For the fifth year in a row, midwifery students at the Faculty of Health Sciences, University of Ljubljana, organised the “Student Midwifery Forum” as part of International Day of the Midwife (May 5). Each year they choose a topical, somewhat pressing theme. This year, the forum focused on the “Challenges of the postpartum period”.

More and more boldly and loudly, the desire for “continuity of midwifery care“ is coming to the fore—something midwives very much want, as it is the type of care that is best for the woman, the children, the family, and ultimately for high-quality and safe midwifery care. This means supporting a (healthy) woman during pregnancy, labour, and the postpartum period, as midwives are currently more or less limited to delivery rooms, even though our education and the licence we are granted give us competencies that allow much more. You can find the competencies listed further down in the post.

So, what we need to change in Slovenia is for midwives to be included in practice in the five preventive check-ups during pregnancy (at 16, 32, 37, 38 and 39 weeks of pregnancy) listed in the “Rules on the provision of preventive health care at the primary level”, and in community nursing care. Above all, community nursing care should also start mentioning midwifery care and the midwife, because a midwife is the best choice for caring for a pregnant woman, a woman in labour, a postpartum woman, and a newborn—not just nursing care and a nurse.

Community nursing care (hereinafter CNC) is based on the principles of primary health care and operates as comprehensive nursing care for healthy and ill individuals and families in their homes, and for communities from the perspective of integrating preventive, curative and social care. CNC is organised as an independent service or an organisational unit of primary health care in health centres (Health Services Act, Official Gazette of the Republic of Slovenia, No. 23/05 – consolidated text; Health Care and Health Insurance Act, Official Gazette of the Republic of Slovenia, No. 100/05 – consolidated text). Community nursing care may be provided by a nurse with a higher or university-level education as an independent activity (concession), but it is included in the public health network. CNC is organised 24 hours a day, every day of the year.

Areas of work in CNC are:

MIDWIVES’ COMPETENCIES IN COMMUNITY CARE

Anita Prelec, BSc, MSc (UK)

Within her competencies, a midwife works independently if she has:

• the appropriate education (professional title),
• a professional qualification obtained through internship and the professional exam (professional qualification title) + diploma,
• registration and a valid licence

An additional special requirement is APPROPRIATE PROFESSIONAL COMPETENCE.

Directive 2005/36/EC and Directive 2013/55/EU. These directives have historical value, as this was when professions were defined for the first time—i.e., who a midwife is in the EU. They raised the required level of education for midwives (and also nurses) in all EU Member States. Standards also improved, and care became safer and higher quality. The directives set out: prior education requirements (12 years of general education completed), requirements regarding the duration of studies (three years of schooling or 4,600 hours of education (ECTS)), the scope of theoretical training (at least 1/3 of total training), and the scope of clinical training (at least 1/2 of total training).

There are 34 regulated health professions, as the conditions for practising a profession are set by the Health Services Act or the subordinate act “List of health professions”, which was adopted by the “Order on the list of professions in health services“.

Regulation of midwifery care (and nursing care) is intended primarily for the users of our care (in midwifery care, that means women, pregnant women, women in labour, postpartum women, newborns, children, and ultimately families). It protects them from the risk of unprofessional and poor-quality practice. High-quality and safe practice is ensured by: establishing professional guidelines, standards and recommendations; defining professional activities and competencies; and regulating health professionals (appropriate education/professional qualification, registration, holding a licence, enabling removal from the register/withdrawal of the licence).

EFN COMPETENCY FRAMEWORK – ICM COMPETENCIES (from 2015) – Professional activities and competencies in nursing and midwifery care

The issue with nurses with a master’s degree is that they do not have the basic education of a registered nurse (and vice versa). This is therefore a problem for registered midwives with a master’s degree in nursing when it comes to providing polyvalent community nursing care, and so they cannot be granted a licence to work independently in NURSING care (they do, however, have a licence to provide midwifery care and all the competencies listed above).

Prelec clearly points out that, under the Directive, a midwife and a nurse are DIFFERENT professions, with different professional competencies, and their work can overlap to some extent only in certain narrower professional areas (she gives the example of midwifery and nursing care of the newborn). In the end, she presented initiatives for changes that we were all very happy about—both midwives and nurses:

A midwife best meets the needs of the pregnant woman, postpartum woman, newborn and young family. Therefore, it is in everyone’s interest that, within community care, a midwife cares for the postpartum woman and newborn up to the completed 6th week of age and carries out preventive visits for pregnant women.

