Journal of Psychosomatic
Research, Vol. 19, pp. 289 to 293. Pergamon Press, 1975. Printed in Great Britain
SECOND STAGE MEDICAL INTERVENTION PAIN DURING CHILDBIRTH*
AND
FREDERICKJ. KLOPFER,ROSEMARY COGAN?and WILLIAMJ. HENNEBORN (Received 20 June 1975)
THE USE of medication as a medical intervention technique to alleviate pain during second stage labor has been a largely unexamined practice. Similarly the relationship between the administration of episiotomies or the use of forceps and changes in pain perception has scarcely been subjected to empirical investigation. Since the relief of the mother’s pain is at least one, if not “the prime function” [l] of an obstetrician during delivery, the relationship between pain and these 3 medical procedures requires more careful examination. The stated purpose of second stage medication is often the relief of pain [l, 21. Aiken and Cope [3] examined the comparative efficiency of two kinds of medication, promazine and Diazepam, in reaching this goal. Pain during labor, as reported by senior midwives, was reduced significantly more with promazine than with Diazepam. Brown et al. [4] separately checked the relationships between various dosages of oxytoxics or analgesics and pain reactions revealed by obstetrics reports. They found no significant relationship between dosage level and pain reactions for either type of medication. They then considered the possibility that differences in medication levels chosen by obstetricians might be attributable to patient requests for medication not reflected in obstetric reports of pain. It was impossible to assess directly this hypothesized relationship with their data, but the tentative conclusion, based on secondary evidence, was that no such relationship existed. The present study seeks to provide more direct evidence by including pain reports of the mother as well as the physician. The pain reports used here were from a population of women trained in prepared childbirth, and reports from the labor coach (usually the husband) and the childbirth educator were also obtained and analyzed. The approach taken in the present study is also more basic. Rather than assess the relative efficiency of two kinds of medication [3] or several dosage levels of one kind of medication [4], the question is whether medication per se yields pain reports different than reports in births where medication is absent. Since an episiotomy involves an incision in the muscular tissue of the perineum, the procedure might be expected temporarily to increase pain. Presumably the procedure would be no more painful than a tear, the alternative possibility. One researcher [5] found no differences in pain reported during the first perinatal week for women who had experienced an episiotomy vs those who had received a tear. The effect of an episiotomy on pain during labor has yet to be examined. The use of forceps may sometimes be required in childbirth. The effects of this procedure on pain reported *This work was supported by funds from Childbirth Without Pain Education League, Inc., and from Public Health Service Research Grant No. MH 24249-01 from the National Institute of Mental Health. TRequests for reprints should be addressed to Rosemary Cogan, Department of Psychology, Texas Tech. University, Lubbock, Texas 79409. 289
FREDERICK J. KLOPFER, ROSEMARY COGAN and WILLIAM J. HENNEBORN
290
by the mother
in
conclusion
that
pain
was
than
births
her
first
births
without
perinatal with
forceps.
week
forceps
were
were
It may
also
found
be that
examined to produce
forceps
are
more
a medical choice in difficult, therefore painful, births. Alternatively, may add to discomfort during birth and the post partum period.
by
Baker
more
[5].
post
The
partum
likely to become the use of forceps
METHOD From a population of women who were students of a childbirth education group* offering classes in many parts of the United States, a group of 107 births were drawn. Births were selected which met the following restrictions: a labor coach accompanied each woman throughout both labor and birth; the birth was vaginal; no medication was administered during the first stage of labor; labor was neither begun nor maintained by induction; and reports of the birth were complete from the mother, her labor coach and the childbirth educator. In addition, physician reports were available for 49 of the births. The mothers, labor coaches and childbirth educators received questionnaires before the birth to be completed after the birth. Each questionnaire contained four items designed to assess the degree of pain experienced by the mother in each of four phases of childbirth [6]: the latent phase (dilation from 0 to about 5 cm); the accelerated phase (dilation from 5 to about 8 cm); the deceleration or transition phase (dilation from 8 to about 10 cm); and the second stage of labor. The items asked respondents to indicate whether (1) the mother was unaware of the particular phase under consideration or whether she seemed to feel (2) no pain, (3) no pain, but much effort, (4) moments of discomfort, (5) some pain, or (6) severe pain. Physicians were asked to assess the mother’s pain during late labor and birth only. One hundred and six of these birth reports were then divided into 5 groups. In each of the descriptions below, medication refers to second stage medication of any kind. Group l-no episiotomy, no forceps, no medication (NE, NF, NM): Group 2-episiotomy, no forceps, no medication (E, NF, NM); Group 3-episiotomy, no forceps, medication (E, NF, M); Group 4-episiotomy, forceps, no medication (E, F, NM); and Group 5-episiotomy, forceps, medication (E, F, M). Frequencies of reports are summarized in Table 1. With these 5 groups, it was possible to compare pain in 5 groups TABLE 1. FREQUENCYOF REPORTS OF SECOND STAGE MEDICATION,EPISIOTOMY,
AND FORCEPSIN 107 PREPAREDBIRTHS No Episiotomy
Episiotcmy Forceps N(P)* Medication
18(S)
No Medication
*N=
6(l)
No Forceps NC')
Forceps M(P)
NO Forceps N(P)
17(7)
O(O)
l(l)
50(27)
O(O)
15(8)
the number of birth reports (to be included, a birth needed to be
described by the woman, her labor coach and her childbirth educator) and P = the number of births for which physician reports were also available.
