-
ANALGESIA AND ANAESTHESIA. INMODERN OBSTETRICS
By G. C. STEEL, M.R.C.S., L.R.C.P., D.A.Anaesthetist, Queen
Charlotte's Maternity Hospital, Chelsea Hospital for Women,
etc.
'Quot homines, tot sententiae.' Many speakersare discussing the
relief of pain in midwifery;each has his own hobby-horse. Such a
state ofaffairs proclaims the inescapable fact that, so far,we have
failed to make childbirth safely painless.Yet definite progress has
been made.There are many ways in which the problem may
be tackled; there is a wide variety of drugs avail-able, many of
which are reasonably safe and effec-tive. It is the lack of
understanding of when andhow to use them rather than the excessive
use ofthem which is a matter for reproach at the presenttime.
Every analgesic drug used in midwifery shouldfulfill as many as
possible of the following criteria-it should be effective, safe,
easy to administer,cheap and transportable; it must have a
minimaltoxic effect on mother and child, and should notaffect
uterine contractility.The choice of drug will then be influenced
by(a) The action of the drug;(b) The needs of the patient;(c) The
rate of breakdown of the drug.(a) Drugs used for the alleviation of
the pain of
childbirth are either sedative, hypnotic,
soporific,antispasmodic, analgesic or anaesthetic; many havea mixed
action. It is essential that these propertiesbe carefully assessed
and the correct drug given asindicated by the patient's needs. It
is as uselessto give chloral and potassium bromide in
pharmaco-logical dosage to a woman suffering agonizing painas it is
to give her a caudal block in the early stagesof labour when she is
suffering no pain but is ina state of uncontrollable fright. We
must face thefact that, as yet, there is no one drug that
isuniversally efficacious.(b) The needs of the patientNo two
patients are identical and their needs
are correspondingly variable. The wide range ofthese needs must
always be recognized, for failure'to do so will result in failure
to provide relief. Inaddition, whatever the mother may need in
theform either of reassurance, sedation, analgesia oranaesthesia,
it is of the greatest importance thather sleep requirements be not
overlooked.
' For some must watch while some must sleep.'It is imperative
that no mother should be allowedto lose her reserves of strength
through not beingadequately rested during the course of a long
labour. There is no excuse for the primipara whostarts off in
the evening with vague and uncertainpains being allowed to lie
sleepless through thenight so that, with the coming of day, she
faces asevere physical and mental ordeal, weary andapprehensive
instead of being calm and refreshed.That this should happen is an
adverse criticism ofthe management of the case. A strategic
conserva-tion of her strength for the moment when it is mostneeded
should be the aim of such sedation.(c) The rate of breakdown of the
drugOnce it is realized that this factor should have a
strong controlling influence on the choice of drug,then the
chances of a baby being born with its vitalcentres depressed by
narcotics is minimized. Thisapplies not only to the analgesic drugs
of the firststage, but also to the inhalational agents used
lateron. At all times, with the normal or abnormalcases, the
guiding principle of timing and dosageof drugs should be, that the
child must not behandicapped in the first critical minutes of
itsindependent existence by having in its system anundue amount of
a depressant drug which it hasto break down without the help of the
maternalsystem, from which it has been so recently severed.
Before the various methods are discussed, thereis one more
aspect of the problem .which we mustexamine, namely the antenatal
instruction of thepatient in the part that she has to play in the
birthof her child and the effect that the analgesia willhave on her
appreciation of pain. The choice isclear; one can either give the
mother a carefully-worded description of the task that lies ahead
ofher, emphasizing the work that she has to dorather than the pain
that she may feel; with theresult that she will be able to
co-operate as anintelligent and informed partner, with the
analgesicdrugs exercising their optimum effect; or onemay leave her
in total ignorance of the procedureand, during labour, give her
drugs, partly hypnoticand all depressant, thus reducing her to the
statusof an unskilled labourer.The influence of fear upon the
appreciation of
pain and the measures that can be taken to com-bat the
fear-tension-pain cycle have been re-peatedly emphasized by Grantly
Dick Read.Stripped to its essentials it amounts to this: fearbegets
tension which, in its turn, causes pain.
