Upon my wife's encouragement I reviewed the recent discussions about
the use of epidural analgesia for the relief of labor pain.  I would
liketo take advantage of the opportunity to add my own perspective
to the discourse.  But first, some identifying information is in
order.  I am a 42 y/o board certified osteopathic rural Maine OB/GYN; father of
five home-birthed, home-schooled children; married to a 15 year LLL
leader now lactation consultant.  Epidural training during residency
allowed me to become skilled not only in that procedure but also, as a
consequence, in the use of forceps and the vacuum extractor.  During
training we were encouraged to recommend epidurals precisely to
achieve the goal of attaining proficiency in these techniques.
While I was resistant to this line of reasoning, there was no
shortage of patient demand for epidurals.  Patient demand for pain
relief is a strong motivator for one among whose prime goals in life
is the relief of suffering.

How one deals with suffering is greatly affected by the local
culture.  Upon relocation to Maine I found myself in a community
whose common knowledge included the presumption that no (zero)
analgesics could be provided once active labor began.  Not
surprisingly, most women did just fine and the total C/S rate was a
reasonable 13% with a below-state-average perinatal mortality rate.
 I did little to change this community perception
about labor analgesia for three years.  As a consequence there are
now women in this community who will never forgive me for reassuring
them that their labors-from-hell were natural, normal, and would
ultimately be remembered as edifying.

I was reluctant to return to offering epidurals based upon my previous
experience.  You all seem to be well versed in the varigated problems
associated with their use.  And despite the anti-money-grubbing-physician
rhetoric in some of the corespondence, there is not so much money to
be made doing an epidural that it is worth the time wasted waiting for
a now delayed delivery.  Never-the-less there was still the patient's
desires to be respected.  For us the answer has been found in the use
of intrathecal (spinal) analgesia.

Now I know that some of you out there are going to need to take a
break right now, take a few deep breaths, check your pulse, put on a
natural sounds tape.  When you are ready you can start the next
paragraph.

Good to have you back!  When we first started using this technique
five years ago about 30% of our patients immediately requested it and
responded favorably.  Since then this technique has become known simply as
"that shot" and is requested by about 80% of the laboring mothers - the
cultural expectations have completely changed. This procedure is
indeed no more difficult than starting an I.V.   I do not require an
I.V. for its use.  The patients may be up and about like any other
normal laboring mother.  When morphine and Fentanyl are used the
patients have excellent first stage labor analgesia, still experience
an urge to push and, although there is not substantial second stage
analgesia due to the activation of pressure receptors, the patient
typically does not mind as she is now at a point at which she can
take control of the process.  (There is also a technique that will
provide excellent second stage analgesia if needed by the patient).
 The result has been the relief of much pain, a high degree of patient
 satisfaction, no change in the C/S rate (still 13%), no change in the use
 of forceps or vacuum (10%), and, not inconsequentially, an enhancement
 of my own sense of ability in being able to safely and effectively
address the needs of my patients.  And yes, as terrible as this may be,
 I even get paid to do it.  (Medicaid $30 - 60% of my OB practice)

Stephen B. Graham, D.O.