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July 1984 — About 3 degrees south of the Arctic Circle
"Do you want the vacuum, doctor?" the small Inuit nurse asks, really more of a suggestion than a question.
"Uhh, the vacuum?" I say, hesitating. "Yah....OK, sure". It was the kind of exchange that occurs when a kindly experienced nurse meets a young inexperienced doctor.
We were in the delivery room in Frobisher Bay, North West Territories, before Frobisher Bay was renamed Iqaluit in the new territory of Nunavut. The patient was a very young Inuit girl having difficulties trying to push out her first baby. I remember that the baby she eventually delivered was a huge healthy boy; he had lots of straight black hair falling in a wet curtain over his forehead. The vacuum that the nurse handed me that day had a soft plastic cup that fit onto the baby's head. It was attached to a hand pump with a pressure gauge and a release valve. This was one of my first jobs as a doctor and I had never heard of a vacuum extractor before. In medical school and internship we had only used forceps, vacuum deliveries being out of medical vogue at the time.
July 2008 — About 8 degrees north of the Equator
TThe baby is already dead. The girl is only 16 years old and she has been in labor for 2 days. She has a fever and is leaking thick, green amniotic fluid. Initially, we were able to locate the fetal heart, but that was four hours ago and we haven't been able to find it since, despite numerous attempts. The young girl is exhausted and ill and cannot push any more. The vacuum I use today is a hard metal cap; otherwise it is just like the one I used in Frobisher Bay. I am praying that I can deliver the baby with the vacuum, otherwise the only thing I can do will be a destructive delivery. I have seen one done during a short mission in Ethiopia, but I have never done one on my own. I remember the feeling of revulsion as I watched the Ethiopian doctor insert a long metal instrument into the soft spot of the baby's head, trying to decompress the skull and allow its passage through the pelvis. I also remember that this didn't work and he then had to dismember the baby and deliver it piece by piece into a bucket.
I pull and pull with the vacuum. We are only trying to save the mother now. Finally the head delivers. I ask Zac to deliver the rest of the baby because I don't have any strength left in my arms.
But nothing is easy tonight. The cord rips off the placenta; I remove the placenta manually. She bleeds vigorously for a few minutes. I massage her uterus through the abdominal wall and the bleeding slows to a trickle. It takes me a long time to sew up the episiotomy; the light has faded and I cannot see. Someone goes back to the compound to get me a head torch. The blood has attracted the flies; they swarm about the perineum. I sew, then wave the flies away, then sew some more.
Someone wraps the body of the baby in gauze and places him on the table next to the girl. She is flat and expressionless. Spent. The girl's parents thank us. They know that this is not the worse outcome; at least their daughter is still alive.
When I finally look up from my work, someone has already taken the baby away.
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