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Peace Corps / Yemen JournalWhen he took the gauze off the ear lobe and removed the cotton wool, a thick, oily liquid came oozing out of the earhole, and the area from the scab up to the entrance to the ear could be seen crawling with maggotsabout two-hundred, each a millimeter or so long.
Black Rain, Masuji Ibuse
It's two-forty p.m., and I'm sitting outside Gladys's house in Utmah. It's a clear, sunny day with a nice breeze. The yard faces a valley and several mountain ranges. This is pretty close to heaven. Over head three falcons and four huge ravens are chasing each other. In the evening I sit outside and watch the sun set behind the mountains. The road coming into Utmah from Sana'a isn't bad. One and a half hours on paved road and two and a half hours on dirt mountain roads. The dirt road is smooth, but we rode on the back of a pickup truck on top of butagas tanks (like the gas tanks for barbecue grills). It was cool and windy, but what a view. The area is green with agricultural terraces built along the mountain side. I like it here. It's nice to have a place to go outside and retreat in the sun.
Because the hospital here is isolated, there is more freedom. Everything is nice. Even a stray cat that Gladys feeds is nice: nicer than out cat in Wesab. The doctor wants me to stay here with Gladys, who works mostly in women's health. Few people believe that Patricia will return from the States.
We didn't hear about the riots in Yemen until after they were over. People were rioting in the cities about food prices, and several people were killed.
We've had two deliveries since I've been here. The doctor performed the first delivery. The woman was the wife of the director of the post office. She was only in her seventh month and had three miscarriages in the past. I guessed her to be in her late teens. It went smoothly, and the baby looked surprisingly good for being premature. The doctor had them stay overnight at his house since they were important people. It must be hellish for the doctor's wife since she never knows when he'll be bringing people home. It's good that Gladys lives right on the hospital grounds because she gets called so often in the evenings and nights for deliveries and other emergencies.
We had our second delivery yesterday in the afternoon. The woman had been in labor since the night before, and this was her second delivery. I got to deliver the baby with Gladys there to assist in taking care of the newborn. It was weird because there was very little amniotic fluid, and when the baby delivered, parts of the amniotic sack stuck to the baby's body. The baby came out face up (normal is face down) and was floppy and lethargic. All we had to suction the baby's mouth and nose was a dirty tube and mouth suction. The baby looked premature: lots of vernix, the cheesy stuff that protects the baby's skin in utero and disappears as the baby matures, and underdeveloped genitals. It was a baby girl weighing 2,150 grams.
With the pregnant woman were five other women and a little girl. At first they were all in the room, then we made them leave except for the patient's mother and sister. After the delivery everyone came back in, even though we asked them to stay out. They all saw how lethargic the baby looked and kept asking if it was going to die.
I returned to deliver the placenta, and Gladys took care of the baby. Something happened to how she tied the umbilical cord, and the family came to me freaking out, saying the baby was bleeding and going to die. I quickly got a cord clamp on, but the baby had lost a lot of blood. It didn't help that the baby had looked bad to begin with. All this was going on, and the doctor still hadn't come over. We had to ask one of the nurses to get him.
The doctor looked at the baby and asked us what we wanted him to do. He recommended them to take the baby back to Sana'a, but he didn't think the family would. Throughout the delivery, the women in with the patient kept telling us symptoms they had and wanted medicines. One had abdominal pain, another an eye problem, and one had a miscarriage the previous week.
It's crazy here. You just have to think this is natural selection at work. I have seen more miscarriages here and women with bleeding than I care to think about. There is definitely more job satisfaction here than in Wesab.
The government is building a road from Utmah to Wesab, and occasionally we hear dynamite going off to clear way for mountain roads. It's busy here: not much time to think. At the clinic from nine to noon, lunch, reading outside in the afternoon, and maybe visiting with women, dinner, then the doctor and one of the nurses come over to chat and give Arabic lessons. They usually stay until ten or ten-thirty. Lights out at eleven.
August 17, 1992
I've had strange, sad dreams the last two nights. The first dream I was back in the States for a week. Peace Corps was going to transfer me back to Saudi Arabia. I had said good-bye to my parents at the airport. D. knew I had been home, but he never called. I was at the airport, thinking of calling him. Then someone was chasing me. By the time it was over, I had missed my flight. The second dream I had gone to visit D. in a college town, but it wasn't Gainesville. He saw me in the street but hadn't said hello. I was waiting outside a building, and he came out dressed in a suit with a graduation cap and gown on. He looked in my direction then walked away. He seems far away. I see things much clearer now.
