Labor analgesia for the 21st century

T HE GREATEST ADVANCES in analgesia and anesthesia for labor and childbirth in the 20 th century have been (1) the discovery and development of today's safe and efficacious analgesic techniques; (2) the social acceptance that it is unnecessary for parturients " . . . to bring forth children in pain and sorrow"; 1 (3) the development of organizations dedicated to teaching and training in this highly specialized field; and (4) the wider availability of obstetric care, including modern analgesia and anesthesia. These events have been less than 150 years in the making and have gone hand-in-hand with a dramatic reduction in maternal mortality in developed countries. Anesthesia is usually accorded its due place in this chronicle, 2 but analgesia is still regarded as an intervention that hampers 'natural childbirth,' prolonging labor and increasing the incidence of operative delivery. Hopefully the weight of evidence now accrued will settle the arguments about a causal relationship between analgesia and mode of delivery) Unfortunately there are still instances of the 'them and us' attitude. A recent report in the obstetric literature is typical of the lack of cooperation and coordinated understanding so necessary for the future. 4 Obstetric analgesia is now as much a part of our (Western) culture as air travel, the mobile phone, and the personal computer. Humankind's conquest of pain should have been achieved, in obstetrics at least. But has it? Sadly, modern, safe, and effective obstetric analgesia is still unavailable to most women worldwide. Moreover, the provision of safe pain relief services is restricted by bureaucratic and political conflict in some of the world's most economically developed societies, such as the