Report of the stay in Lumbo by Paulien Verhoeven
Week 1
After a very warm welcome at Villa Moringa I started in the clinic on Monday. I also feel welcome there, after an introduction to Carolien, the director, I could start. I started by participating in the prenatal check-ups and got to know the ultrasound machine. Excellent machine, the pull ball did not work (for 6 months) but after thorough cleaning it works again! Very handy! I am there in the afternoon or when it is busy in the delivery room. I have also been called a few times to come to the delivery room with the ultrasound because they were unsure about the position or they were afraid of a gemelli. It really is not comparable to the Netherlands in any way, I knew that but when you are here you experience it even more. So much respect for the midwives here who do their work here with so few resources and so little care in case of emergency. It is cozy, there is a lot of laughter and they are genuinely interested in me and I in them!
When Susanne is there she translates a lot, which is nice, then you can ask a little more in-depth questions, but with the SayHi app (which they find terribly funny) and my increasing understanding of Portuguese (I still find speaking difficult) we come a long way. The basic skills regarding ultrasound are very basic, also those of Dr Carlos who is supposed to be an expert… Enough to do and they are very eager to learn! Also experienced some tough things in the delivery room, a child who was born in very poor condition and who we had to resuscitate (I really wonder if this will work out) was picked up 2 hours later to be transferred to another hospital. And also some other case studies that were tough. But also many beautiful natural births, where daring to let nature take its course was beautiful to experience. Actually, every Dutch midwife should be here for a while…
Week 2
Monday I started a new week in Lumbo with renewed energy! To my great surprise I found the lady whose birth I had been allowed to attend a week earlier at work! The baby was at grandma’s and in between she went home to feed. Licinia is not present due to a disappointing eye operation in Nampula, she will probably not be present for a while. Although I had a very nice week with Licinia I do notice that now that she is not here the other midwives feel freer to get started with the ultrasound. Imelda and Jessica in particular are very interested! What strikes me is that they (including Licinia) hardly know anything about the device. For example, they did not know about the different presets and so they made an obstetric ultrasound with the preset of adult abdomen or another non-working preset. They were already so surprised why I had such beautiful images, now they understood why. For that reason I decided to make a step by step instruction for using the ultrasound with the correct settings for ultrasound 1st trimester/echo 2/3rd trimester and gynaecology. This instruction is now with the ultrasound device.
Furthermore, the practice is very basic and there is a shortage of gel.
Called all pharmacies in Nampula, nowhere to be found. I got a tip from one of the pharmacists to use Aloevera gel. You can get it here! Called ultrasound suppliers in the Netherlands to see if this is indeed an option and it is! Immediately jumped in the car and bought all the Aloevera gel in the Lumbo region! The advice was to dilute it a little with water and it works! Beautiful ultrasound images and enough ultrasound gel in stock now! That is very nice, because due to the shortage Lucinda really allowed me to use a mini drop of gel that was actually not possible to use for ultrasound.
What did I see with the ultrasound, mostly nice ultrasounds fortunately and with some regularity an unexpected gemelli in the third trimester. There is no woman who comes for a consultation in the 1st trimester, usually you see them for the first time between 24-28 weeks. Early term determination is therefore not an option. I saw the last woman of today in the midwifery department. She was admitted there because she was supposed to be in labor with a magnesium drip and antihypertensives. During the check-up, the RR was okay at that time but I was shocked by her small belly! Because the door is hermetically sealed for everyone after the ultrasound consultation, I saw no possibility to look with the ultrasound. After a lot of searching, Dr Dandi (very pleasant doctor from the Emergency Room! Very eager to learn and also very interested in the ultrasound) turned out to have a key after he had complained about it to Licinia. With the ultrasound, it turned out that the baby was only 30 weeks (!, all measurements cf 30 weeks) and there was hardly any amniotic fluid. So besides the problem of high blood pressure there was now an additional problem in the form of threatened prematurity and too little amniotic fluid. The lady received lung maturation and was informed that her baby would probably have to be transferred after birth. Three hours later this lady gave birth to a tiny baby girl in the clinic in no time, who is doing well under the circumstances! Because the baby was breathing independently she was placed warmly with the lady. I am very curious to see how this will continue.