I like it enough here in Utmah that I think I would return to stay permanently if Patricia doesn't return. The only drawback is the living conditions. Gladys is older and has very set ways. The only running water is out of a spigot right next to the toilet. Not very pleasant to wash your face. I can't believe Christmas is less than ten days away. It sure doesn't feel like it.
December 20, 1992
On Thursday we had a difficult day. Called in to the hospital at 8:30 a.m. for a delivery. The room had not been cleaned from the previous day's delivery. Dried blood and body tissue on the floor and delivery table.
This was the woman's sixth pregnancy, but she only had three living children at home. Her bladder was distended, and she hadn't been able to urinate since dinner the night before. We catheterized her to get the urine out. Her membranes were still intact. When Gladys went to rupture them, the fluid was thick and green-brown. Normal amniotic fluid is clear. The baby was delivered soon thereafter, but in bad shape. The baby, a boy, had inhaled a lot of the meconium-stained amniotic fluid. It had a faint heartbeat and tried to gasp a few times. Gladys and I suctioned and did chest compressions for about thirty minutes before we gave up. The heartbeat stopped, and he no longer tried to breathe.
The whole time we were trying to revive the baby, the mother and another woman with her kept telling us the baby was dead, leave it alone. There was something not quite right about the baby, the neck had a swelling in it. Gladys and I were more upset a bout the baby than the family. To them it was just another dead baby from God. The other woman got angry with us for crying. I felt sick. The baby looked so peaceful, like he was sleeping.
When they were ready to leave, they asked me to hand them the baby. It was cold and floppy and lifeless. I keep telling myself it is for the best, that God takes care of those who can't.
January 16, 1993
Had a strange dream last night. Accidentally poisoned a whole town of dogs. Been feeling bored a frustrated lately. Doesn't help not to have books and stuff with me. Been wearing the same four outfits for the last six weeks. Also, the suspense of waiting for Patricia's return the last few afternoons. What's going on out there in the world? The world would be a better place if more Hemingway novels were out there. High snuggle factor tonight, chilly and damp.
March 11, 1993
On Monday morning, a man came to out door saying there was a delivery. He then brought his wife upstairs to our door. The woman was screaming with the pain of her contractions.
They were standing in the foyer with the front door wide open. He lifted her dress and insisted we look. She was wearing a pair of men's boxer shorts. Hanging between her legs was the umbilical cord. We said we had to go to the clinic, so they drove us. We forgot our keys, so I had to bang on the doctor's door to get them, and so he could see the patient. Because of Ramadan, he had just gone to sleep at 6:30 a.m.
The umbilical cord had been hanging out at least twelve hours. The umbilical cord is very sensitive to touch, and it spasms. When the cord spasms, it cuts off circulation to the baby. There was little hope for the baby.
August 17, 1992
The family kept saying the baby was lying sideways, which can only be delivered by c-section. I did the first vaginal exam, but I couldn't tell what was coming out first, but it wasn't a head. The doctor then did the exam, said it was an arm and proceeded to pull the arm out. I guess what I felt was a shoulder.
He then shoved the arm back in. All I could think of was to give her Valium to decrease the contractions and send her into the city, four hours away. The doctor said he was going to try to deliver the baby.
With the next contraction, the woman pushed hard, and the head barely could be seen on the left side of the vagina. The doctor put his hand in and literally pulled the head out, then the rest of the body, which had been diagonal in utero.
We did some half-hearted attempts to resuscitate the baby, but decided it was hopeless. The woman already had five other kids, so her vagina was loose, and she didn't tear. It was sad because the baby was a big boy and looked like he could have been healthy. Around the arm that came out was a white constricted area from being squeezed between the head, the cervix, and the cord.
I wasn't as upset since it was kind of expected. Everyone in the family thanked God that the baby was out and the mother seemed okay.
