidelity is an import component in curing a patient. However, treatment fidelity of the medical staff (when it concerns their own health) is generally known to be low. I am not an exception in this respect. Sometimes, I’m too absorbed in my work, I easily forget to take my medication or I don’t allow myself a break. Lucky enough, I always have my colleagues around to remind me to take good care of myself. I have been a good patient where working on the doctor’s bucket list mentioned above is concerned. However, in the battle between treatment fidelity and boyfriend fidelity, the latter won, and the ‘local boyfriend’ item was crossed out of the list. 'Baby, there aint nobody out there like you'.

From a colourful Ljubljana, I wish you all a beautiful springtime! In my next blog, I will return to writing about my internship.

Knitting Midwives

Dear readers,

Of course I can’t go without devoting a blog to women. I hadn’t been in Slovenia for long, when I could already enjoy International Women’s Day (March 8). Here, this day is celebrated as a sort of Mother’s Day and comes with the tradition of giving flowers to a woman. I was surprised by my sweet colleague giving me a tulip, a flower that conveys comfort and warmth and is the symbolic flower of The Netherlands (my homecountry). I was just having a couple of tough days, so the gesture of the flower really moved me. Having those strong midwives around at the labour ward here, inspires me to stand my ground and know my worth. 

Knitting midwives
Strong women are often also patient women. Long (night)shifts inevitably come with periods where you can only be a patient guard. Slovenian midwives have their very own way of getting through these periods. Imagine my surprise when I first saw my colleagues resorting to… knitting! A couple of knitting midwives isn’t something you would easily find in a Belgian labour ward. However, my colleagues convinced me to give the knitting a try, as a good way of maintaining the dexterity a midwife needs. I leave it to you to imagine my clumsy tries in the beginning, but I have good hopes that I will further master the fine art of knitting.

Michel Odent

It has not been my only encounter with knitting midwives. They also pop up in the ideas of Michel Odent, the well known French obstetrician. According to Odent, many of the current (medical) practices surrounding birth are determined by culture and tradition and do not necessarily favor the women and children involved. He claims that these practices might affect the emotional state and stress level of pregnant women. This, he says, can have a negative influence on pregnancy, delivery, and even the mother-child bond and further development of the baby.

It comes as no surprise then, that Michel Odent pleads for change. He promotes the idea that pregnant and delivering women should basically be left in peace, as this would make the delivery easier. He is therefore firmly against males (doctors, but also the fathers) attending birth. Their attendance would only enhance the risk of stress, hormonal disbalance and hampering of the natural oxytocin flow. Instead of fostering that flow, we give women synthetic oxytocine without, claims Odent, properly understanding the possible long term consequences. He feels that ideally, the only one in the room besides the woman who is in labour should be a quiet midwife. To prevent her from instilling stress in the soon-to-be mother, she should be engaged in… knitting!

Recently, dr. Odent visited Ljubljana for a three day seminar at the University MedicaI Centre Ljubljana (UMCL) entitled ‘Childbirth in the scientific context of 2016’. I was invited to attend a day of his lectures by Petra Petročnik, who is the departmental Erasmus+ coordinator. Thanks to her efforts, I could even attend them for free.

The day was very well organized by, among others, Anita Prelec, who is the head midwife at the UMCL maternity unit and board member of the Nurses and Midwives Association of Slovenia and president of the professional section of midwifes. Since 2009, she is also a board member of the European Midwives Association. 

In his lectures, dr. Odent explored the contradictions he perceives between ‘tradition and cultural conditioning’ surrounding birth, and new scientific knowledge. Regardless of one’s own viewpoints, it was a thought provoking exercise, that inspires to really think about what we do as midwifes, and why.

Women in Slovenia

Slightly more than half of the people living in Slovenia is a woman. Should you happen to meet one of them and not know her name, your best guess would be to call her either ‘Marija’ or ‘Ana’, as they are the most common female names in the country. In 2014, Eva was the most common name given to baby girls.

In that year, 21,200 children were born in Slovenia. Women here have their first child at a mean age of 29.1 years (as a comparison: in The Netherlands this is 29.4 years and in Belgium 28.2). This mean age has risen considerably over the years (in 1994, it was 24.8 years). In 2015, the crude birth rate in Slovenia was 10.1 life births per 1000 people.

If the Slovenian mortality rate stays the same, the baby girls will on average live well into their eighties. Life expectancy of women in Slovenia is 83.7 years. Long live women! ;-) Women in Slovenia are also more satisfied with life than men. And many of them will probably receive some form of higher education. In 2014, 60% of the graduates were women. Also, approximately 4 out of 10 people with a PhD in the country are female. Quite a rise since 1906, when Marija Urbas was the first Slovene woman to obtain a doctorate!

All that glitters is not gold, however. Among other things, women in Slovenia still run a somewhat higher risk of ending up in poverty than men. This goes especially for women who are more than 65 years old or unemployed. Furthermore, there were over 1,600 victims of physical and/or sexual violence a year over the last years. Around 200 women a year reporting sexual violence in the broader sense. Judging by police data, women most often fall victim to domestic violence.