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.

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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

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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

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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

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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

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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.

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