Breaking the waters is something they do not do, they also do not have a water breaker. I have tried to get one (called Dr. Carlos and Caroline, the director) but this seems impossible. I really think this could be of added value here.
What I find striking and intense is that seriously ill women in a late stage of the disease regularly report to the clinic with pre-eclampsia. (Pre-eclampsia is more common here, one of the main causes of death) In 26 years as a midwife, I have not yet seen these serious complications due to pre-eclampsia in practice and this week already twice. I find that impressive to see. In both cases the baby died and in one case the mother also. Mothers are not informed about the symptoms due to pre-eclampsia as standard during pregnancy and therefore arrive at the clinic with very serious symptoms. I made a small advice card regarding pre-eclampsia. The midwife responded positively to this. My plan is to have more sturdier smaller cards printed in the Netherlands and to give them to Marjanne in August.
The midwife, Jessica, does the contraceptive consultation that they have. The Implanon is used a lot here, which I understand because you can place it directly and it is questionable when you will see women again. Together with Jessica I looked at the different spirals and we did an instruction lesson “placing IUD”. She is enthusiastic, tomorrow she wants me to place the T-safe IUD in her! Young women who do not have children yet also report to her consultation hours. Jessica gives a lot of information, also about protection against HIV which is alarmingly high here. (while condoms are for sale everywhere, even on the market in Lumbo) I am shocked by the high level of prostitution here, also within marriage, simply because it provides money to live.
Especially at the end of the day I have nice conversations with the midwife (it is quieter then and we often sit and wait for a woman in labor). They are very curious about how things are done in the Netherlands. We talked about different birthing positions (I noticed that almost all women here lie on their backs during the expulsion). I showed them videos of deliveries in all-fours, they found this very interesting and watched the videos in amazement. The women do catch the contractions in different positions, they do this in a room where the women who have just given birth are also. They only move to the delivery room towards the expulsion.
I also talked to them about the external version. They don’t do that here, the women have to go to Nampula for that. This would also be a nice project to take on, with a success rate of 40% it certainly reduces the chance of a section with all the associated risks!
Before I went to Ilha I was called by Dr. Dadi if I wanted to come for 3 more ultrasounds. In the meantime I am known as “a senhora branca em Lumbo” and they come from far and wide for an ultrasound, especially now that there is no more ultrasound in Monapo, this one is broken. I saw a woman with an IUVD at 22 weeks, she was immediately put in the ambulance that was already leaving together with a woman with an NVO for a caesarean section.
With the 2nd woman I saw a heart defect in the child, a heart defect that you often see in a child with Down syndrome, because I also saw a lot of fluid in the intestines of this child this suspicion was confirmed even more. I tried to explain this to Dr. Dadi, he advised the woman to go to Nampula. She did not do this, the day before yesterday she gave birth here to a child with Down syndrome. This is very rare here. The child did not drink well but went home with the mother. I wonder how long this will last, oh poor thing…
With the last woman before my departure to Ilha I saw an intact ectopic pregnancy of no less than 10 weeks! This woman had been in a lot of pain, I understand that! I had never seen it so big! Furthermore, an acute skills training was organized, which they apparently do monthly. I thought it looked good! Everyone can join, even the taxi driver who is sometimes used to transport a woman in labor (due to lack of fuel for the ambulance) participated with great enthusiasm!
After a nice weekend in Feitoria on Ilja de Mozambique with an interesting tour with Amassi in Macuta town, I started again with fresh energy in the clinic.