I was going to tie off the baby's umbilical cord, but the doctor said there was no need to. When I took the clamp off the umbilical cord, the baby didn't bleed out. The heart wasn't pumping blood, and the blood had clotted. I'm surprised how healthy t he baby looked, wrapped up, so alive. The family had the baby wrapped up and lying on the floor. The mom ended up having blood clots retained in her uterus. A clot the size of a small mango plopped out.
I had set the baby on a bed with the mother in the room where she was recuperating. Just as we were leaving, I checked in on them again, and flies covered the baby's face. This episode is a prime example of the importance of prenatal care. If she had come in, we could have felt abdominally if the head was down or not. She then could have been referred to the city early on, and the baby delivered by c-section. It seems senseless. We were all worn out after that and slept until the afternoon.
May 16, 1993
Last night the doctor came to get us for a delivery at ten-fifteen p.m. The woman was still in the Landcruiser. She came in when we got there. They had been driving since about six-thirty that evening, the woman screaming at the top of her lungs. The doctor said he thought it was a breech presentation, the legs or butt of the baby coming out first instead of the head. Sure enough, when we got her out of the truck and onto the stretcher, a little baby foot was sticking out of a hole in the crotch of the woman's pants.
Got the woman on the delivery table with some struggling, and the doctor told Judy and me to try to deliver it and left the room. We tried to find out how long the body had been out, but the woman kept saying that it came out somewhere on the road. The baby, a boy, was out up to his armpits. Seemed like the body had been out a while since the legs and lower torso were already cold. I tried to get the arms and shoulders delivered but couldn't. We called the doctor back in.
He came in and twisted and pulled on the baby while I reached in with my hand to pull the arms out. The woman was screaming while we were doing this. I had to exert so much pressure to get the arms out that it felt like I was breaking something. The doctor stops and leaves to refer to his obstetrics book. We listened to the baby but got no heart rate. The textbook said that if the head isn't delivered within ten minutes after the body, the fetus will probably die from asphyxiation. The baby's right leg was swollen, and it had lacerations in its groin area. Possibly, that leg had been out first.
August 17, 1992
The doctor returned to attempt to deliver the head by twisting the body around to get the head positioned right. The woman was screaming and screaming. He pulled on the body so hard that it seemed the head might snap off and the body would come out. The way he manipulated the body sickened me. I thought I was going to cry or throw up. He wasn't worried about injuring the baby since we assumed it to be dead. When the head wouldn't budge, he went back to his book, and Judy gave it a try. The trick is to get your finger into the baby's mouth to flex the head and make the head easier to pull out. Judy got the mouth, and we pulled on the baby, but it wouldn't budge. We noticed it had a dimple at the base of the spinal cord, which could indicate spinal bifida, causing hydrocephaly, or excess fluid in the brain that increases the size of the head making it impossible to pass through the pelvic bone structure of the mother. I can still see the doctor twisting and turning the baby's body, looking like something would break or snap.
The woman looked older, in her forties. Didn't get a history, but she had a previous c-section, which increases her risks for a regular vaginal delivery. After one and a half hours, the doctor decided to send them to Sana'a, eight to ten hours away, with the baby hanging out of her vagina.
The husband said they had not been expecting her to go into labor so soon, and they were on their way to Sana'a but decided to stop at our health center to give it a try.
At one point, while the doctor was pulling on the baby, we noticed that her abdomen was still very big. We thought it might be twins, but never did know for sure. the doctor kept referring to his book, saying, "This is where I think we are now," which usually followed with a quote suggesting a c-section. The doctor told the husband she had to go to Sana'a, but the woman refused until she got pain medication. I was worried that the woman might rupture her uterus if it kept contracting, and she did have a previous c-section. I gave her a shot of pain medicine and sent one with the family to administer in the truck half way to Sana'a.
We got her onto the stretcher and out next to the truck. The husband then tells her to get in, as if hopping into a truck with a baby hanging out between her legs was easy. It took three of us to lift her. The truck was crammed full of people, including a bunch of little kids. Guess the whole family was taking her to Sana'a. When we left at 11:45 p.m., they were still sitting in the parking lot.
I wonder what happens to patients like her, but we'll never find out. We speculated on how they would get the baby out since you can't do a c-section if it's already partially out of the vagina. Judy thought they might have to decapitate the baby and get the head out through a c-section. Amazing all the horrible things that can possibly happen.
Photographs by Cindy Chu
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