319copyright.
on April 1, 2021 by guest. P
rotected byhttp://pm
j.bmj.com
/P
ostgrad Med J: first published as 10.1136/pgm
j.25.285.319 on 1 July 1949. Dow
nloaded from
http://pmj.bmj.com/
-
POST GRADUATE MEDICAL JOURNAL
This build-up may therefore be best attackedalong the fQllowing
lines: fear is to be eliminatedby antenatal instruction and tension
by means ofsuggestion and relaxation exercises. Should thistherapy
prove so successful as to eliminate thenecessity for analgesic
drugs, so much the better:if not gas and air or sonlething similar
can beused with probably enhanced effect.
It is a great pity that there have not been moreattempts to make
large scale assessments of thevalue of this method. Unfortunately,
however, itseems that the question of suggestion or indeed.of any
similar form of therapy in midwifery isdoomed all too frequently to
arouse the emotionalrather than the objective approach in the minds
ofthose concemed.The advisability of showing the expectant
mother how to use the gas and air apparatusduring the latter
part of her pregnancy has beenemphasized by Minnit (I947). Viewed
objectivelyit is hard to find any valid reason for this practicenot
being generally adopted. Provided that thepatient is not
psychologically unsuitable; the useof the apparatus. should be
carefully demonstratedto her in the antenatal period. The
advantages ofdoing so are that she will, in the first instance,
havethe reassurance that something will be done tohelp her.
Secondly, that it is easier for her toappreciate what she is being
told at this time ratherthan at the last minute when she is
disturbed byher pains and by the bustle of the labour ward.From the
point of view of efficiency, the merits
of antenatal instruction are obvious. There re-main traces,
however, of a curious belief in someobscure ethical reason for a
mother going intolabour uninstructed in the use of analgesia and
inwhat she will have to do. This is as untenable asthe idea that
the boxer who goes into the ring un-trained and uninstructed is the
spiritual better ofhis well-prepared opponent.
The Conduct of the First StageDuring the first stage, especially
in primipara,
the mother is conscious of colicky contractions ofa progressive
nature. Whilst the initial contrac-tions do not usually register on
the consciousnessas an overwhelming agony, nevertheless as timegoes
on and their intensity increases, the in-evitability of the process
may cause alarm andstarts to sap the mother's morale. It is at
thistime that the value of antenatal training should bemanifest. If
some form of drug therapy isnecessary, those suitable may be
classified as:
Given by mouth'Mother's Mist' is a chloral, potassium
bromide and tincture of opium mixture, the exactproportions of
the three ingredients varying in
different hospitals. Given early in labour to anapprehensive
woman it may exert a moderatesedative effect; in pharmacological
dosage itcannot be expected to have any genuine analgesiceffect on
the pains of a fully established labour.
The barbiturate group is a very large one, rangingfrom the
lighter members, which are rapidlybroken down, to the heavy, which
have' a pro-longed effect, being slowly broken down. Theireffect,
generally speaking, is partly sedative, partlyhypnotic and partly
analgesic. Several of themore rapidly excreted barbiturates have
been givenduring labour in order to produce partial analgesiaor
partial amnesia. Provided that the rate ofbreakdown of the drug is
always used as a yard-stick, the use of the barbiturates for this
purpose isjustified. Pentothal sodium, pentothal acid andseconal
have all been used successfully. Their dis-advantage is that it is
difficult to assess the rathervariable degree of breakdown, and
repeat doses arerequired at frequent intervals. There is no
doubt,however, that in a suitable case, the efficacy of gasand air
is very considerably enhanced by the use ofone of the light
barbiturates, though pethidine nowseems likely to replace them.The
medium and heavy groups should be used
with caution. Generally speaking it is inadvisableto use them
for prolonged analgesia towards theend of the first stage. Their
place in midwifery isto give the patient who is just starting off
withuncertain pains the benefit of a good night's rest.The benefit
that accrues from a good night's restat the beginning of labour
cannot be overem-phasized. Not only does it conserve the
mother'smuscular strength for the moment of need, butalso tends to
prevent her morale from, breakingdown. To be of safe benefit the
drug should beused early on in labour and in adequate dosage;it is
useless and dangerous to let the hours pass byand then give a half
dose towards the end of thefirst stage. As patients show a marked
variation intheir reactions to the barbiturates, it is well
toexclude the possibility of untoward reaction bygiving the mother,
about a fortnight before theconfinement is due, a normal dose of
the particularone it is proposed to use.
