INHALATIONAL ANALGESIA IN LABOUR: FACEMASK OR MOUTHPIECE

1030

problem because they have to be informed of the abnormality by post, and because the X-ray report (sent to the woman’s general practitioner with a recommendation for referral) is more likely to suggest the possibility of malignancy. However, the number of these cases is fairly small. Only 8% of women referred were eventually diagnosed as having cancer, so a lot of highly skilled effort was employed in investigating women with benign disease or no disease, who, in the absence of screening, might have imposed no load on the services. If this happened in a routine screening programme, the high referral-rate could severely strain some general-surgery clinics, to the possible detriment of women presenting with symptoms. Widespread screening would almost certainly require a back-up service of specialised breast units, sufficiently experienced to sort out quickly the serious cases from the more benign. CONCLUSION

Our preliminary findings suggest that as screening tests for breast cancer both clinical examination and mammography have their limitations, but both are necessary if many false negatives are to be avoided. The value of mammography was perhaps more open

question; however, far, mammography compares favourably with clinical examination in its detection of cancers, its lower rate of referral and biopsy of women who do not have cancer, its lesser degree of observer variability, and in the comparative accuracy of its prediction of malignancy. Moreover, the New York study suggested that women with cancers detected by mammography alone had a much better survival-rate than those found by clinical examination alone. However mammography carries a radiation hazard and is expensive and it presents the surgeon and the pathologist with difficult borderline abnormalities whose management creates real problems. We hope that the further results of this study, in which we aim to screen several thousand women, will help to give more information on these points, as well as on the follow-up of women with cancers detected by both methods. to

so

We thank the many people whose help has made this study possible: Dr Ian Seppelt, formerly medical officer of health for Ealing, whose support enabled the screening clinic to be set up; Dr J. M. G. Wilson for his collaboration in design of the study; Dr Barbara Thomas for her role in the feasibility study; Miss Ann Casey, radiographer to the project; Mrs Kay Head and Mrs Jill Steele who did the clinical examinations; Dr D. MacErlean who read mammograms in the feasibility study; Mrs June Harris and Miss Margaret Cozens who are responsible for the records; and to Miss R. Clayton, Mrs D. Harrison, and the clinic staff. We also thank the surgical and histopathology staff of Charing Cross and Hammersmith Hospitals and the computer staff of the Chronic Disease Study Unit of the London School of Hygiene and Tropical Medicine, and Prof. R. E. Steiner and Prof F. Doyle of the diagnostic radiology department at Hammersmith Hospital, Prof. J. N. Morris of the Community Health Department at the London School of Hygiene and Tropical Medicine, and Dr R. Linden and Miss Marjorie Turner of the Hammersmith, Hounslow, and Ealing Area Health Authority for their encouragement. The study is supported by a grant from the Department of Health and Social Security. Requests for reprints should be addressed to J. C., Department of Community Medicine, University College Hospital Medical School and Royal Free Hospital School of Medicine, 115 Gower Street, London WC1E 6AP.

Hospital Practice INHALATIONAL ANALGESIA IN LABOUR: FACEMASK OR MOUTHPIECE P. F. DOLAN

Department of Anæthetics, Welsh National School of Medicine, Heath Park, Cardiff CF4 4XN. M. ROSEN

Department of Anœsthetics, University Hospital of Wales, Heath Park, Cardiff CF4 4XN. offered as an alternative to a facemask increased the acceptance of inhalational analgesia during labour from 76% to 96% of 50 patients. 92% of those patients offered a choice of a mask or mouthpiece would use the same device in another labour compared with only 64% of those offered only a facemask.

Summary

A

mouthpiece

INTRODUCTION

A FACEMASK is normally used for the self-administration of inhalational analgesia during labour, but some patients reject this valuable method of pain relief because of fear of the facemask. In a pilot study a mouthpiece seemed to satisfy some of these patients. This study- quantifies the effect of a choice of facemask or mouthpiece on patient acceptance of inhalational

analgesia. METHOD

By self-administration patients were offered 50% nitrous oxide and 50% oxygen (’Entonox’). Consecutive patients (group I) used the facemask and anyone who refused was then offered a plastic mouthpiece (B.O.C. Ltd, no. 332555) fitted to the entonox handpiece in place of the facemask. Three further groups were offered only the facemask (group II), only the mouthpiece (group III), and a choice of either (group iv). Parity, duration of inhalation, the use of pethidine within 4 hours of commencing inhalation, and the duration of each stage of labour were recorded. In addition, the midwife completed a questionnaire concerning her opinion of the patient’s pain relief (complete, considerable, slight, or none), drowsiness (too drowsy, satisfactory), and restlessness.1 After labour, each patient was asked (P.F.D.) "Did you like using the mask or mouthpiece ? Would you

DR CHAMBERLAIN AND OTHERS: REFERENCES

1. 2.

3. 4. 5. 6. 7. 8. 9.

10. 11.

Shapiro, S. Bull. N. Y. Acad. Med. 1975, 51, 80. Mole, R. H. Paper read at an M.R.C. Conference on Breast Cancer, held at West Drayton, in June, 1974. Price, J. L., Nathan, B. E. Proc. R. Soc. Med. 1975, 68, 438. Price, J. C., Butler, P. D. X-ray Bull. 1971, 19, 3. Denoix, P., and Committee on TNM Classification. TNM Classification of Malignant Disease, U.I.C.C., Geneva, 1968. McMahon, B., Cole, P., Brown, J. J. natn. Cancer Inst. 1973, 50, 21. Sansom, C. D., Wakefield, J., Yule, R. Med. Offr. 1970, 123, 357. Bloor, M. J., Gill, D. G. Commun. Med. 1972, 129, 135. Thorner, R. M., Remein, Q. R. Principles and Procedures in the Evaluation of Screening for Disease (Pub. Hlth Monogr. no. 67). U.S. Department of Health, Education and Welfare, 1961. Registrar General’s Statistical Review of England and Wales, Supplement on Cancer 1966 to 1967, H.M.S.O., 1972. Knox, E. G. in The Future and Present Indicatives; p. 30. London, 1973.