of analyses: (1) births with and without medication, with an episiotomy, without forceps; (2) births with and without medication with an episiotomy and with forceps; (3) births with and without an episiotomy without medication and without forceps; (4) births with and without forceps with an episiotomy and without medication; and (5) births with and without forceps with an episiotomy and with medication. It is interesting to note that when medication was used in second stage an episiotomy was performed in 97 % of the births, while when medication was not used in second stage 79 % of the births were accompanied by an episiotomy. Forceps were used in 50 % of medicated births and in only 8 ‘A *Childbirth 92501.
Without
Pain Education
League,
Inc.,
3940 Eleventh
Street,
Riverside,
California
Second stage medical intervention
and pain during childbirth
291
of non-medicated births. In no instance were forceps used unless an episiotomy had been performed Both wives and husbands in the two forcep groups attended somewhat more classes than wives and husbands in the other groups, which may suggest that post-maturity was involved in forceps use. Second stage labor lasted longer for wives in the E, F, M group. Since medication used in second stage among this group included spinal anesthesia (4 cases) and an injection which led to unconsciousness (4 cases), local injection which led to sleepiness (2 cases) or a local injection (8 cases), it seems probably that second stage was lengthened by a relative inability of women in this group to push voluntarily during second stage. Among the E, NF, M group medications were limited to local injections (16 cases) and a tranquilizer or muscle relaxant (1 case). Second stage among women in this group did not differ in length from second stage in the other groups and it seems reasonable to assume that voluntary pushing was used by these women as effectively as by women in other groups. There were proportionally more multiparous mothers in the NE, NF, NM group (60 %) and in the E, NF, NM group (36%) than in the other groups (11-17x). Aside from the above mentioned differences between groups, all groups were rather homogeneous with regard to age, number of classes attended by wives and by husbands, and length of first and second stages of labor. Within the general analyses numbered one, three and five above, it was possible to perform 14 different specific comparisons since reports from 3 respondents, the mother, labor coach and childbirth educator, described all 4 phases of labor while physician reports described late labor and birth. Data from birth group 4, that is, births with episiotomies and forceps but without medication, contained only one birth with a physician report, so it was impossible to perform the two comparisons of physician data for general analyses two and four, leaving 12 comparisons for both of these general analyses. RESULTS
AND DISCUSSION
The Median Test was applied [7] and the data are summarized graphically in Fig. 1. Following the guidelines set by Siegel [7], either the X2 or Fisher’s Exact
-NE ---._. -..
I O-5
Mothers’
‘rLabour
I 5-8
I 8-10
E g
NF NF N;
E
F
I 2ND
assessment
coaches’assessment
ChIldbirth educators’ assessment
5rPhysicians’
assessment
FIG. 1. Reports of pain during labor and birth by the new mother, labor coach, childbirth educator, and physician.