By injectionWith the advent of the more modern drugs,
the use of morphia and scopolamine to produce'twilight sleep '
can no longer be consideredjustifiable. For morphia, or omnopon
andscopolamine, there is, however, still a definiteplace in
midwifery. In cases of primary uterineinertia where sedation is
indicated, the drug ofchoice is morphia or omnopon. The addition
ofscopolamine is favoured by many. The uselesscontractions which
occur during primary uterine
UIY I1949320copyright.
on April 1, 2021 by guest. P
rotected byhttp://pm
j.bmj.com
/P
ostgrad Med J: first published as 10.1136/pgm
j.25.285.319 on 1 July 1949. Dow
nloaded from
http://pmj.bmj.com/
-
STEEL: Analgesia and Anaesthesia in Modern Obstetrics
inertia are often more painful than those of normallabour. Given
this form of treatment, the patientwill fall asleep, to awaken
several hours later withthe cervix well dilated. Once again it is
necessaryto emphasize that if the patient is to benefitwithout
running undue risk, the drug must begiven as early as possible. The
full effect of themorphia should never be allowed to overlap
intothe second stage.
PethidineThere can be no doubt that pethidine is gaining
a well-deserved place in midwifery. Being bothanalgesic and
antispasmodic, it is especially usefulfor combating the colicky
pain of the first stage.The initial dose should be given as soon as
thepains are beginning to cause genuine discomfort,that is, at the
time when sedatives such as'mother's mist' are no longer effective.
Gener-ally speaking ioo mgm. is sufficient, but somefavour an
initial dose of 150 mgm. A second in-jection of ioo mgm. may be
given if necessary,but further doses should not be given without
dueconsideration. Most workers believe that it haslittle or no
adverse effect on the baby, thoughGallen and Prescott (i944) feel
that it should notbe given within 21 hours of the estimated time
ofdelivery.The effect on the strength and frequency of the
pains is variable and generally speaking the firstor second
injection seem to make little difference;Barnes (I947) noted that
in 67 per cent. the con-tractions were unaffected, in 23.3 per
cent. thestrength was increased and in 8.8 per cent. de-creased. On
several occasions the writer hasnoticed that the pains have died
away for a shortinterval after the third or fourth injection,
thoughnot after the first or second. The injection isusually given
intramuscularly. In urgent cases itmay be given intravenously
provided that it isgiven very slowly.
Pethidine and ScopolamineMore recently pethidine has been
reinforced by
the addition of scopolamine. The combination isboth rational and
efficacious. Pethidine is amarked analgesic, it also has an
antispasmodicand, to a certain extent, a sedative action; to thisis
added the amnesic and antispasmodic effect ofscopolamine. In a
series reported by Roberts(I948) the degree of relief obtained was
assessedas good in no less than 82 per cent. of cases. Veryfew
cases showed any Acopolamine excitement andit is suggested that due
regard should be paid tothe patient's temperament. Occasionally
thecombination is repeated, but a large percentage dowell on only
one dose, or one dose with pethidineonly repeated an hour later.
This is in interesting
contrast to the twilight sleep technique in whichthe
scopolamine, not the morphine, was repeated.
By InhalationThe latter part of the first stage is
frequently
thought to be the most painful part of labour. Inaddition to the
physical pain, the mother has notyet experienced that type of pain
which by its verynature proclaims that the end is in sight, and
givesher the reassurance of that knowledge. Un-fortunately, the
obstetrical division of labour intofirst and second stages tends to
create the assump-tion that the beginning of the second stage is
thetime for stepping up the degree of analgesia. Thisis not so: the
best time to start increasing thedegree of analgesia is in the last
half hour of thefirst stage. It is at this time that the
administrationof the inhalational agents should be started.Gas and
air is sometimes criticized as being
totally inadequate for obstetrical analgesia. Whilstit is true
that it is sometimes insufficient for theactual birth, to condemn
it as useless shows up theweakness of the nursing and obstetrical
staff ratherthan the defects of the drug. The degree ofsuccess
obtained with gas and air is in direct pro-portion to the amount of
trouble taken by theattendant. At risk of being monotonous, a
fewcardinal rules must be reiterated. The patientmust be thoroughly
and painstakingly instructedin the use of the apparatus as early in
labour aspossible, or better in the antenatal period. Sheshould be
told, firstly, that the gas will not sendher to sleep but that it
will ' blanket down ' thepain very effectively; secondly, that the
fact thatshe will be able to hear what is being said to herneed not
make her think that it is not working;finally, so that she can get
the full effect of the gas,she should not wait until the
contraction is fullyestablished but must start to inhale the
momentthat she gets the first warning of the approachingpain. Too
much attention cannot be paid to theefficient fit of the facepiece
and the stopping up ofthe safety hole.