An additional visit by registered midwives – an extension of rights, as these are vulnerable groups; additional mental health screening; she understands the needs of a young family because she is professionally trained and has the competencies.

MIDWIFE IN THE COMMUNITY NURSING SERVICE

Mojca Petek, registered midwife (Health Centre Idrija)

At Health Centre Idrija, they moved from monovalent to polyvalent care, as the workload for only two employed midwives to cover all midwifery visits was too high. The lecturer touched on some of the history of midwives’ work and the content of home visits for the pregnant woman, postpartum woman and newborn.

History of home midwives: midwives assisting at birth –> before WWII, midwives’ visits up to 9 days after birth –> more and more births take place in maternity hospitals and the midwife becomes a socially oriented health professional –> help in antenatal clinics and to community nurses –> after the establishment of the centre for polyvalent community care (1954), staffing changes and the midwife is replaced by senior nurses, who could meet all curative and preventive needs.

*see competencies above –> A registered midwife can also carry out the mentioned activities in the patient’s home (Rules on minimum conditions of competence and acquired rights for the professions of physician, specialist physician, general practitioner, doctor of dental medicine, specialist doctor of dental medicine, registered nurse, registered midwife and master of pharmacy, 2017. Official Gazette of the Republic of Slovenia, No. 4)

Preventive visits in CNC are:

• a newborn visit, 2 visits for the postpartum woman, 6 infant visits (4 newborn and 2 infant) in the first year of life, and two additional visits for infants of blind and disabled mothers,
• a visit for the pregnant woman after 32 weeks of pregnancy,
• a newborn visit within 24 hours of discharge from the maternity hospital,
• a newborn visit at 1 week,
• a newborn visit at 2 weeks,
• a newborn visit at 3 weeks,
• a visit for the postpartum woman up to 6 weeks after birth.

*VISIT FOR THE PREGNANT WOMAN after 32 weeks of pregnancy (building a trusting relationship with the postpartum woman).

With a preventive home visit, the midwife (or nurse):

• Gets to know the pregnant woman and the family’s social and health circumstances.
• Monitors the normal course of pregnancy and informs her about all changes and activities (which we previously said the midwife is competent for and the best choice).
• They support pregnant women in strengthening and maintaining health and preventing disease.

At the preventive community visit, she informs the pregnant woman about:

• Physical and emotional changes.
• Hygiene routines, nutrition, exercise.
• The consequences of harmful habits.
• Motivation for breastfeeding.
• Information about the onset and course of labour, breathing techniques.
• Information about warning signs in pregnancy.
• Counting fetal movements.
• Advice on newborn equipment.
• Rights they can claim at the Social Work Centre.
• Preparing the hospital bag.
• Encouraging the partner to be present at the birth.
• Postpartum mental distress (women should also receive this information, for example, in childbirth preparation classes. Midwives are again trained and competent to organise and deliver these).

*NEWBORN VISITS

4 preventive visits in the newborn period (midwifery visits); the first visit should be carried out within 24 hours after discharge from the maternity hospital (including Sundays, holidays, etc.), then in the 1st week, 2nd week and 3rd week, and 2 preventive infant visits at 4–5 months and 10–11 months of age. The problem in some health centres is that they are not informed when a woman is discharged from the maternity hospital (or the woman does not call them herself).

Health education and counselling that midwives (or nurses) (should) provide in the field includes:

• Breastfeeding.
• Newborn equipment, suitable microclimate.
• Emotional and psychological support.
• A healthy lifestyle.
• Newborn care.
• Bathing the newborn.
• Demonstration of umbilical cord care.
• Choosing the newborn’s personal paediatrician.
• Supporting parents in integrating the child into the community.