Probability Test was used to assess comparisons between groups. Analysis of groups one and two yielded no differences in pain reported with or without medication in second, stage with an episiotomy (Analysis group 1) or with an episiotomy and with forceps (Analysis group 2). Analysis group 3 yielded no differences in pain reported
292
FRBDERICKJ.KLOPFER,ROSEMARYCOGAN~~~WILLIAMJ.HENNEBORN
with or without an episiotomy without medication and without forceps. Analysis group 4 yielded no differences in pain reported with or without forceps with an episiotomy and without medication. Analysis group 5, testing differences in pain reported with and without forceps with medication and with episiotomies, yielded one significant difference from the 14 comparisons made. Childbirth educators reported reliably more pain during transition when forceps were used. In at least 30 of the 66 specific comparisons made in this study, reliable differences were neither expected nor obtained. It would seem highly unlikely for pain estimates in early labor to be reflected in medical intervention techniques not employed until the second stage. The only assumption making such predictions tenable would be that births which required second stage medication,episiotomies or forceps were more difficult labors throughout and the data do not support such a contention. It did seem, however, that the use of these techniques might have been predictably associated with differences in pain reported during transition. With one exception, not only were such predictions not borne out, but pain experienced during second stage itself was not affected by the presence or absence of medication, episiotomies or forceps. Among the present population of women, who received extensive psychophysical preparation for labor and birth, the use of medication in second stage was not associated with any decrease in pain during second stage. The data of Brown et al. [4] suggested that the administration of medication during childbirth may be associated with prenatal variables rather than events during labor and birth. Although other interpretations of the present data are possible, the data suggest that medication during second stage among women prepared to work with labor and birth and supported by a prepared labor coach may serve no pain-relieving function. Medication may affect neonatal development [8, 91 and the present data suggest that the benefits of taking pharmaceutical risk may be minimal. Episiotomy and forceps were not associated with any increase in pain during second stage. The single instance in which either procedure was associated with a higher pain report from any participant observer was in the assessment made by the childbirth educators of transition in births accompanied by medication and forceps. Since the childbirth educator is likely to report her assessment of labor pain during the days following birth, she may have been responding to the same post partum increases in discomfort following the use of forceps which Baker [5] has reported. Alternatively, the reliable difference in this lone instance may represent a statistical artifact. Since there were no increases in pain associated with the use of forceps in reports of either the women or labor coaches, both of whom were present during transition, it does not seem likely that any elevation in pain experienced by the laboring women occurred in association with the use of forceps. Even more striking is the lack of differences in pain reported for births in which an episiotomy or forceps were used regardless of whether medication was or was not used in second stage. A decrease in pain during the second stage was reported by mothers and childbirth educators in all groups. A decrease in second stage was reported by labor coaches and physicians only in the E, NF, M group. There appears to be a regular difference in reports of pain during second stage between observers as has been reported by Cogan [lo].
Second stage medical intervention
and pain during childbirth
293
REFERENCES 1. DAWSONA. M. Relief of pain in labour. In Psychosomatic Medicine in Obstetrics and Gynaecology (edited by MORRISN.), pp. 238-240. K. Karger, Base], Switzerland (1972). 2. HUTER J. Analgesia and anxiolysis during labour by drugs. In Psychosomatic Medicine in Obstetrics and Gynaecology. (edited by MORRIS N.), pp. 258-260. S. Karger, Basel, Switzerland (1972). 3. AIKEN R. A. and COPE E. The value of promazine and Diazepam as adjuncts to pethidine in labour. In Psychosomatic Medicine in Obstetrics and Gynaecology (edited by MORRIS N.), pp. 241-243. S. Karger, Basel, Switzerland (1972). 4. BROWNW. A., MANNINGT. and GRODINJ. The relationship of antenatal and perinatal psychologic variables to the use of drugs in labor. Psychosom. Med. 34,119-127 (1972). 5. BAKERS. A survey into post-natal perineal discomfort. London: S. Maw & Sons, 1973. Cited in Pain after Birth. Brit. Med. J. 565, 5892 (1973). 6. FRIEDMANE. A. Labor: Clinical Evaluation and Management. Appleton-Century-Crofts, New York (1967). 7. SIEGELS. Nonparametric Statistics for the Behavioral Sciences. McGraw-Hill, New York (1956). 8. BOWESW. A., BRACKBILLY., CONWAYE. and STEINSCHNEIDER A. The effects of obstetrical medication on fetus and infant. Monog. Sot. Res. Child Dev. 35, 1 (1970). 9. STANDLEYK., SOULE A. B., COPANSS. A. and DUCHOWNYM. S. Local-Regional anesthesia during childbirth: effect on newborn behaviors. Science 186, 634 (1974). 10. COGAN R. Comfort during prepared childbirth as a function of parity reported by four classes of participant observers. J. Psychosom. Res. 19, 33 (1975).