Lately some new types of gas and air machineshave been brought
out. The principle is that ofthe venturi tube in which a gas is
passed through atapered jet at high velocity. The negative
pressurewhich this creates in a side tube attached to thejet sucks
in the requisite amount of air. Thewriter's impression has been
that analgesia ismore readily attained with this type than withthe
models which do not use this principle.Gas and oxygen is the
non-austerity counterpart
to gas and air, and as the patient can be given ahigher
concentration of nitrous oxide without fearof suboxygenation, the
results are correspondinglybetter. Given co-operation on the part
of thepatient and skill and patience on the part of the
YUIY I949 321copyright.
on April 1, 2021 by guest. P
rotected byhttp://pm
j.bmj.com
/P
ostgrad Med J: first published as 10.1136/pgm
j.25.285.319 on 1 July 1949. Dow
nloaded from
http://pmj.bmj.com/
-
POST GRADUATE MEDICAL JOURNAL
anaesthetist, this method is exceedingly hard tobeat for
efficacy, combined with safety. It is avery great pity that
economic and other factorspreclude the wider employment of this
excellentform of analgesia.
TrileneTrichlorethylene is a valuable and excellent
analgesia for use in obstetrics. The rare casethat is
unmanageable under gas and air will fre-quently quieten down under
trilene. There is noevidence that trilene either slows labour or
causesfoetal asphyxia, though very occasionally the babyseems to be
rather limp and unenthusiastic. Ofthe various types of apparatus
for self administra-tion, the Freedmans and the trilite inhaler
bothgive a fixed concentration; in the Cyprane andthe Siebe-German
Hyatt, the concentration canbe varied by means of a locking
mechanism con-trolled by the anaesthetist or obstetrician. Boththe
latter types are useful for the single-handedobstetrician who has
to apply forceps or undertakesome sinm-ilar manoeuvre.The value of
trilene lies in the fact that it is a
most helpful adjuvant to, or replacement for, gasand air or
oxygen when this proves inadequate.At the present time the question
of allowing mid-wives to use trilene is being investigated.
Whilstone hopes that this may be possible at some futuredate, it
would be a pity if this meant the light-hearted abandonment of gas
and air analgesia.The latter can be of great help in labour, and
itsfailures are by no means invariably the failures ofthe drug or
of the apparatus. Ideally the patientcan well be started on gas and
air followed bytrilene when, or if, the former proves
inadequate.
The Conduct of the Second StageFrom the point of view of
analgesia, there is
little to be feared in the second stage up to thepoint of the
head dilating the vulva, provided thatadequate steps have been
taken to deal with the lastpart of the first stage. If gas and
oxygen is beinggiven the patient ghould be given three breaths
ofpure gas the moment she suspects the pain isstarting, followed by
a mixture of 85 per cent.gas and I5 per cent. oxygen until the
contraction isfirmly established, then told to bear down.Trilene
added to gas and oxygen or given by itselfis very useful in the
second stage. Not beingexcreted as rapidly as nitrous oxide there
is some'hang-over' between pains so that the patientis pleasantly
muzzy. Sometimes gas and oxygenis not quite enough to cover the
birth of the child;in this instance the anaesthetist is better
advised toadd a trace of trilene or ether rather than to lowerthe
oxygen content and so sub-oxygenate the child,on the threshold of
its independent existence.
Cyclopropane is also suitable, but should not begiven if trilene
has been already used.