The community midwife (or nurse) observes the following in the newborn:

• Physical examination of the newborn
• Handling
• Newborn care and help with care
• Bathing the newborn
• Skin changes
• Umbilical cord care
• Urine and stool output
• Jaundice
• Assessment of the baby’s behaviour
• Assessment of the baby’s needs
• Breastfeeding and the newborn’s weight gain

*POSTPARTUM WOMAN VISIT

2 visits for the postpartum woman up to 6 weeks after birth

Health education and counselling includes:

• Emotional and psychological support from the family.
• The importance of expressing emotions among family members.
• A safe environment.
• Monitoring the postpartum woman’s discharge.
• Healthy nutrition and sufficient fluid intake.
• Training to strengthen the pelvic floor muscles (hereinafter PFM).
• Sleep and rest, changed day and night rhythm.
• Physical activity after birth.
• Visit to the gynaecologist.
• Sex life and contraception after birth.
• Strengthening the postpartum woman’s self-esteem.

Maintaining and strengthening mental health:

• empowering the postpartum woman,
• psychophysical wellbeing,
• building self-confidence.

The postpartum check-up includes:

• Measuring and monitoring vital signs.
• Monitoring lochia.
• Checking the perineal wound or C-section wound and removing stitches/staples.
• Checking uterine involution.
• Checking/observing blood vessels in the legs.
• Checking the breasts and nipples.
• Checking urination, bowel movements, haemorrhoids.
• Monitoring breastfeeding and helping with breastfeeding.
• Carrying out a screening test for postpartum depression (EPDS questionnaire) 4–6 weeks after birth

This shows that a community visit for a pregnant woman, postpartum woman and newborn cannot last only 20 minutes.

The current situation in community nursing care is such that polyvalent care is provided today, which remains an open question also at the Chamber and Association (and since the Chamber and Association also includes the Midwives’ Section, we are really counting on them!). Namely, the opinion of the Community Nursing Section is not in favour of employing midwives in CNC and providing monovalent CNC. This limits midwives’ employment to perinatal care (even though we have already talked about midwives’ competencies and training), and most preventive community visits are carried out at the expense of the postpartum woman and newborn; there is also the problem of an ageing population, lots of nursing care.

POLYVALENT VS. MONOVALENT CARE

BREASTFEEDING

Asst. Tita Stanek Zidarič, registered midwife, MSc (UK), IBCLC, lecturer

At the forum, I was glad to hear my colleague’s lecture, as she realistically presented that breastfeeding counselling alone is so complex that one person truly cannot cover pregnant women, postpartum women, newborns, older adults and the dying across all areas with sufficient quality. And that the community visit for a pregnant woman, and later for a postpartum woman and newborn, cannot be equated time-wise with other visits, for example wound care.

Recommendations and benefits of breastfeeding are clear and well known, yet the statistics from the HRAST study (IVZ, 2009) are concerning: the study data show that 99.4% of mothers established breastfeeding in the maternity hospital. In the third month, 78.4% of mothers were breastfeeding (just under half of mothers breastfed exclusively, i.e. 48.5%), and in the sixth month 61.5%. In the sixth month, only 0.6% of mothers were still exclusively breastfeeding. The study included most mothers who gave birth at the Ljubljana maternity hospital in October 2009.

For women to be able to follow through on their decision to breastfeed, they need: appropriate information, help and support.

Early postpartum period – up to day 9, when the main changes begin: uterine involution (involution processes), healing processes, onset of lactation and maintaining it, establishment of ovarian activity – hormonal states. Late postpartum period – up to day 42, which is mainly about adapting to life with the baby and balancing hormonal status.

Breastfeeding is not limited either by the time intervals between feeds or by the duration of an individual feed.

Counselling! This is where many pitfalls arise, because breastfeeding advice is given by midwives, community midwives, community nurses, maternity ward nurses, child health clinic nurses, the paediatrician, the gynaecologist, a doula, mum, mother-in-law, sister, grandmother, friend, neighbour, Facebook, forums and others. We want CONSISTENT information from different professionals who advise on breastfeeding, and continuity of care (as also suggested by the previous speakers at the forum).

The healthcare system also needs more IBCLC counsellors (International Board Certified Lactation Consultant – internationally certified lactation counsellors). Slovenian Association of Lactation and Breastfeeding Counsellors. Breastfeeding counsellors do not deal only with breastfeeding, but also with pooping, sleep, mental health and other issues, which the lecturer presented with examples from practice that she encounters. That is why we emphasise once again that midwifery visits cannot be time-limited. Sometimes they can last 2 hours, because only after spending more time with a mother—sometimes by chance—do problems and distress come to light. And midwives approach women differently than nurses.