Research, Vol. 19, pp. 289 to 293. Pergamon Press, 1975. Printed in Great Britain
SECOND STAGE MEDICAL INTERVENTION PAIN DURING CHILDBIRTH*
AND
FREDERICKJ. KLOPFER,ROSEMARY COGAN?and WILLIAMJ. HENNEBORN (Received 20 June 1975)
THE USE of medication as a medical intervention technique to alleviate pain during second stage labor has been a largely unexamined practice. Similarly the relationship between the administration of episiotomies or the use of forceps and changes in pain perception has scarcely been subjected to empirical investigation. Since the relief of the mother’s pain is at least one, if not “the prime function” [l] of an obstetrician during delivery, the relationship between pain and these 3 medical procedures requires more careful examination. The stated purpose of second stage medication is often the relief of pain [l, 21. Aiken and Cope [3] examined the comparative efficiency of two kinds of medication, promazine and Diazepam, in reaching this goal. Pain during labor, as reported by senior midwives, was reduced significantly more with promazine than with Diazepam. Brown et al. [4] separately checked the relationships between various dosages of oxytoxics or analgesics and pain reactions revealed by obstetrics reports. They found no significant relationship between dosage level and pain reactions for either type of medication. They then considered the possibility that differences in medication levels chosen by obstetricians might be attributable to patient requests for medication not reflected in obstetric reports of pain. It was impossible to assess directly this hypothesized relationship with their data, but the tentative conclusion, based on secondary evidence, was that no such relationship existed. The present study seeks to provide more direct evidence by including pain reports of the mother as well as the physician. The pain reports used here were from a population of women trained in prepared childbirth, and reports from the labor coach (usually the husband) and the childbirth educator were also obtained and analyzed. The approach taken in the present study is also more basic. Rather than assess the relative efficiency of two kinds of medication [3] or several dosage levels of one kind of medication [4], the question is whether medication per se yields pain reports different than reports in births where medication is absent. Since an episiotomy involves an incision in the muscular tissue of the perineum, the procedure might be expected temporarily to increase pain. Presumably the procedure would be no more painful than a tear, the alternative possibility. One researcher [5] found no differences in pain reported during the first perinatal week for women who had experienced an episiotomy vs those who had received a tear. The effect of an episiotomy on pain during labor has yet to be examined. The use of forceps may sometimes be required in childbirth. The effects of this procedure on pain reported *This work was supported by funds from Childbirth Without Pain Education League, Inc., and from Public Health Service Research Grant No. MH 24249-01 from the National Institute of Mental Health. TRequests for reprints should be addressed to Rosemary Cogan, Department of Psychology, Texas Tech. University, Lubbock, Texas 79409. 289
FREDERICK J. KLOPFER, ROSEMARY COGAN and WILLIAM J. HENNEBORN
290
by the mother
in
conclusion
that
pain
was
than
births
her
first
births
without
perinatal with
forceps.
week
forceps
were
were
It may
also
found
be that
examined to produce
forceps
are
more
a medical choice in difficult, therefore painful, births. Alternatively, may add to discomfort during birth and the post partum period.
by
Baker
more
[5].
post
The
partum
likely to become the use of forceps
METHOD From a population of women who were students of a childbirth education group* offering classes in many parts of the United States, a group of 107 births were drawn. Births were selected which met the following restrictions: a labor coach accompanied each woman throughout both labor and birth; the birth was vaginal; no medication was administered during the first stage of labor; labor was neither begun nor maintained by induction; and reports of the birth were complete from the mother, her labor coach and the childbirth educator. In addition, physician reports were available for 49 of the births. The mothers, labor coaches and childbirth educators received questionnaires before the birth to be completed after the birth. Each questionnaire contained four items designed to assess the degree of pain experienced by the mother in each of four phases of childbirth [6]: the latent phase (dilation from 0 to about 5 cm); the accelerated phase (dilation from 5 to about 8 cm); the deceleration or transition phase (dilation from 8 to about 10 cm); and the second stage of labor. The items asked respondents to indicate whether (1) the mother was unaware of the particular phase under consideration or whether she seemed to feel (2) no pain, (3) no pain, but much effort, (4) moments of discomfort, (5) some pain, or (6) severe pain. Physicians were asked to assess the mother’s pain during late labor and birth only. One hundred and six of these birth reports were then divided into 5 groups. In each of the descriptions below, medication refers to second stage medication of any kind. Group l-no episiotomy, no forceps, no medication (NE, NF, NM): Group 2-episiotomy, no forceps, no medication (E, NF, NM); Group 3-episiotomy, no forceps, medication (E, NF, M); Group 4-episiotomy, forceps, no medication (E, F, NM); and Group 5-episiotomy, forceps, medication (E, F, M). Frequencies of reports are summarized in Table 1. With these 5 groups, it was possible to compare pain in 5 groups TABLE 1. FREQUENCYOF REPORTS OF SECOND STAGE MEDICATION,EPISIOTOMY,
AND FORCEPSIN 107 PREPAREDBIRTHS No Episiotomy
Episiotcmy Forceps N(P)* Medication
18(S)
No Medication
*N=
6(l)
No Forceps NC')
Forceps M(P)
NO Forceps N(P)
17(7)
O(O)
l(l)
50(27)
O(O)
15(8)
the number of birth reports (to be included, a birth needed to be
described by the woman, her labor coach and her childbirth educator) and P = the number of births for which physician reports were also available.