Caudal BlockMisapprehensions concerning the uses and
effects of caudal block are widespread, so it is aswell to
recapitulate its salient features. Anaestheticfluid, injected
through the sacro-coccygeal liga-ment into the sacral canal will
lie in the sacralportion of the epidural space. If a
sufficientamount is injected it will fill up the canal and
thenstrip its way up the lumbar and thoracic portionsof the
epidural space. When the top level liesbetween D12 and D8, all the
pain.impulses ofthe uterine contractions are obliterated. (AboveD8
the motor supply is cut off and the contrac-tions disappear.) This
block can be prolongedfor the entire course of labour by further
injectionsat regular intervals, the needle being left in situ.There
can be no doubt that as far as analgesia
is concerned this method is excellent. With fewexceptions, the
labour is genuinely painless. Thecervix also softens appreciably
and the perinealfloor becomes soft and relaxed. There are,
how-ever, certain disadvantages which cannot be over-looked. The
landmarks are frequently obscured,rendering the proceeding a
difficult one as re-gards technique; the dangers of infection and
ofa calamitous fall in blood pressure though remoteare,
nevertheless present. The forceps rate,especially in primipara, is
exceptionally high: thisis because the head comes down well to the
perinealfloor but then stays there. At this stage, when themother
should be actively pushing down, she hasnot the slightest
compulsion to do so, beingtotally unaware of when her contractions
areoccurring. Even if she is told to push at the rightmoment she
only does so in a half-hearted way,being unable to appreciate
either that a contractionis occurring or that her efforts are in
fact causingthe head to advance. The lack of tonus of themuscles of
the birth canal also means that a highproportion of
occipito-posterior cases fail to rotate.These are serious drawbacks
and it appears un-likely that this method will become
universallyapplicable. The effect of the block in causing
re-laxation of the cervix is, however, noteworthy,and it may yet
find a place as a form of treatImentin appropriate cases.
The Operative Procedures of ObstetricsForceps. The
straightforward low forceps ex-
traction is adequately covered by gas and oxygenaided by a small
amount of trilene or ether. Atall times anoxia is to be avoided,
especially if thereis any degree of foetal distress.The high or mid
forceps, possibly complicated
by foetal distress and by the necessity for internal
sYulY I1949322copyright.
on April 1, 2021 by guest. P
rotected byhttp://pm
j.bmj.com
/P
ostgrad Med J: first published as 10.1136/pgm
j.25.285.319 on 1 July 1949. Dow
nloaded from
http://pmj.bmj.com/
-
STEEL: Analgesia and A-naesthesia in Modern Obstetrics
rotation, is a much more difficult problem; it canbe one of the
most difficult tasks the anaesthetisthas to face and must not be
lightly dismissed.The needs of the three parties concerned are
farfrajn identical and may indeed prove to be con-tradictory. The
obstetrician must have anadequate degree of relaxation for his
manoeuvres,the mother should be adequately protected fromthe shock
that may arise from these manoeuvres:yet the fulfilment of these
needs must not entailnarcosis of the infant's possibly already
enfeebledvital centres. To reconcile these factors undergeneral
anaesthesia is a task for the skilled andnot for the casual
anaesthetist. Two safety rulesmay be profitably observed; firstly,
the patientmust be sufficiently deep for the application of
theforceps and the subsequent traction; secondly, itis a beneficial
practice to give the patient nothingbut pure oxygen from the moment
the head isborn until the cord is clamped.
Consideration of the problem of the com-plicated forceps case
inevitably brings forward theclaims of spinal and extradural nerve
blocks;claims that are well substantiated in ease
ofmanoeuvrability, the cutting off of shock impulsesto the mother
and the absence of adverse effects onthe child. Against this is
arrayed the classicalantipathy to the use of spinals in labour as
wellas thq routine risks of fall of blood pressure, spinalheadache
and the possibility of infection. It isprobable, however, that the
dangers of spinals inmidwifery are due more to the inexperience of
thecasual anaesthetist than to the drug.or the fact ofpregnancy. A
convincing series of complicatedforceps cases done under spinal has
been reportedon by Anderson (1946). It is also interesting tonote
that spinal block has been used to controlcertain cases of post
partum uterine atony (Hansen,I943) and that Weintraub, et al., have
success-fully treated post spinal headache in obstetricalcases by
the application of tight abdominalbinders.A single caudal block has
the advantages that
the solution remains outside the dura and that therisk of
headache is minimized; against this isthe fact that the extradural
block is much moreslowly acting than is an intrathecal one so there
isan interval of at least 20 minutes before the forcepscan be
applied. Furthermore, touch is often onlypartially affected and so
it may be necessary to givea light gas and oxygen as well. This
should not betaken as proof that the caudal block is a failure,the
patient merely requires to be in a light sleep,the baby is
unaffected and the operation can becarried out easily and
unhurriedly. The value ofthese two types of nerve block for
obstetrics hasnot yet been fully realized.