From the audience, there was concern among community nurses, as they are in a dilemma about how to advise on breastfeeding depending on the chosen paediatrician, since they do not always agree on breastfeeding advice, weight gain and more. This is why the lecturer’s message stands out even more: cooperation is extremely important—not only between midwives and nurses.

A MOTHER’S EXPERIENCE

Maja Tomc

This year again, we were able to listen to a mother’s experience—someone who, in principle, does not know the state of Slovenian midwifery and the reasons why things are the way they are.

She mainly highlighted that her expectations differed from reality; the birth itself was not exactly easy, and then breastfeeding difficulties appeared as well. What helped her a lot was knowing how to hand express milk, which was especially helpful at the beginning. The baby would not latch, so she stimulated her breasts for milk production to start, and for each feed she expressed milk that the baby then licked from the breast. Even though she asked for help in the maternity hospital, she did not receive appropriate help. They advised her to use nipple shields; the latch still wasn’t correct, she had cracked nipples and pain.

Breastfeeding difficulties continued at home. She asked the community nurse for help, who advised using a pump. She was glad the nurse suggested this option rather than formula, as there was enough milk. The milk just needed to be removed from the breast so mastitis wouldn’t develop—which, unfortunately, she did get. She emphasised that mothers expect help when they ask for it. The nurse encouraged her to pump and feed the baby her own milk by bottle (for 2 weeks), for which she was very grateful. During that time, her nipples healed enough that she started breastfeeding again, and they have now been breastfeeding for 7 months. But it still takes effort.

By reading literature and looking for solutions, she later realised on her own that she and her baby also had breastfeeding difficulties due to a tongue-tie.

As for newborn care, the care was also not adequate. In the maternity hospital, on day 1 they showed her how to care for the baby and told her that on the second day she would do the care herself, supervised by a nurse. Of course, that did not happen; she also sought help from another mother in the room who already had one child at home. The community nurse came to her only on day 5 because there were holidays in between. Also, no one warned her about urate crystals, which can be present in the first days after birth when the newborn urinates.

I think it is unrealistic to expect that, with a full ward, nurses will do morning care with every mother. So, when handing over information while demonstrating care, they should realistically tell mothers to watch and listen carefully to how morning care is done, because tomorrow they will already be washing the baby themselves. If they need help, of course they can call. But with 30 women and newborns on the ward and 3–4 nurses, it is not realistic to expect nurses to be with every mother during morning care, especially since mothers care for their babies more slowly (e.g., around 40 minutes). However, no one told this mother that or set those expectations, so her expectations were different—which is understandable.

POSTPARTUM COMPLICATIONS IN WOMEN

Assoc. Prof. Miha Lučovnik, MD, specialist in gynaecology and obstetrics

Complications: 85% of women have at least one health problem in the first 8 weeks after birth: perineal pain, breastfeeding difficulties, infection, bleeding. At least 3% require rehospitalisation (Glazener CM et al. BJOG 1995; 102: 282-7).

At the Ljubljana maternity hospital (the lecturer almost certainly claims it is the same elsewhere), the main reason for return after a vaginal birth is breast problems, and after a C-section, wound problems are in first place; the rest is the same as after a vaginal birth.

TABLE: Collection of perinatal results (NPIS is not useful for the postpartum period) shows different results.

After a C-section, there are no more dehiscences (so the surgical technique is good), but there are more wound haematomas. After 2012, obstetric practice has been such that all women receive low-molecular-weight heparin after a C-section, and as a result there are more haematomas. Someone might say: why not stop giving it then? If we look further, deep vein thrombosis is the 5th cause of maternal death. And if we weigh these two, we would probably all rather choose a haematoma.

Example: a 33-year-old first-time mother, 1 week postpartum, fever 38.3°C, dry cough. The family doctor refers her to a pulmonologist, who prescribes the antibiotic Amoksiklav (pneumonia). The cough persists; 3 weeks postpartum she suddenly loses consciousness and dies. Autopsy shows the cause of death: pulmonary embolism. And so the risk of a haematoma when using low-molecular-weight heparin is the “lesser evil”.