of analyses: (1) births with and without medication, with an episiotomy, without forceps; (2) births with and without medication with an episiotomy and with forceps; (3) births with and without an episiotomy without medication and without forceps; (4) births with and without forceps with an episiotomy and without medication; and (5) births with and without forceps with an episiotomy and with medication. It is interesting to note that when medication was used in second stage an episiotomy was performed in 97 % of the births, while when medication was not used in second stage 79 % of the births were accompanied by an episiotomy. Forceps were used in 50 % of medicated births and in only 8 ‘A *Childbirth 92501.
Without
Pain Education
League,
Inc.,
3940 Eleventh
Street,
Riverside,
California
Second stage medical intervention
and pain during childbirth
291
of non-medicated births. In no instance were forceps used unless an episiotomy had been performed Both wives and husbands in the two forcep groups attended somewhat more classes than wives and husbands in the other groups, which may suggest that post-maturity was involved in forceps use. Second stage labor lasted longer for wives in the E, F, M group. Since medication used in second stage among this group included spinal anesthesia (4 cases) and an injection which led to unconsciousness (4 cases), local injection which led to sleepiness (2 cases) or a local injection (8 cases), it seems probably that second stage was lengthened by a relative inability of women in this group to push voluntarily during second stage. Among the E, NF, M group medications were limited to local injections (16 cases) and a tranquilizer or muscle relaxant (1 case). Second stage among women in this group did not differ in length from second stage in the other groups and it seems reasonable to assume that voluntary pushing was used by these women as effectively as by women in other groups. There were proportionally more multiparous mothers in the NE, NF, NM group (60 %) and in the E, NF, NM group (36%) than in the other groups (11-17x). Aside from the above mentioned differences between groups, all groups were rather homogeneous with regard to age, number of classes attended by wives and by husbands, and length of first and second stages of labor. Within the general analyses numbered one, three and five above, it was possible to perform 14 different specific comparisons since reports from 3 respondents, the mother, labor coach and childbirth educator, described all 4 phases of labor while physician reports described late labor and birth. Data from birth group 4, that is, births with episiotomies and forceps but without medication, contained only one birth with a physician report, so it was impossible to perform the two comparisons of physician data for general analyses two and four, leaving 12 comparisons for both of these general analyses. RESULTS
AND DISCUSSION
The Median Test was applied [7] and the data are summarized graphically in Fig. 1. Following the guidelines set by Siegel [7], either the X2 or Fisher’s Exact
-NE ---._. -..
I O-5
Mothers’
‘rLabour
I 5-8
I 8-10
E g
NF NF N;
E
F
I 2ND
assessment
coaches’assessment
ChIldbirth educators’ assessment
5rPhysicians’
assessment
FIG. 1. Reports of pain during labor and birth by the new mother, labor coach, childbirth educator, and physician.