1031 like to use the same again ?" Each patient was also asked how much the inhalation had helped her pain. RESULTS

Of 50 consecutive patients 76% accepted the facemask. A further 20% accepted the mouthpiece. Patient acceptance of inhalational analgesia was increased to 96% (p < 001). There were no statistically significant differences between groups II-IV in parity, duration of labour, duration of inhalation, or pethidine administration. There were no differences in drowsiness or restlessness, but the midwives’s assessment showed that analgesia was improved (P < 0-05) for those who used the mouthpiece. Furthermore, significantly more mothers offered only the mouthpiece considered this helped them compared with those offered only the mask (P <0-05). Significantly more patients who had a free choice liked using the device (96%) than those who had only the mask (75%; P = 0-00006) or the mouthpiece (89%; P =0-04). 92% of those who had a choice would use inhalational analgesia again compared to 64% who used the mask (p = 0-00008) or 83% the mouthpiece (p 0-08). There were no differences between multipart and primiparx. =

DISCUSSION

Self-administered inhalational analgesia can only be of use if it is acceptable to the patient. The mouthpiece, offered as an alternative to the facemask, increases the

acceptance of inhalational analgesia. Furthermore the assessments of analgesia show an improvement with the mouthpiece, probably indicating increased patient satisfaction. Patients spontaneously mentioned certain advantages of the mouthpiece. There is no smell of rubber, spectacles may be easily worn, and there is no claustrophobic or suffocating sensation, no pressure on the face, the hands are left free, the mouthpiece provides something to bite on, and impeded nasal breathing (a bad cold) is of no consequence. Patients using the mouthpiece did not complain of the drying effect of unhumidified gas which had not passed through the nose, probably because of the intermittent, short duration of use. The mouthpiece has been extensively used in our labour wards for the last two years without adverse incident. It is cheap, and can be re-used after sterilisation. It

acceptable alternative to those patients who do not like the facemask, making inhalational analgesia acceptable to nearly every patient. It is clearly important to offer the patients a choice. provides

an

due to Prof. W. W. Mushin for constructive the midwives of the Cardiff Maternity Hospitals without whose willing help this study would not have been Our thanks

advice, and

to

possible. Requests

for

to

1.

are

reprints

and tables of results should be addressed

P.F.D. REFERENCE W. Br. med.

Major, V., Rosen, M., Mushin, W.

J. 1966, ii,

1554.

Round the World devices". The

sphygmomanometer was perhaps the most complicated thing we regularly carried. Now it would need a pantechnicon

United States TEMPORARY REPRIEVE

It seems that the new Secretary to H.E.W. has persuaded the Administration to continue to support medical and other health schools by direct student grants, instead of phasing out such support, as had been proposed. Dr Mathews has himself been head of a university with a medical school to finance, so he knows the problems. The medical schools will be suitably relieved. Even so, they never got what was promised from the 1971 Health Manpower Act, which set$2500 as the capitation per student; no school in fact got more than$2000. In July, the House passed a Bill requiring the students in schools receiving such grants to pay back the amount equal to the award in service or in cash, and the Senate is considering this proposal. The argument is based on the high costs of medical education, the high level of support, and the fact that physicians are the highest paid workers in the country. The Administration’s view is that medical students pay too little in tuition costs. They pay between$1000 and$4000 a year of the$15 000 or so it costs to educate them, and the official view is that they should pay more, the Government loaning the sum if necessary against repayment in cash or service. There is some confusion of thought here. In any sensible taxation system the higher the salary, the greater the amount paid in taxation. If doctors earn higher salaries, they should pay more in taxes, which should return the Government aid to the Administration. Perhaps the trouble is that the income tax set-up is permeated with too many loopholes by which taxation can legitimately be avoided. GADGETS GALORE

One does were

not

have to be all that old

to

remember when .here

hardly any medical gadgets, or what we call

here

"health

to

carry round all the health devices available-res-

piratory machines, muscle stimulators, pumps, dialysis machines, and so on, plus a seemingly endless variety of tubes. In this country there has been no system of regulatory control over the quality, testing, reliability, safety, or efficiency of these devices. It is true that after malfunction or other problems are detected the Government can request their recall, and the person who has suffered injury, or his family, can sue via the courts. But this may be quite difficult even if the manufacturing company is a reputable concern, and there are not a few which are far from reputable. With increasing sales of the devices, amounting now to many millions of dollars per year, and with their increasing complexity, problems have mounted precipitously. It might be thought that here was an area where politicians zealous for reelection and for the welfare of their constituents would have been eager to see the public protected. But not so. Since 1961 more than 30 introduced Bills have failed to pass. A major factor in this has been the opposition of the manufacturers, but it seems that they have now seen the red light and have decided to support the passage of regulatory legislation. However, critics feel that legislation which is pressed for and agreed to by the industry is perhaps not going to protect the public adequately, though it might well benefit the industry. It might indeed help to protect the industry from liability suits, and make it more difficult for injured clients to be compensated. The Food and Drug Administration, which seems likely to be the overseer, has itself been under much fire in recent years for its tendency to cautious inaction, which is said to deny our citizens the therapeutic benefits of some drugs available overseas. Whether it would be able to cope with a new load of heavy duties, many of them of a new kind, is open to question. But nothing has emerged from Congress yet, and perhaps

nothing will.