What is more concerning is that the leading cause of maternal death between 2002 and 2014 was suicide (NIJZ, 2016). Mental health was already discussed by previous speakers. We also mentioned the EPDS questionnaire, and even while listening to the mother’s experience we could sense the distress the woman found herself in due to inadequate support and counselling. And postpartum depression is an important postpartum complication. The prevalence of postpartum depression symptoms in Slovenia is about 21% (every fifth woman). The most important factor affecting the duration of an episode is the duration of depression before appropriate treatment begins (Gavin Ni. Obstet Gynecol. 2005, Podvornik N. Zdr. Varst 2015, Koprivnik P. Med Razgl 2005).

The lecturer highlights another very important point. Until celebrities in the US spoke out about having mental health issues or postpartum depression, it was talked about even less (Down Came the Rain: My Journey Through Postpartum Depression; Brooke Shields). Perhaps if our celebrities also spoke out about having found themselves in distress, women would recognise the problem more easily, admit it to themselves, and take timely action and seek help.

Once again, the lecturer presents the importance of screening. Whooley’s questions, which are effective for screening purposes:

1. In the past month, have you often felt down, depressed, or hopeless?
2. In the past month, have you often had little interest or pleasure in doing things?

If the answer is yes to at least one question, the woman should be referred to a clinical psychologist or psychiatrist <for a diagnostic assessment and appropriate therapeutic support!

He also sees the key to addressing postpartum problems in appropriate COMMUNICATION.

PHYSICAL RECOVERY OF A WOMAN AFTER CHILDBIRTH

Senior lecturer Mag. Darija Šćepanović, senior physiotherapist

After childbirth, many changes take place in a woman: hormonal, haematological, musculoskeletal. See “Physical activity in pregnancy”– NIJZ 2016

In her lecture, the lecturer focused on musculoskeletal issues:

1. Separation of the rectus abdominis, 66% (pathological separation) – 100%

They assume this occurs due to: the hormone relaxin, oestrogens, progesterone, mechanical pressure (on the linea alba, i.e. connective tissue and abdominal muscles due to the growing uterus), congenital weakness of connective tissue, and strong abdominal muscles already before birth. Physiological separation is less than or equal to 2 cm or two finger widths; excessive separation is said to be greater than 2 cm.

It does not resolve on its own by the end of the puerperium; it can still be present 5–8 weeks postpartum in 36–80% of women. In some, it is still present 12 weeks postpartum. Postpartum recovery is individual. Physiotherapists teach women how to check for themselves during exercises whether an exercise is suitable for them based on the test, or whether it could worsen their condition.

The basis for recovery is core stabilisation exercises (the linea alba must be stable), then they start exercises that shorten the rectus abdominis; if needed, an abdominal binder is used. It can take up to 1 year of exercises (or more) for the condition to normalise (again, she points out the individual nature).

A question from the audience was whether pressure on the fundus affects separation of the rectus abdominis. The lecturer replied that systematic check-ups mention that pressure on the fundus affects diastasis of the pubic symphysis.

2. Urinary incontinence, 23–67%; up to 1/3 of women have urine leakage after birth

Cause: childbirth itself results in pelvic floor laxity; there may be perineal injury (spontaneous tear or episiotomy) – which impairs support for the pelvic floor muscles (PFM). Stretching of pelvic tissue during birth can damage nerves, muscles and connective tissue. Muscles can recover with training (exercises), and nerves can also recover. Connective tissue, however, cannot (surgical repair is needed). These injuries affect the ability of the urethral sphincter to contract effectively in response to a full bladder. Recovery is longer with ruptures. If the pelvic floor detaches from the pelvic wall, pelvic organ prolapse may occur later in life.

Recovery depends on perineal injuries—what kind of perineal injury it was (spontaneous or episiotomy)—and the strength of the pelvic floor muscles. At least six months of pelvic floor muscle training is needed to train the muscles. In the videos, she showed us what happens to the PFM when coughing. That is why it is essential to contract the PFM before exertion (sneezing, coughing, lifting loads, jumping, etc.). And that is why it is very important for a woman to have well-trained PFM if she runs.

