FINDING OUT WHAT IS AVAILABLE

The kinds of pain relief which are likely to be available will depend to some extent on where you plan to have your baby. Simple measures, such as hot packs and pethidine are usually accessible wherever you have your baby. A warm bath or shower is possible at home in early labour and many hospital labour wards are also able to offer private shower facilities. TENS may, or may not, be available depending on local enthusiasm for this technique - which seems to vary considerably between different centres. If you are thinking about using hypnosis you will need to consult a hypnotherapist early in your pregnancy. Most hospitals nowadays would not object if you wanted your therapist to be present during the labour - at your expense! Acupuncture is unlikely to be available anywhere.

Obviously, the facilities that are available in a large hospital will not be available at home or in a small unit. If you are planning to have a home delivery, it will not be possible, for instance to have an epidural. Nitrous oxide will probably be available for a home birth in the UK, but not in Australia. Birthing units have recently become fashionable in some places. Again, the choice of pain relief will be limited and if an epidural is required this will usually mean being transferred to a hospital labour room.

Most women who live in the English speaking world are booked to have their baby in a hospital environment. In Australia, for instance, over 99 per cent of deliveries occur in hospital. Between different hospitals, however, there may still be differences in the range of options available for pain relief and anaesthesia in childbirth. There are several reasons for such disparities. Some units are simply too small to be able to offer all methods of analgesia; there may not be sufficient expertise, or the facilities may be inadequate. Only larger units usually have adequate manpower to be able to offer an epidural immediately on request - day or night.

The range of facilities also depends on relative cost and the health care system. To provide an epidural service in a public hospital, for example, medical salaries must be funded from the public purse: to be cost effective this means that there must be a sufficient demand and workload. In the private sector, on the other hand, where the patient pays the anaesthetist on a fee-for service basis, epidural analgesia may be more readily available - but only as a direct cost to the patient. If you belong to a medical insurance scheme, professional fees are of course recoverable in whole, or in part, from your insurance fund.

Within each centre, the opinions of obstetric and nursing staff also have an important influence on the pain relief facilities that are available. Some centres are more receptive to consumer opinion than others. In the more progressive centres, medical and nursing staff meet regularly to discuss their practices and consider how further improvements can be made. They have a well organised antenatal education program and actively seek the opinions of patients about their experience of the service. Units such as these are much more likely to be considerate and flexible towards the wishes of patients than units dominated by staff who are indifferent to consumer opinion.

Ultimately, your doctor and midwife are responsible for the safe delivery of your baby. They may have their own views about pain relief and may persuade you to accept (or reject) one method in favour of another. Naturally, you must be guided by the advice of your attendants. They, in turn, have a responsibility to explain their views long before your baby is due. After all, you might want to change your mind! If you have any special preferences, therefore, you should discuss them with your doctor or midwife early on in your pregnancy. Don't be afraid to ask what kinds of pain relief will be available and who will decide which one to use.

Most obstetricians and midwives nowadays (with certain provisos) consider that decisions about pain relief should lie with the mother, herself. At least, this has been the author's experience over the years. It would appear, however, that such liberal attitudes are not universal. One patient (a medical practitioner) from Western Australia once wrote to me:

So be warned! Find out what the views of your doctor and midwife are beforehand. Ask if you will be free to choose your own pain relief. And if not, why not? After all, most mothers are free to choose their doctors and where they wish to have their babies. But these decisions need to be made early in your pregnancy. So make sure that your questions are answered adequately and that you feel satisfied about where to have your baby, right from the beginning.

The same applies to anaesthesia for caesarean section. If there is sufficient time, and there are no contra-indications, caesarean section can usually be performed under either general or epidural anaesthesia. Once again, in the author's experience, most obstetricians nowadays leave this decision to the patient and her anaesthetist. Not all centres, however, have anaesthetists who are suffIciently experienced in epidural anaesthesia: they may insist on a general anaesthetic. There are also, apparently, some obstetricians who routinely insist on general anaesthesia for caesarean section, or who will not permit your partner to be present if the operation is performed under an epidural. If you are likely to require a caesarean section, therefore (and this is always a possibility), you should inquire who will determine the kind of anaesthetic that you receive, and - if you have an epidural - whether your partner will be able to be present. If these questions are not answered satisfactorily, you might prefer to book your confinement elsewhere.

In summary, not all centres are able to offer a full choice of pain relief and anaesthesia in childbirth. It is best therefore to find out everything you can before deciding where to have your baby and who to look after you. After all, you are having the baby! You have every right to know what to expect if you should require pain relief or an anaesthetic. You will ehen know about any restrictions or limitations which might apply during your confinement from the very beginning. This will avoid any misunderstandings which might otherwise occur and will allow you to make alternative arrangements, in good time, if you are not satisfied.