Since the public has already been told so much about obstetric anesthesia, we deem it best to go into the whole subject thoroughly, so that the expectant mothers who read this book will be able to form an intelligent opinion regarding the question, and thus be in a position to give hearty cooperation to the decision of their physician to employ, or not to employ, any special form of anesthesia or analgesia in their particular case. In order to give the reader a complete understanding of "painless labor," it will be necessary to give attention to that newer and more safe method of obstetric anesthesia called "sunrise slumber." This method of anesthesia consists in the employment of nitrous oxid or "laughing gas," and will be fully considered in this chapter.

OBSTETRIC FEAR

In this connection we desire to reiterate and further emphasize some statements made in the preceding chapter concerning the unnatural fear and abnormal dread of childbirth.

We feel that it is very important in connection with this new movement in obstetrics to reduce the woman's pain and suffering to the lowest possible minimum, that the trials of labor should not be overdrawn and the pangs of confinement overestimated. We must not educate the normal woman to look upon labor as a terrible ordeal—something like a major surgical operation—which, since it cannot be escaped, must be endured with the aid of a deep anesthesia.

The facts are that a very small per cent of healthy women suffer any considerable degree of severe pain—at least not after the first child. We often observe that judicious mental suggestion on the part of the physician or nurse in the form of encouraging words and supporting assurances tends to exert a marked influence in controlling nervousness and subduing the sufferings of the earlier labor pains.

We must not allow the efforts of medical science to lessen the sufferings of child-bearing, to rob womankind of their natural and commendable courage, endurance, and self-reliance.

We do not mean to perpetuate the old superstition that pain and suffering are the necessary and inevitable accompaniments of child-bearing—that the pangs of labor are a divine sentence pronounced upon womankind—and that, therefore, nothing should be done to lessen the sufferings of confinement. Severe and unnatural pain is not at all necessary to childbirth, and there exists no reason under the sun why women should suffer and endure it, any more than they should suffer the horrors of a very painful surgical operation without an anesthetic. In this connection, it should be recalled that analgesic drugs have been introduced into obstetric practice only during the last fifty years, while such methods of relieving pain have been used in general surgery for a much longer period. It is now only sixty-nine years since Simpson first employed anesthetic in obstetrics, while six years afterwards Queen Victoria gave her seal of approval to the use of chloroform in labor cases.

Thirty years ago, in speaking of the expectant mothers, Lusk warned us:

NITROUS OXID—"LAUGHING GAS"

Nitrous oxid, or "laughing gas," was first used in labor cases in 1880 by a Russian physician. During the last twenty-five years it has been used off and on by numerous practitioners in connection with confinement, but not until the last few years has this method of relieving labor pain come into prominent notice.

While the "laughing gas" method of obstetric anesthesia did not gain notoriety and publicity from being exploited in magazines and other lay publications, it did get its initial boost in a very unique and unusual manner. A gentleman who manufactured and sold a "laughing gas" and oxygen mixing machine for the use of dentists, insisted that this method of anesthesia should be used in the case of his daughter, who was about to be confined. This patient was kept under this nitrous oxid anesthetic for six hours—came out fine—no accidents or other undesirable complications affecting either mother or child, and thus another and safe method of reducing the sufferings of childbirth has been fully demonstrated and confirmed, although it had previously been known and used in labor cases to some extent.

Starting from this particular case in 1913, many obstetricians began experimental work with "gas" in labor cases; and, at the time of this writing, it has come to occupy a permanent place in the management of labor, alongside of chloroform, ether, and "twilight sleep."

ANALGESIA VS. ANESTHESIA

The reader should understand the difference between analgesia and anesthesia. Anesthesia refers to the condition in which the patient is more or less unconscious—wholly or partially oblivious to what is going on, and, of course, entirely insensible to all pain. Analgesia is a term applied to the loss of pain sensation. The patient may not be wholly or even partially unconscious—merely under the influence of some agent which dulls, deadens, or otherwise destroys the realization of pain. This is the condition aimed at by the proper administration of any form of "twilight sleep," whether by the scopolamin-morphin method, or by the nitrous oxid ("sunrise slumber") method.

Any method of treatment which can more or less destroy the pain of labor without in any way interfering with its progress, and which in no way complicates its course or leaves behind any bad effects on either mother or child, must certainly be hailed with joy by both the patient and the physician. While chloroform has served these purposes fairly well, there have been numerous drawbacks and certain dangers; and it was the knowledge of these limitations in the use of both chloroform and ether, that has led to further experimentation and the development of these newer methods of producing satisfactory analgesia—freedom from pain—without bringing about such a state of profound anesthesia as accompanies the administration of the older methods.