Monday morning I saw Dr Carlos from Ilja de Mozambique who was supposed to be here twice a week, I have only seen him twice so far. I have seen him do 1 ultrasound and that is really sad. Furthermore, he is absolutely not interested in learning things… I had a beautiful book in English with all the abnormal ultrasound findings with the intention of giving it to him, but I didn’t do that. I gave it as a gift to Dr Dandi, the all-round doctor at the clinic. He is a really fantastic guy, works super hard, is always there and is incredibly committed to people. He is very interested in the ultrasound and wants to get the most out of it while I am there. He is very happy with the book. I looked up the abnormalities that we have seen in the past few weeks in the book and discussed them. So we should not rely on Dr Carlos but on the very interested Dr Dandi and the midwives Jessica and Enilda.
I did discuss with Dr Carlos why no membranes are broken in the event of a non-progressing dilation. He said that he did, but that they are afraid of infections. If you use it correctly, it could prevent a section with an even greater risk of infection! He shared this opinion. Last Saturday I had 2 specula and other supplies for placing an IUD sent from the Netherlands with urgent transport, with that package I included a reusable membrane breaker that we still had at the practice. I hope it will arrive in time before my departure.. I placed 1 IUD with Jessica but all she had was a plastic (single-use speculum…) with the probe that I had with me we did the placement but it was not convenient.
This week I practiced with Jessica and Emilda on the ultrasound, I think Jessica in particular has insight and Enilda is also getting better and better. Also talked about the maintenance of the ultrasound, being careful with the probe, how to clean it etc. etc. I bought some soft small towels that they can use when cleaning the probe.
I really see case studies here like I have never seen before even though I have been a midwife for 26 years! For example, I saw a lady for her first check-up at the consultation. At the first check-up it is customary for the partner to come along. Both tested positive for HIV. The midwife convinced them to start taking medication. Despite the fact that this medication is sufficiently available, not everyone wants to take it. It is not entirely clear to me why not. Enilda indicated that this often has to do with denial. This woman turned out to have syphilis as well as HIV (this combination is more common due to the reduced resistance with HIV and the high incidence of STDs). The ultrasound showed that the baby had died at a term of approximately 28 weeks. I saw a lot of (in my opinion) blood in the baby’s abdomen. The parents accepted this information with resignation.
Today I saw a lady who had been sent from Menapo to Lumbo for an ultrasound. Her uterus was high up on the ribcage and she had thought she was pregnant all this time. In Menapo there had been some doubt. I was shocked when I looked at the ultrasound! Her entire uterus was full of a Molar pregnancy (wild growth of placental tissue without a baby), unbelievable! Dr Dadi was there because I had called him in shortly before because I had again found a hypoplastic heart during an ultrasound, I wanted to show him the images of this. He saw how shocked I was and said that I had never seen anything like this before. “Welcome to Africa” he said….
I have also been to a number of beautiful deliveries this week. During those deliveries I consistently take the doppler to listen to cortons and to my surprise I saw that it is now often prepared in the delivery room. During a difficult expulsion, the suggestion was made to go for a different position (which I had discussed with midwives before) or to get out of bed for a moment, sway my hips a bit, and so it happened that we all did a little dance in which we made our hips turn vigorously. Loud laughter all around of course, but when she lay back down on the bed we saw a small segment! A beautiful girl was born!
Today midwife Inocencia (you may remember her as Isha) also returned from vacation. It was nice that I got to know her too. I think she is an interested and good midwife. I had a beautiful delivery with her and enthusiastic family members in the delivery room! A beautiful scene.
Conclusion, I have had another innovative, educational and pleasant week. Next week is my last week here. I notice that I find it difficult to leave here, there is so much to do here and I am having such a good time here. If I didn’t have so many lovely people in the Netherlands that I care about so much, I would honestly consider staying longer. I’m curious how it will feel to start working in my practice in the Netherlands again, how often everything I’ve seen and experienced here with these incredibly strong women will go through my thoughts…