Caesarean SectionIt must be realized that there is no one form
of
anaesthesia that is ideal for every case of Caesareansection.
The factors that are to be taken intoconsideration are legion, yet
one still hears onemethod or another being extolled as the
universalmethod of choice. The reason for the operation,the
mentality of the patient and the type of opera-tion, should always
be considered. Apart fromthe metabolic diseases such as diabetes
whichmust strongly influence premedication and an-aesthesia, there
is the profound difference betweenthe classical and the lower
segment operation as itaffects the anaesthetist. When the classical
opera-tion is performed, it can be done under gas oxygenand minimal
trilene or ether or with cyclopropane,without any undue risk of
narcotizing the infant.But, the more deliberate lower segment
extractionpresents a very different problem. The interval oftime
between the induction of anaesthesia and thedelivery of the infant
is much longer with con-sequent build up of anaesthetic drug in the
foetatcirculation: more relaxation is needed. Finallythe patient
has to be taken to a deep plane ofanaesthesia to permit of a long
length of gauzebeing packed down around the uterus just a
fewseconds before the child is launched on its in-dependent life.
The obstetrician who is able toomit this-Jatter step confers a boon
on theanaesthetist and on the child.Under these circumstances it is
surprising that
one still sees the statement that gas and oxygen issufficient
for the operation. It must be clearlyunderstood that the lower
segment operation,especially in instances where premedication
hasbeen withheld, cannot be covered by gas andoxygen alone without
an undesirable degree ofsuboxygenation being necessitated. Ether,
trileneor cyclopropane should be added in sufficientquantities
adequately to protect the mother untilthe moment of incising the
uterus, and then pureoxygen should be given until the cord is
clamped.Thus the child is given as reasonable a start in lifeas is
possible under the circumstances. After thecord is clamped, the
mother can be given j gm.of pentothal so that she awakes from a
pleasantpentothal anaesthetic. The use of curare inCaesarean
section has lately received attention(Gray, 1947).
For a long time there has been widespread mis-trust of the use
of spinal analgesia for Caesareansection. More recently the
question has been re-opened and a most convincing series has been
putforward by Rufus Thomas (I947). The pos-sibility of increased
contractile action of theuterus and that of sub-oxygenation of the
patientthrough paralysis of the lower intercostals and
theembarrassment of diaphragmatic actioxi by the
3tuly I1949 323copyright.
on April 1, 2021 by guest. P
rotected byhttp://pm
j.bmj.com
/P
ostgrad Med J: first published as 10.1136/pgm
j.25.285.319 on 1 July 1949. Dow
nloaded from
http://pmj.bmj.com/
-
324 POST GRADUATE MEDICAL JOURNAL July 1949
full term uterus must not be overlooked(Mackintosh, I949).
Epidural analgesia has the advantages that thereis no need for
special positioning of the patientduring or after the operation,
and that there is nolikelihood of post spinal headache. The degree
ofanalgesia achieved is not as complete as in thecase of an
intrathecal injection and a light gas andoxygen will probably have
to be given, as touchis frequently only partially obliterated. In
spite ofthis and the fact that an epidural injection does
notproduce analgesia for a good 2o minutes, the pro-cedure is well
worth while. The patient needonly be kept lightly asleep, the baby
cries immedi-ately and the empty uterus contracts down firmly.35-45
cc. of nupercaine i/6oo injected betweenDI2 and Li will usually
suffice. A carefulwatch should always be kept on the blood
pressure.The solution can also be given as a caudal in-
jection. into the sacral canal. There is littledifference in
effect between this and a lumbarepidural injection except that
slightly greateramounts of the analgesic agent may have to begiven
with the former approach, as the solutionprobably has to fill up
the sacral canal before itstarts to strip its way up the lumbar and
thoracicportions of the epidural space.There is no longer any doubt
that these three
forms of nerve blocks have a claim to serious con-sideration as
well as general anaesthesia and localnerve block. Eventually their
position will beevaluated, but meanwhile we can utter the
warningthat the dangers probably lie in the inexperienceof the
casual administrator rather than in thedrug or the patient.
