Nitrous Oxide for Labor Analgesia Sandra Hoffman MS RNC-EFM Debbie Biffle BSN RNC NE-BC ANW Innovation Summit 2016

Nitrous Oxide for Labor Analgesia

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Acknowledgement and Thank You to The Abbott Northwestern Foundation for support of nitrous oxide for labor analgesia research!

Thank you to Dr Susan Sendelbach-ANW Director of Nursing Research for project assistance!

• Sandra Hoffman has no disclosures• Debbie Biffle has no disclosures

Images in this presentation are public domain images

Disclosures and Acknowledgments

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• Discuss nitrous oxide use for labor analgesia

• Describe candidates for nitrous oxide, and contraindications for use

• Describe nursing research regarding nitrous oxide for labor analgesia

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Nitrous Oxide at the Present

• Most utilized gaseous anesthetic worldwide• #1 utilized modality for labor analgesia worldwide• UK- 60% of laboring women utilize N20• Australia- 50% utilization• Norway- offered at 85% of birthing centers• Finland- 48% utilization • More common than regional anesthesia worldwide

(Rooks, 2007; STAKES 2006)•

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& in the United States…

UCSF (over three decades)Vanderbilt (over 10 years)

Only recently widely available in the Twin Cities (Birthing centers and hospitals)

Growing consumer interest….ANW program started May 2016

Long history of safe use- over 50 years!

Why has it taken so long to catch on in the US?

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• 61% of women who have singleton vaginal births in the U.S. receive regional anesthesia for labor pain. Epidurals are the most effective pain mgt modality.

Nitrous Oxide: Why so long to adopt?

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• All women do not need or want regional anesthesia. Those who do are may be denied accessibility due to lack of or competing needs for the services of anesthesia professionals.

• This is especially true for women living in rural areas and delivering in institutions where anesthesia may not staff 24/7.

(Rooks, 2007)

Nitrous oxide may become increasingly in demand as the supply of anesthesiologists and nurse anesthetists to provide 24/7 access to labor epidurals and the need for some kind of relatively effective analgesia during labor (Rooks 2010)

Nitrous Oxide

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Women want choices!• Great adjunct for natural childbirth because it does not affect

the fetus like narcotic analgesia

• Does not have the numbing effect of an epidural

• Has a calming effect which is helpful to relieve anxiety during labor

• Some women are not candidates for epidural

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50% Nitrous Oxide/50% Oxygen used in labor is analgesia-not anesthesia!

• Analgesia or “minimal sedation” per American Society of Anesthesiologists (ASA)

• No special regulations or guidelines-”minimal risk”


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• Patient awake and alert

• Protective laryngeal reflexes intact

• Self administration

• Effect titrated by frequency and intensity of inhalation

Analgesia…NOT Anesthesia

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• Rapid onset/offset• Low cost• Can be given at any point in labor– (never “too late”)

• Does not diminish contractions or slow labor• No impact on the ability to push• No known effect on fetal heart rate or newborn

APGARs • Allows for intact, but lessened, sensation of labor and

birth – (which is desired by many women)

• Procedural analgesia option: repairs, manual removal, manual OP rotation, tamponade balloon placement


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Nitrous Oxide Advantages

• Easy to set up quickly, and teach the patient how to use. Self administered

• Option for women who want minimal intervention, rapid onset of action

• May be able to postpone or avoid narcotics or epidural

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Nitrous Oxide Mechanism of Action: How Does it Work?

• Nitrous oxide works by reducing the perception of pain and lowering anxiety levels.

• Resulting euphoria and dissociation may make pain more manageable.

• The ability to self administer nitrous oxide may help the woman feel more in control of pain (Zauderer 2016)

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Nitrous OxideIs it safe for the fetus or newborns?

• Potential neurotoxicity of anesthetic agents has been topic of interest in recent years

• phenomenon called “apoptosis” seen ONLY in animal studies when exposed to extreme amount over long periods of time

• Also applies to sedatives, hypnotics, narcotics, and all anesthetic gases

• Nitrous oxide is one of a very long list of agents of interest in this regard

• Studies have not shown an effect on the fetal heart rate, breastfeeding, APGAR or behavioral assessment scores


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• Can be used in any stage of labor, no time limit established in the literature

• Normal low risk patients >-37 weeks gest.

• Initial electronic fetal monitoring tracing reflects adequate oxygenation.