3. Pain in the pelvic girdle (this is not lower back pain),

“The hormone relaxin softens the ligaments of the pelvic girdle, making them more stretchable. Without this, a natural birth would not be possible. The joints are also more mobile and unstable due to relaxin and therefore more strained, which leads to pain. Hormone levels rise already at the beginning of pregnancy, so pain can appear even before the twelfth week, most often in the fifth and sixth month. With timely professional treatment, it can be well controlled and usually disappears after birth; if neglected, it can develop into chronic pain and accompany a woman for up to two years after the baby is born.” Effective treatment requires an appropriate diagnosis and cooperation between specialists in gynaecology and obstetrics, physiotherapists, nurses, midwives, occupational therapists, social workers and pain management specialists.source

Pain most often occurs in the back of the pelvis, buttocks and pubic bone, and can radiate to the back and inner thighs down to the knees, to the hips and groin.

7% of women also have severe pelvic girdle pain after birth, especially if it was not treated and managed during pregnancy. Special exercises are needed to strengthen and stabilise the back muscles; it takes about 6–12 months to ensure adequate pelvic stability. Acupuncture can help.

4. Physical activity

Recovery depends on whether the woman gave birth vaginally or had a C-section, whether she was active during pregnancy or had a high-risk pregnancy. Correct exercises are important, as are appropriate positions for sitting and lying down, lifting loads correctly, getting up and lying down. Because the PFM may be less elastic after birth—especially if the woman did not do PFM training exercises before pregnancy—she should be particularly careful not to start running too early. It is better to postpone running for a while until the PFM are “back in shape”.

At the Ljubljana maternity hospital, all women are given the FIT MAMA brochure. After birth, a physiotherapist performs a test for rectus diastasis, teaches them how to activate the deep abdominal muscle, and talks to them about getting up and lifting loads correctly.

The lecturer’s advice is to wait 6 weeks before physical activity, except for what is in the booklet. Depending on the birth, activity during pregnancy, activity before birth, and whether she did PFM training, it will depend on when she can safely start other forms of physical activity.

Pilates is not suitable exercise in the postpartum period – article. If there are problems and physiotherapy treatment is needed, women with difficulties can come to Ljubljana with a referral from their personal gynaecologist.

In response to a question from the audience about sitting cross-legged, the lecturer replied that pregnant women should be careful to avoid extreme stretching, and in cases of pubic pain it is absolutely not recommended.

POSTPARTUM COMPLICATIONS IN NEWBORNS

Jani Breznik, MD, paediatrics resident

Birth weight:

• Extremely low BW < 1000 g
• Very low BW < 1500 g
• Low BW < 2500 g

Small for gestational age (SGA) – asymmetrical means head size matches gestational age, but weight is low (late IUGR); symmetrical means head circumference is small and something has been happening with the fetus during pregnancy, so it is very small. The other extreme is a large fetus (LFD = LFG). The lecturer lists the most common issues parents turn to paediatricians for in the first 6 weeks postpartum as: poor weight gain, umbilical issues, (physiological) dermatological changes,

1. Poor weight gain

• Physiological weight loss up to 10%; preterm babies 10–15% (up to 20%); SGA very low loss or none.
• In the first 14 days after birth, the newborn should reach birth weight. Some reach it earlier. From then on, they follow their percentile curve (after 5 months they double BW and at 1 year they triple BW).
• Healthy preterm babies have the expected newborn weight at the due date. Their growth and development are always assessed by corrected age.
• In SGA, weight gain is greater so they reach their limit as quickly as possible, and therefore their energy needs are higher.
• Expected growth in preterm and SGA babies is higher because they have greater needs.
• Breastfeeding is adjusted depending on birth weight and whether the baby is term or preterm.
• Thickened formulas are anti-reflux. If breastfeeding (or feeding with expressed breast milk) does not establish in preterm babies, special adapted milk needs to be given up to 35 weeks of age.
• With poor weight gain, the cause must always be found. For checking progress, daily weight gain (at approximately the same time) is more realistic than a test feed.
• Colic – in a healthy baby who is gaining well, it is most often due to too much stimulation during the day and too little sleep. It usually resolves around three months and the cause is unknown.

