Using Nitrous Oxide for Labor

A little over a year ago, we began using Nitrous Oxide on our unit for analgesia for laboring women.  I had heard about Nitrous while at an AWHONN meeting several years earlier.  At that time, I brought information back and discussed it with our head of Anesthesia who said it really wasn't a great idea and so I let it drop.   In the spring of 2015 one of our obstetricians became interested in using Nitrous for his laboring patients and we decided to form a task force of all of the Ob Directors in our System, our OB Educators, Anesthesia, and OB Physician champions.  We pride ourselves on being cutting edge with offering new things and a free-standing birthing center in our area was already offering Nitrous.  We had had some requests for Nitrous on our social media page.  In our discussion we wanted to be able to provide an alternative analgesia for patients who wanted it and to also use it as a bridge for patients before they receive an epidural.  

Our Perinatal Practice Nurse investigated the evidence for us.   We found the following:

›Minimal Risk- No Complications

›Maternal

›No impact on cardio-respiratory functioning

›No impact on labor progress or post partum bleeding

›Minimal/possible side effects: nausea, vomiting, drowsiness

›Fetus

›No change in FHTs

›No impact on Agpar Scores or resuscitation

›No impact on cord pH

›No known effects on breastfeeding

›Efficacy

›Pain relief- satisfactory

›Anxiety- favorable

›Satisfaction- favorable

The next steps were to discuss scope of service and ownership of the Nitrous program.  For us, we decided to make this a provider order with our physicians and midwives.  The financial decisions had to be made as to what equipment we would purchase and how we would pay for it.  Because we do not have Nitrous in our medical gases in the L&D rooms we went with the portable Nitrous units.  In addition, we had to decide how we were going to charge for the Nitrous and how we would be reimbursed for it.  For us, we decided to just charge for the disposable circuits.  We had to develop a policy and we decided to reach out to other organizations who were using Nitrous.  They were very helpful for us with our own policy development.  We had to consider how we would maintain safety and security of the Nitrous and we worked that into our policy.  We decided to utilize a written consent for use of the Nitrous.  Our consent also included a screening checklist.

There are some contraindications to using Nitrous and they are listed below:

  ›    Cannot hold their own face mask/ mouth piece
›Impairment of consciousness, or intoxicated with drugs and/or alcohol
›Documented vitamin B12 deficiency and are receiving vitamin B 12 supplementation
›Have impaired oxygenation (O2 sat consistently less than 95% on Room Air)
›Previous adverse reaction to nitrous oxide
›Category III fetal heart rate tracing
›IV opioids within the last 2 hours
›Received Methadone, Subutex, or Suboxone in the last 5 days
›Hemodynamic instability as defined by a Systolic Blood Pressure < 100.
›Decreased cobalamin function (e.g. Crohn’s disease, Celiac disease, gluten intolerance, pernicious anemia, strict vegan diet).
›Pneumothorax, bowel obstruction, increased intra-ocular pressure or recent eye/ear surgery in previous 3 months. 

Before implementation we had to consider the safety of our pregnant staff members and allowed them to opt out of caring for women using Nitrous.  We had to prepare brochures that could be used in our childbirth education classes and birth center tours.  We worked with our Marketing Department to get some press on the start up.  We made some adaptations to our Electronic Health Record so we would be ready to document the Nitrous use.   We were almost ready to start!  

Training of the team came next!  The training was multimodal.  We used a knowledge-based training that was completed by staff on-line first.  The company we purchased the Nitrous machines came in and went over the equipment with the staff and finally, the staff signed an attestation that they would use the equipment safely according to the policy.  AND WE WERE OFF!!  Ready to go!

The feedback from the patients the first year have been good.  We have had an occasional disappointment with Nitrous, "I didn't like how it made me feel".  It has offered us an additional option for pain management during labor and immediately after delivery (i.e. for repairs).  It has been an effective bridge for some women prior to them receiving their epidural.  Other women have used Nitrous throughout their labors successfully.  We feel like it has decreased our use of IV pain medication.  We have noted that if the Nitrous is brought into the woman and explained to her prior to labor being very advanced that it works better.  It does seem to have a direct impact on reducing the patient's anxiety.

So after one year, what is my advice to others considering this for their own Obstetrical Units?  Just do it!  Nitrous has been a win-win for us.  It is low cost.  It is a patient satisfier.  It is patient centered, safe and effective.  

We would be willing to share our Policy and Procedure as well as our Patient Information Sheet and Consent if you contact me.