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.