Today was International Day of the Midwife (IDM), this year themed 'Women and Newborns: The Heart of Midwifery! In Ljublana, it didn't went unnoticed, as we, midwifery students, occupied the central square near the famous Triple Bridge. Apart from stands with information, there was a 2 kilometer Midwifery Run to bring our beautiful profession into the limelight.
'I am a midwife, this is what I do'
The above is the slogan used for this year's IDM social media campaign (#IDM2016), inviting midwives from across the globe to share a photo and some words about what they do to give women and newborns the best possible care. Talking to some of my fellow students, I noticed how differently the role of a midwife is worked out from country to country. For me, used to the Belgian context, Slovenian midwifes have a rather independent role. Although home births are not an established here, midwives are the ones who guide the low risk labours in a clinical setting and conduct the deliveries. Some fellow students from Estonia, on the other hand, told me that they considered Slovenian midwives to be less independent than their Estionian counterparts and their role to be rather limited. It illustrates that the position of the midwife is still subject of debate and too often under pressure. Personally, I think that the encounter with a midwife differs in character from one with a gynecologist or a doula. That is why I would advocate for an own, independent role of midwives. In Slovenian, they aren't called babica, also the word for (wise) grandmother, for nothing. All women should be enabled to draw from that well.
"May the wise midwives of today leave their special mark in the hearts of women with their knowledge, respect, loving kindness and warmth so very much needed by the birthing women, as well as their children longing to find themselves earthside, breathing with lungs fully for the very first time.
May they be there with their loving support when couples become families and when families expand - changing the world one mother, one baby, one family at the time. Wishing all the very best to all the midwives of this world on this International Day of the Midwife!"
A quick guide to Slovenia in some surprises... 1. The toilets
No, seriously. In Ljubljana, even the toilets are a source of amazement. They don't just do 'male' and 'female' at the Pritlice; a third, 'genderneutral' option is also provided. My good old curiousity led me to have look inside... only to be amazed again, this time by a lovely handwritten proverb.
2. The climate
No, I don't dislike snow. In fact, I like the view of an old city covered in a spotless white veil. But ten centimetres of snow falling in the midst of spring...? I couldn't help but feeling somewhat sad about the branches and blossom giving way under a weight that shouldn't be there.
3. Lolita
Talk about sweet surprises! I had already put patisserie Lolita on my to do-list early on in my internship. After passing by numerous times, I recently decided to take action, and that proved to be a great idea. On the friendly waiter's advice, I decided to have this 'Mangolita' monocake to go with my coffee... and boy, a good choice it was. It was exquisite!
4. Koper
During my previous trip to Slovenia, I visited the lovely coastal towns of Isola and Piran. Some weeks ago, I decided to complete this trinity, so on my day off, I headed for Koper by bus. Windy as it was, it was good to stroll around the city and see the Adriatic again. Though the palm trees and the old city center weren't lacking, I must admit that Koper has a less romantic feel to it than Isola and Piran. Still, sipping coffee to the sound of a whispering sea makes for a fine day out!
5. Skuhna
Who would have thought that I would get a taste of my beloved Nigeria right here in Ljubljana? You can take that quite literally, as I am referring to the Nigerian dish I had at Skuhna, a restaurant where migrants from Africa, South America and Asia prepare food according to their various culinary traditions. A lovely social initiative that allows the cooks to integrate while you travel by using your tastebuds.
6. Wise words for the good life
There is at least one restaurant in Ljubljana that serves it meals with a side dish that nourishes the mind rather than the body. Its menu is also partly a scribbling pad, in which customers may leave a message. Between the soup and the salad I found one that seems to apply to the way many students approach their Erasmus exchange period.
7. Street view, classic style
What they can do, I can do, so eat your heart out, Google! ;-) Ljubljana offers all one needs for a nice classic style street view, and adds a modern twist to round it off.
8. Build to last?
You can't be in Ljubljana without stumbling upon the name 'Emona', or, as below, one of its variants. It refers to the Roman settlement of Emona, that was constructed in what is now Ljubljana in 14 AD, succeeding an earlier settlement. They did a good job, as the city of Emona outlasted the Roman empire itself by about two centuries... Present day Emonika is quite a different story. In fact, this huge project for a shopping, working, entertainment and-what-more center never really took off, and to date, construction still hasn't started. To be honest, this isn't all that bad, since Ljubljana can do without another symbol of modern trade. In the meanwhile, I'll happily stick to the kind of local, small scale trade that has proven its worth over the centuries.
9. @Home
Ah, the sweet scent of home, where, in my rare free time, I rest and plan new wanderings. Unless, that is, the rather whimsy April weather thwarts the plan. Yes, I know that (meteorological) beauty is often in the eye of the beholder, but let's be honest: beautiful spring sunrises AND dreary, wintery afternoons within one week in April...? As we say in Dutch: April doet wat hij wil ('April does as it pleases').
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:
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:
Nederlandse Vereniging voor Anesthesiologie [NVA] en Nederlandse Vereniging voor Obstetrie en Gynaecologie [NVOG] (2008) Richtlijn medicamenteuze pijnbehandeling tijdens de bevalling. Found on the internet:
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:
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.
"May the wise midwives of today