2. Umbilicus

• The umbilical stump usually falls off between day 5 and day 14 (mummification) and then heals completely within 12 to 15 days.
• A minimal yellowish discharge and drops of blood are normal.
• Proper cleaning is needed, as the umbilicus is an ideal site for infection and entry of (pathogenic) microorganisms into the body.
• Bathing is not recommended until the umbilicus is completely healed.
• Proper care is needed – see “Newborn umbilical cord care“

Umbilical issues:

• Bleeding – referral to the paediatrician for vitamin K
• Omphalitis or umbilical inflammation: the navel is red, swelling appears, and there may be a foul-smelling purulent discharge, fever, or poor appetite. In such cases, umbilical cleaning and a referral to a pediatrician will be recommended.
• Hernia – generally, it does not become incarcerated; if it causes feeding difficulties, surgical removal is necessary.
• A polyp is usually larger than a granuloma. If it cannot be treated with cauterization, it must be surgically removed.
• Granuloma: soft, fleshy, and moist tissue with yellowish discharge – cauterization with silver nitrate.
• The umbilical stump falls off after >3 weeks; we must ensure that disposable diapers do not cover the umbilical stump.
• Other Issues
• In premature babies: apnea, feeding difficulties, thermolability, susceptibility to infections, hernias.
• Jaundice
• Feverish condition – more than 37.5 °C axillary and in the ear, and more than 38 °C rectally.
• Eye inflammation – serous discharge; massage the medial corner of the eye, clean with NaCl. If there is purulent discharge, refer to a pediatrician for a conjunctival swab (chlamydia, gonococcus – gonorrhea).
• Dermatological issues:

1. Physiological: marbled skin (from warm water to a cold environment) – if the baby is lively and feeding well, it is not due to a shock state;
2. baldness;
3. milia, most commonly on the nose and forehead, disappear spontaneously;
4. neonatal acne – due to maternal hormones, the skin is clearing;
5. erythema toxicum neonatorum – the cause is unclear, it causes no problems and resolves spontaneously;
6. stork bite – usually disappears by 1 year of age, considered a vascular anomaly.
7. Cradle cap – if not addressed early, it spreads. An oil solution, cap, and leaving it on for some time before combing are needed. Proper care is important;
8. Diaper rash – most often fungal, not so much bacterial. More common now that cotton diapers are less used. Regular cleaning with water, frequent diaper changes, and more contact with cotton diapers are necessary. A cotton diaper can be placed inside a disposable diaper.
9. Hemangioma – if they do not grow with the child, they cause no problems. If it grows with the child, a referral to a dermatologist is necessary.

PSYCHOLOGICAL PROFILE OF WOMEN AFTER CHILDBIRTH

Tara Henigman, B.Sc. Psychology, Gestalt Int. Spec.

The lecturer elaborated on the previously mentioned topic – the mental health of women after childbirth.

Once order is disrupted, a new chaos initially emerges because we don’t know how we will cope with the new situation. This is the transition to establishing a new system and restoring order. When problems arise, pathology must always be sought within the entire family, not just in the woman. Sometimes a rift between partners occurs simply because he is not pregnant, doesn’t have sleep problems, isn’t as enthusiastic about the pregnancy, and so on. The mother’s condition is not always a reflection of her pathology, but rather reflects the dysfunctionality of the entire family dynamic. Especially if the woman has too many obligations: caring for the child, caring for the living space. And because she works 24/7 doing only this and doesn’t go to work, she feels inferior. In Slovenia, 1800-3600 women annually experience postpartum depression.

Roles within the family or between partners must be well distributed so that they can remind each other without resentment: “Hey, you didn’t take out the trash. – Oh, thanks for reminding me.”

An important observation came from the audience. Mothers feel lonely. They no longer socialize unless pre-arranged or through Facebook. This is also why breastfeeding consultant workshops are being canceled due to low attendance.

I will conclude by saying that I expected greater attendance at the forum, not only from nursing students but also from community nurses from gynecological dispensaries, home care nurses, heads of health centers, gynecological clinics, and others responsible for organizing healthcare activities, and ultimately, the role of midwives in practice. Nevertheless, the students once again excelled with their choice of topic and the organization of the forum itself. All praise to them.

Forum 2018 Photo Gallery

Photo Gallery from Midwifery Day 2018

Gallery of Toddler and Adult Run for Midwifery Day 2018

Mrtvorojenost in izguba otroka – 4. babiški forum 2017

3. študentski babiški forum več kot uspel