• Contraindications: Vit B12 Deficiency, narcotics in the last 2 hours, drug use or intoxication, respiratory compromise, pt can’t hold own mask, etc.

Who may use Nitrous Oxide? (Allina)

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Equipment• Portable tanks (N20 and 02) or may use wall O2

• Blender device mixes 02 and N20 to deliver a set 50:50% concentration

• Self administration by face mask with a demand valve-only get the nitrous by inhalation

• Patient exhales into the mask, scavenging system filters and diverts exhaled gas to wall suction. Not exhaled into room air

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Patient/Family Education

• Intermittent vs continuous use• Peak analgesic effect lags the start of it’s

administration by 50 seconds, uterine contractions typically peak 30 seconds after they start• Educate that may not provide complete pain relief• Elimination quickly via lungs (elimination half life

5 min)


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• The effects on human fetuses or in children later in life who were exposed to nitrous oxide or other anesthetic agents in utero are unknown.

• Low concentrations and brief period to which a fetus would be exposed during labor (even a prolonged one) would be unlikely to result in a measureable effect even if such effects were later shown to be real.

(Starr and Baysinger, Anesthesiology.theclinics.com 2013

? Neurotoxic effects

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• There is a general lack of US data on maternal and fetal outcomes, and a specific lack of data on:

-sense of control/satisfaction with the childbirth experience -effect on mother/baby interaction -breastfeeding -admission to special care nursery -infant outcomes at long term follow up -costs

The Need for Research

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• ANW Foundation Innovation Grant Awarded June 2016!• Project collaboration: St Catherine University, Dr Jane

Wrede-Bethel University Midwifery Program Director

Research Question: Is there a difference in maternal characteristics and/or maternal and newborn outcomes when women have received nitrous oxide or received nitrous oxide continuously or intermittently

Abbott Northwestern Nursing Research

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• Describe the characteristics of women who choose nitrous oxide for labor versus those who do not (age, parity, ethnicity/race, delivery type, doulas, provider type, type of insurance)

• Maternal outcomes (pain scores, vacuum or forceps, vaginal lacerations, delivery type, length of first and second stage labor, length of stay)

• Newborn outcomes (APGAR scores, nursery disposition, cord blood gas results if obtained, resuscitative measures)

Study Aims

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Some Data……..

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Nitrous OxideIn Conclusion:• Nitrous is a great option for many laboring women–Many women will desire and appreciate

• Nitrous oxide can be a useful tool in helping patients who desire a less-medicated birth

• Nitrous can also provide pain relief for bedside procedures requiring analgesia or anxiolysis

• Documenting safety/outcomes is important05/03/2023

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• AHRQ (2011). Evidence-based practice center systematic review protocol. Project title: Nitrous oxide for the management of labor pain. Retrieved from http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=675&pageaction=displayproduct

• American College of Nurse-Midwives. (2010). From the American College of Nurse-Midwives: Nitrous oxide for labor analgesia. Journal of Midwifery & Women’s Health, 55(3), 292– 296

• Collins, M. (2015). A case report on the anxiolytic properties of nitrous oxide during labor. Journal Of Obstetric, Gynecologic, & Neonatal Nursing: Clinical Scholarship For The Care Of Women, Childbearing Families, & Newborns, 44(1), 87-92. doi:10.1111/1552-6909.12522

• Khadem, N., Zirak, N., Soltani, G., Sahebdelfar, N., Sepehri Shamloo, A., & Ebrahimzadeh, S. (2013). Comparison of epidural versus entonox for labor analgesia in nulliparous women. تروما و جراحی 5-1), 1(1, نشریه . Retrieved form http://www.ijs.ir/

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• Posner, G., Black, A., Jone, G., & Dy, J. (2013). Oxorn-Foote Human Labor & Birth. (6th Ed.) New York, NY: McGraw Hill.• Rosen, M. (2000). Nitrous oxide for relief of labor pain: A systematic review. American Journal of Obstetrics and Gynecology. 186, 110-26• Rosenstein, M., Flood, P., Thiet, M. P., Nakagawa, S., Bishop, J., & Cheng, Y. (2014). 598: The use of nitrous oxide analgesia during labor at a single

institution in the United States. American Journal of Obstetrics and Gynecology, 1(210), S294-S295. http://dx.doi.org/10.1016/j.ajog.2013.10.631• Rooks, J. P. (2007, May). Use of Nitrous Oxide in Midwifery Practice–Complementary, Synergistic, and Needed in the United States. Journal of

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