It should be borne in mind that in using "sunrise slumber" (nitrous oxid) for labor pains, the gas is so administered that the patient is just kept on the "borderline"—in a typical "twilight" state—and not in the condition of deep anesthesia which is developed when nitrous oxid is employed by physicians and dentists as an anesthetic for major and minor surgical operations.

Analgesia is the first stage of anesthesia—the "twilight zone" of approaching unconsciousness—in which the sense of pain is greatly dulled or entirely lost, while even that which is experienced is not remembered. It seems to the authors that "gas" is the ideal drug for producing this condition whenever it is necessary, as nitrous oxid is the most volatile of anaesthetics, acts most quickly, and its effects pass away most rapidly, while its administration is under the most perfect control—it may be administered with any desired proportion of oxygen—and may be discontinued on a moment's notice. It is practically free from danger even when continued as an analgesic for several hours. Nitrous oxid never causes any serious disturbance in the unborn child, as chloroform sometimes does when used too liberally.

EFFECTS OF NITROUS OXID

It will not be necessary to compare the favorable and unfavorable claims for nitrous oxid as we did the contentions for and against "twilight sleep." Whatever service "laughing gas" or "sunrise slumber" can render the cause of obstetrics we can accept, knowing full well that, in competent hands, it can do little or no harm; and this we know from the facts herewith recited and from the further fact that we have gained a wide experience with this agent in the practice of both dentistry and surgery. In a general way, the influence of "sunrise slumber" on mother and child may be summarized as follows:

1. It can accomplish its purpose—can quite satisfactorily relieve the mother of severe pain—when employed as an analgesic. It is not necessary to administer the gas to the point of anesthesia except at the height of suffering at the end of the second stage of labor, when the head of the child is passing through the birth canal.

2. This method can be stopped at any moment—the patient ran be brought out from under its influence entirely and almost instantaneously. It is not like a hypodermic injection of a drug which may exert a varying and unknown influence upon the patient, and which, when once given, cannot be recalled.

3. It is a method which may be used in the patient's home just as safely as in a hospital; the only drawback being the inconvenience of transporting the gas-containing cylinders back and forth. This is even now partially overcome by the improved combination gas and oxygen form of apparatus which has been devised.

4. The administration of nitrous oxid analgesia or anesthesia does not interfere with or lessen the uterine contractions or expulsive efforts on the part of the mother—at least not to any appreciable extent.

5. Just as soon as a severe uterine contraction—attended by its severe pain—begins to subside, the gas inhaler is immediately removed, and in a few seconds the patient is again conscious. It is not necessary to keep the patient continuously under the influence of the drug, as in the case of the scopolamin-morphin method of "twilight sleep."

6. This method ("sunrise slumber") is certainly far more safe in ordinary and unskilled hands than the "twilight sleep" procedure. The patient is more safe with this method in the hands of the average doctor or trained nurse.

7. It has been our experience that nitrous oxid in the smaller, interrupted and analgesic doses, actually tends to stimulate the uterine pains and contractions, while at the same time rendering the patient quite oblivious to their presence. When properly administered, the freedom from pain is perfect.

8. Under the influence of "gas," patients often appear to "bear down" with increased energy. It certainly does not lessen their cooperation in this respect.

9. We have not observed, nor have we learned of, any cases of inertia (weak and delayed contractions), post partum hemorrhage, or shock, as a result of "laughing gas" or "sunrise slumber" analgesia.

10. This method lends itself to perfect control—it may be decreased, increased, or discontinued, at will; it may be given light now and heavy at another time; while, at the height of labor, it may be pushed to the point of complete anesthesia, if desired.

11. We have found "sunrise slumber" (nitrous oxid) analgesia to be the ideal obstetric anaesthetic, and have adopted it quite to the exclusion of both chloroform and "twilight sleep." We find that this form of analgesia has all the advantages of "twilight sleep" without any of its dangers or disadvantages.

12. A possible objection to the nitrous-oxid method is the cost, especially in the private home. The average cost in the hospitals where we are using this method runs about $2.00 for the first hour and $1.50 for each hour thereafter. This is the cost when using large tanks of gas, and is, of course, somewhat increased when the smaller tanks are used in the patient's home.

METHOD OF ADMINISTRATION

Since it was thought best to give the reader some idea of the technic for the administration of "twilight sleep," it may not be amiss to explain how "sunrise slumber" is usually employed in labor cases. The technic is very simple. The administration of the gas is generally begun about the time the patient begins seriously to complain of the severity of the second stage pains; although, of course, the gas can be given during the first stage pains if desired. In the vast majority of cases, however, we think it is best to encourage the patient to endure these earlier and lighter pains without resorting to analgesic procedures.