Finally, the patient's temperament should betaken into
consideration. There are those whohave only one wish-to know
absolutely nothingabout the operation: those who are indifferentand
those who have a strong desire to be consciousso that they will
hear the baby's first cry. Thesefeelings should not be
overlooked.
External version brings us to the mehtion ofchloroform. There is
no agent which will give thesame degree of relaxation of uterine
muscle that isbrought about by chloroform. The use of thisdrug for
anaesthesia at the end of the second stage,or for forceps, is
gradually being superseded, butit still remains a very useful
weapon albeit onethat has to be used with great caution.
Over a hundred years have passed since JamesYoung Simpson
introduced the use of chloroformin obstetrics. Yet a recent survey,
' Maternity inGreat Britain,' shows that only about 5 per cent.of
those who had their babies at home in the periodreviewed (March
3-9, 1946) were given gas andair analgesia. Such figures should not
call forth
any great degree of self-satisfaction. A completechange of
approach to the problem is overdue.
This can only be brought about by morecollaboration on the part
of the obstetrician, theanaesthetist, the midwife and the
practitioner. Atthe moment each of these is inclined to work
alongseparate lines rather than together. To a certainextent this
is due to each viewing the problem-froma different angle. For
instance, the obstetriciansees analgesia as only one facet of the
whole processof parturition, consequently he is often reluctantto
allow the anaesthetist a free hand in his attemptsto provide
analgesia; whilst the anaesthetist, thenature of whose everyday
work inevitably stressesthe question of the relief of pain, may
feel, for hispart, that progress in this direction is
needlesslyslow.These differences of viewpoint can only be re-
conciled by a mutual effort. The anaesthetist canprofitably
spend more time in the labour wardsthan has hitherto been his
custom, for obstetricalanalgesia and anaesthesia demand skill,
experienceand a thorough knowledge of the physiology ofparturition.
The obstetrician, on his side shouldnot encourage the still
lingering practice of ex-cluding the anaesthetist from the labour
wards: todo so will merely ensure that the analgesia servicewill
never be first class.
' Analgesia is the business of the obstetrician'is no more than
an oft reiterated and misleadinghalf truth. It is surely the
business of theobstetrician, the anaesthetist, the practitioner
andthe midwife: and finally the business of that oftenoverlooked
but very important person who is in-variably at the confinement
though everyone elsemay be late-the patient herself.The pregnant
woman, it is well known, is all
too often the recipient of whispered superstitionsand tales of
obstetrical horror. Yet very few in-stitutions take active steps to
counteract thisnonsense by means of organized instruction duringthe
antenatal period.
Let us hope that more attention will be paid tothe active side
of the attempt to make childbirthpainless, and that in the future
women will come totheir confinements trained in the part they have
toplan and in the apparatus they have to use, andwith fear and
ignorance replaced by trueknowledge.
BIBLIOGRAPHYANDERSON, A. F. J. (I946) Obst. Gyn. Brit. Emp., 53,
347.BARNES, JOSEPHINE (B947),E.M.J., X,437GALLEN, B., PRESCOTT
F.(I94)B.M.,x, 76.HANSEN, J. L. (1943).Acia Obst. Gyk Scand., 22,
30S.MACINTOSH,R R.(I99), B.M.J., x, 409.Maternityu Great Britin
(1948), London.MINNITT, R. J. (I947), 'Gas and Air Analgesia,'
London.READ, GRANTLY DICK (1942), 'Revelation of Childbirth,'
London.ROBERTS, HILDA (1948), B.M.J., 2, 590.THOMAS, RUFUS
(i47), Proc. Roy. Soc. Med., 40, 557.WEINTRAUB, F., ANTINE, W.,
RAPHAEL, A. (1947), Am. 7,
Obst. G'yn., s4, 682.
copyright. on A
pril 1, 2021 by guest. Protected by
http://pmj.bm
j.com/
Postgrad M
ed J: first published as 10.1136/pgmj.25.285.319 on 1 July 1949.
D
ownloaded from
http://pmj.bmj.com/