Probability Test was used to assess comparisons between groups. Analysis of groups one and two yielded no differences in pain reported with or without medication in second, stage with an episiotomy (Analysis group 1) or with an episiotomy and with forceps (Analysis group 2). Analysis group 3 yielded no differences in pain reported
292
FRBDERICKJ.KLOPFER,ROSEMARYCOGAN~~~WILLIAMJ.HENNEBORN
with or without an episiotomy without medication and without forceps. Analysis group 4 yielded no differences in pain reported with or without forceps with an episiotomy and without medication. Analysis group 5, testing differences in pain reported with and without forceps with medication and with episiotomies, yielded one significant difference from the 14 comparisons made. Childbirth educators reported reliably more pain during transition when forceps were used. In at least 30 of the 66 specific comparisons made in this study, reliable differences were neither expected nor obtained. It would seem highly unlikely for pain estimates in early labor to be reflected in medical intervention techniques not employed until the second stage. The only assumption making such predictions tenable would be that births which required second stage medication,episiotomies or forceps were more difficult labors throughout and the data do not support such a contention. It did seem, however, that the use of these techniques might have been predictably associated with differences in pain reported during transition. With one exception, not only were such predictions not borne out, but pain experienced during second stage itself was not affected by the presence or absence of medication, episiotomies or forceps. Among the present population of women, who received extensive psychophysical preparation for labor and birth, the use of medication in second stage was not associated with any decrease in pain during second stage. The data of Brown et al. [4] suggested that the administration of medication during childbirth may be associated with prenatal variables rather than events during labor and birth. Although other interpretations of the present data are possible, the data suggest that medication during second stage among women prepared to work with labor and birth and supported by a prepared labor coach may serve no pain-relieving function. Medication may affect neonatal development [8, 91 and the present data suggest that the benefits of taking pharmaceutical risk may be minimal. Episiotomy and forceps were not associated with any increase in pain during second stage. The single instance in which either procedure was associated with a higher pain report from any participant observer was in the assessment made by the childbirth educators of transition in births accompanied by medication and forceps. Since the childbirth educator is likely to report her assessment of labor pain during the days following birth, she may have been responding to the same post partum increases in discomfort following the use of forceps which Baker [5] has reported. Alternatively, the reliable difference in this lone instance may represent a statistical artifact. Since there were no increases in pain associated with the use of forceps in reports of either the women or labor coaches, both of whom were present during transition, it does not seem likely that any elevation in pain experienced by the laboring women occurred in association with the use of forceps. Even more striking is the lack of differences in pain reported for births in which an episiotomy or forceps were used regardless of whether medication was or was not used in second stage. A decrease in pain during the second stage was reported by mothers and childbirth educators in all groups. A decrease in second stage was reported by labor coaches and physicians only in the E, NF, M group. There appears to be a regular difference in reports of pain during second stage between observers as has been reported by Cogan [lo].
Second stage medical intervention
and pain during childbirth
293
REFERENCES 1. DAWSONA. M. Relief of pain in labour. In Psychosomatic Medicine in Obstetrics and Gynaecology (edited by MORRISN.), pp. 238-240. K. Karger, Base], Switzerland (1972). 2. HUTER J. Analgesia and anxiolysis during labour by drugs. In Psychosomatic Medicine in Obstetrics and Gynaecology. (edited by MORRIS N.), pp. 258-260. S. Karger, Basel, Switzerland (1972). 3. AIKEN R. A. and COPE E. The value of promazine and Diazepam as adjuncts to pethidine in labour. In Psychosomatic Medicine in Obstetrics and Gynaecology (edited by MORRIS N.), pp. 241-243. S. Karger, Basel, Switzerland (1972). 4. BROWNW. A., MANNINGT. and GRODINJ. The relationship of antenatal and perinatal psychologic variables to the use of drugs in labor. Psychosom. Med. 34,119-127 (1972). 5. BAKERS. A survey into post-natal perineal discomfort. London: S. Maw & Sons, 1973. Cited in Pain after Birth. Brit. Med. J. 565, 5892 (1973). 6. FRIEDMANE. A. Labor: Clinical Evaluation and Management. Appleton-Century-Crofts, New York (1967). 7. SIEGELS. Nonparametric Statistics for the Behavioral Sciences. McGraw-Hill, New York (1956). 8. BOWESW. A., BRACKBILLY., CONWAYE. and STEINSCHNEIDER A. The effects of obstetrical medication on fetus and infant. Monog. Sot. Res. Child Dev. 35, 1 (1970). 9. STANDLEYK., SOULE A. B., COPANSS. A. and DUCHOWNYM. S. Local-Regional anesthesia during childbirth: effect on newborn behaviors. Science 186, 634 (1974). 10. COGAN R. Comfort during prepared childbirth as a function of parity reported by four classes of participant observers. J. Psychosom. Res. 19, 33 (1975).