The form of apparatus used is the same as that employed by dentists and contains both nitrous oxid and oxygen cylinders. A small nasal inhaler is best, although the ordinary mouthpiece will do very well. The gasbag attached to the tank should be kept under low pressure and, as a pain begins, the patient is told to breathe quietly, keeping the mouth closed. As a rule this sort of light inhalation serves to produce the desired analgesic effect. It is not necessary to put the patient deeply under in order to relieve the pain.

It is our custom to begin "sunrise slumber" as soon as the uterine contractions become painful. The earlier the gas is started, the more oxygen should be used. Two or three inhalations will suffice to take the "edge" off the earlier and lighter pains. When the pains grow heavier we use less oxygen and permit three or four deep inhalations just before a bearing-down pain. At the first suggestion of a contraction, the patient must begin to inhale the gas; while after the patient has pulled hard on the traction strops—just as the contraction pain is passing—she is given an inhalation containing a larger percentage of oxygen.

At the beginning of a pain, pure nitrous oxid is administered, and the patient is instructed to breathe deeply and rapidly through the nose. The gasbags should be about half filled. The mixture of gas and oxygen must be determined by the severity of the pains and individual behavior of the patient.

Four to six inhalations of the gas are sufficient to produce the required analgesia in the average case. Following the first few deep inspirations through the nose, the patient can be instructed to breathe through the mouth, while the gas is well diluted with oxygen and continued until the end of the pain. In this way a satisfactory analgesia is maintained throughout the "pain" with a minimum of "gas." The proportion of oxygen used will run from nothing up to ten per cent. This procedure is repeated with the occurrence of each pain.

The use of the "mask" is just as effective as a nasal inhaler, but wastes more gas and so is more costly.

When the head is passing the perineum the gas should be pushed to the point of anesthesia, while the patient's color will suggest the amount of oxygen to be used as well as serve to control the administration of the nitrous oxid.

CHLOROFORM AND ETHER

For many years chloroform and ether have been used to alleviate the pains of women in labor. Valuable as these agents are when deep anesthesia is required for the carrying out of operative procedures, they have not proved satisfactory as analgesic agents. If administered in small quantities at the commencement of a strong uterine contraction, the patient does not usually inhale sufficient to abolish pain. She is then apt to be irritated and is certain to insist on being given a larger quantity. If a sufficient amount be administered to satisfy the woman, the continued repetition gradually inhibits the power both of the uterus and of the accessory muscles, so that labor is unnecessarily prolonged, and, possibly, the life of the fetus endangered. Physicians have, therefore, been accustomed to employ these drugs very sparingly, restricting their use to the very end of the second stage, during the painful passage of the head through the vulva. The results of the administration at this time are also uncertain. If delivery be rapid the woman may not be able to inhale sufficient to abolish her consciousness of pain. If it be slow she may take too much and weaken the muscular powers, thereby prolonging labor and, often, necessitating forceps delivery. It is not surprising, therefore, that the medical profession has long been hoping that a more satisfactory method of relieving the pain of labor would be found.

CONCLUSIONS

In summing up our conclusions regarding analgesia and anesthesia in labor cases, the authors would state their present position as follows:

1. That anesthetics or analgesics are a necessary accompaniment of confinement in this day and age; that the average labor case demands some sort of pain-relieving agent at some time during its progress; but that intelligent efforts should be put forth to limit and otherwise control their use. While we recognize the necessity for avoiding needless suffering, at the same time we must also avoid turning our women into spineless weaklings and timid babies.

2. That we should seek to develop, strengthen, and train our girls for a normal and natural maternity; that we should study to attain something of the naturalness and the painlessness of the labors of Indian tribes; and, even if we partially fail in this effort, we shall at least leave our women with ennobled characters and strengthened wills.

3. That the scopolamin-morphin method of inducing "twilight sleep" has its place—in the hands of experts—and in the hospital; and that in many cases it probably represents the best method of obstetric anesthesia which can be employed.

4. That as a general rule and in general practice, the safest and best method of inducing the "twilight" state of freedom from severe pain, is by the use of nitrous oxid or "laughing gas"—the "sunrise slumber" method. It has been our practice to start all general ether anesthetics with "gas" for a number of years, while we have been doing an increasing number of both minor and major operations with "gas" alone.

5. That we still employ general ether or chloroform anesthesia in Cesarean sections and other major obstetric operations, although several operators are beginning to use "gas" in even these heavy cases.

6. That the intelligent and careful use of pituitary extract in certain cases of labor serves greatly to shorten the second stage; that it is of great value in certain "slow cases," and serves greatly to reduce the use of low forceps.

We have treated the subject of obstetric anesthesia in this full manner, because of the fact that so much has appeared in the public press on these subjects, and, further, because we desired that our readers should have placed before them the facts on all sides of the question just as fully as a work of this scope would permit.