fit.—3la.

8. THE RELIEF OF PAIN IN LABOUR. The knowledge of the fact that certain new drugs and methods of anaesthesia are being extensively used for the greater relief of pain in labour has led to a very natural desire on the part of many people that such help shall be made available to all women. It must be realized, however, that there are considerations involved in this matter regarding which the medical profession is still by no means unanimous. The conservatism shown in some quarters towards these newer methods of painrelief has not been due to any lack of sympathy with suffering, but to a very genuine doubt as to their safety from the point of view of both mother and child, and also to a feeling that, where pain-relief was widely used, the necessity for artificial assistance in labour was increased, with certain possible risks. In the Scandinavian countries, where, in many respects, the maternity service is regarded as a model to the world, anaesthetics and analgesics are rarely used in normal labour, and the percentage of instrumental deliveries is extremely low. Similarly in the practice of the big public maternity institutions in Europe and in Great Britain, and in the district midwife services, where the use of methods of pain-relief in normal labour has in the past been very limited, the percentage of assisted labours has been equally low. Amongst Native races the same position obtains. On the other hand, it is undoubtedly the case, generally speaking, that, in those countries where pain-relief is largely used, the need for assistance in labour is more frequent. Furthermore, as regards the safety of the various anaesthetics and analgesics which have been advocated and used there is the widest difference of opinion even among obstetricians of repute. It is therefore not surprising that there has been considerable hesitancy on the part of some medical authorities in recommending a general use of these methods. There are others, however, who look upon the position differently. Agreeing that a more extensive use of anaesthetics and analgesics and a more frequent need for assistance in labour do often coincide, they do not regard this as necessarily cause and effect; rather do they consider them both indications of the same tendency amongst the modern more sensitive women of these countries. They consider that the changed reactions on the part of many modern women towards labour must be met, and can be met safely under certain conditions. They insist that anaesthetics can only be used to full effect by a doctor or in his presence ; that the use of analgesics requires close supervision by the doctor on account of the differing reactions of different individuals ; and that these measures of painrelief are much more satisfactorily applied in hospitals. Many convincing illustrations are available of the beneficial routine use of painrelief under such conditions. It will be realized that the chief difficulty occurs in cases conducted under a midwife system with no doctor present at the confinement. The measures of pain-relief now used in midwifery practice are of two types : — (1) Anaesthetics given mainly in the final stages of labour. (2) Analgesics and amnesics, which are given either by injection or by the mouth, and which are administered at intervals during the more painful stages of the whole labour and sometimes over a period of many hours. Medical opinion generally has been very definitely against the use of anaesthetics, as hitherto available, by midwives alone on account of the dangers associated with their administration. Efforts have been made to develop some method by which a midwife alone could, with safety, give a light anaesthesia suitable for the purpose. Actually New Zealand has led the way in this step by allowing the midwife alone to administer a small quantity of chloroform by an apparatus known as the Murphy inhaler, provided that a doctor has previously certified the patient as suitable for such anaesthetic. This method as used in New Zealand, whilst not proving entirely satisfactory in relief from pain in all cases, has been used to advantage in many thousands of cases over a period of fourteen years without any fatalities. This course has not, however, been deemed advisable in other countries, though the use of glass capsules containing a limited amount of chloroform has been tried to a certain extent in England. More recently attempts have been made in Great Britain to provide a simple and portable gas and air apparatus (a modification of the gas and oxygen machine) which could be used by midwives. Considerable success has been reported with the use of this apparatus in hospital, but it has not been so successful, practically, in district work. An ether-vapour apparatus suitable for use by well-trained midwives is now being tested. On the whole, however, there is still considerable doubt as to the wisdom of entrusting anaesthetics to midwives alone. As regards the use of analgesics and amnesics by midwives there is considerable difference of opinion. The unsupervised use of such potent drugs as morphia and scopolamine or the newer barbiturates would unquestionably be very dangerous, but there are those who believe that, under instruction, midwives could quite safely give these sedatives to a limited, but still quite helpful, degree in any particular case.

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