1847, the scottish obstetrician james simpson administered ether to a woman during labor to treat the pain of childbirth. He was impressed with the degree of analgesia associated with the use of the drug. Nevertheless, he expressed concern about the possible adverse effects of anesthesia: "It will be necessary to ascertain anesthesia's precise effect, both upon the action of the uterus and on the assistant abdominal muscles; its influence, if any, upon the child; whether it has a tendency to hemorrhage or other complications." 1 One and a half centuries later, the maternal and fetal effects of analgesia during labor remain central to discussions among patients, anesthesiologists, and obstetrical caregivers. A number of randomized trials have sought to address the effects of different strategies for analgesia on maternal and fetal outcomes. Despite this effort, it has become increasingly clear that potentially unwanted effects of analgesia for women in labor and their children cannot be determined easily. Remaining controversies in obstetrical anesthesia include that over the effects of regional anesthesia on the progress and outcome of labor, as well as that over its effects on the neonate. In this article we will concentrate on advances in the administration of epidural, spinal, or combined spinal-epidural analgesia during labor. However, there are many other methods of pain management that may be chosen by women in labor, such as opioids, 2 hydrotherapy, hypnotherapy, the use of labor-support personnel (doulas), massage, movement and positioning, and sterile-water blocks, among others. 3 These alternative methods can be used successfully either alone or in conjunction with epidural analgesia. In addition, successful relief of labor pain in itself is not necessarily associated with high levels of satisfaction on the part of parturient women. 4,5 Factors such as the woman's involvement in decision making, social and cultural factors, the woman's relationship with her caregivers, and her expectations regarding labor may be equally, if not more, important. technique of regional analgesia Approximately 60 percent of women, or 2.4 million each year, choose epidural or combined spinal-epidural analgesia for pain relief during labor. 6 Labor pain is transmitted through lower thoracic, lumbar, and sacral nerve roots (Fig. 1 and 2) that are amenable to epidural blockade. Epidural analgesia is achieved by placement of a catheter into the lumbar epidural space. Solutions of a local anesthetic, opioid, or both can then be administered as intermittent rapid doses or as a continuous infusion (Fig. 3). The alternative technique of combined spinal-epidural analgesia has recently gained in popularity. With this technique, a single bolus of an opioid, sometimes in combination with local anesthetic, is injected into the subarachnoid space, in addition to the placement of an epidural catheter (Fig. 3). The use of a subarachnoid bolus of opioids results in the rap-i regional analgesia for vaginal delivery

Common practice during local anesthetic injection is to warn the patient using words such as: "You will feel a big bee sting; this is the worst part." Our hypothesis was that using gentler words for administration of the local anesthetic improves pain perception and patient comfort. One hundred forty healthy women at term gestation requesting neuraxial analgesia were randomized to either a "placebo" ("We are going to give you a local anesthetic that will numb the area and you will be comfortable during the procedure") or "nocebo" ("You are going to feel a big bee sting; this is the worst part of the procedure") group. Pain was assessed immediately after the local anesthetic skin injection using verbal analog scale scores of 0 to 10. Median verbal analog scale pain scores were lower when reassuring words were used compared with the harsher nocebo words (3 [2-4] vs 5 [3-6]; P < 0.001). Our data suggest that using gentler, more reassuring words improves the subjective experience during invasive procedures.

Herbal medicine use may be less prevalent in the parturient population, however, some health care providers may be promoting their use during pregnancy.