CINCINNATI -- Sometimes progress means walking things back a few paces, reaching for older technologies.
Such may be the case in childbirth, where the use of nitrous oxide has been revived in this country as a means of managing pain in labor.
Nitrous oxide gas – also known as laughing gas -- has been around a long time. It was first synthesized in 1772, and it has been used to lessen pain in dentistry since the mid-19th century, and then in the 20th became common in childbirth.
It’s still employed in dentistry and a variety of medical scenarios. But when epidural anesthesia became common in the United States, nitrous oxide fell out of fashion, even as it continued to be used widely in other developing countries. According to an article in The Atlantic, by the 1980s nitrous oxide had all but disappeared as an option for women in labor in this country.
But recently, it has been returning to the service menu of U.S. hospitals. And in February, Mercy Health will begin offering nitrous oxide as an alternative to epidural anesthesia – also known as regional anesthesia -- for mothers in labor at Anderson Hospital. It will be the first hospital in the area, in recent times, to offer nitrous oxide to laboring mothers.
Susan Holden, CNM, MSN, has been a midwife and nurse with the Seven Hills Women’s Health Center for the past 17 years, delivering some 2,000 infants, mostly at Anderson Hospital. Holden said of nitrous oxide gas, “It’s probably one of the older types of pain management worldwide. [Medical professionals in] the United States are trying to get it back into favor. But it has been utilized over the world, and it’s one of the main analgesics in the U.K, Australia, Norway, Finland.
“[It’s] not anesthetic, like epidurals,” Holden said. “But it is analgesic which does relieve some of the pain and actually does more of making women relaxed and able to cope,” she said.
An Aid In Natural Childbirth
Because the proportions of oxygen and nitrous oxide in childbirth assistance are different than in other medical applications, hospital workers could not simply borrow nitrous oxide from another area of the hospital.
According to Holden, who advocated for its inclusion in Mercy hospital maternity services, nitrous oxide is an on-the-spot analgesic with a quick half-life that can be administered by a woman in labor herself, without the aid of an anesthesiologist or even a nurse.
It’s considered safe for the baby. It’s significantly less expensive than an epidural procedure, which involves monitoring by an anesthesiologist.
In January, 2015, ABC News reported that the cost of an epidural can be more than $3,000, while the cost of nitrous oxide can be under $100.
Perhaps most importantly, nitrous oxide gives a woman more power in the process, allowing her to get out of bed if she desires and allowing her to control the amount of pain relief achieved. With an epidural, a woman is confined to bed.
Holden defines a nitrous-assisted birth as a natural childbirth.
“It was utilized in the United States in the 1930s to '50s,” she said. “And they utilized it with other anesthesia products to give the twilight sleep kind of thing, and then it went out of favor. Actually the University of San Francisco has been using it for 30 years. Vanderbilt [University Hospital] has been using it for many years ... It’s just now catching on that women are hearing about it and requesting it, and they want another alternative for pain management besides epidurals.”
“It’s simple,” she said. “It’s safe and effective. It’s inexpensive. It’s accessible, and patients are asking for ways to relieve their pain without the invasion of an epidural,” which involves inserting a catheter into the epidural space.
“We’re very excited to be able to offer this to our patients and the women who are looking to succeed at their natural childbirth, and this I think will give them that little extra relaxation and decrease their anxiety” in childbirth.
An Option When Epidural Can’t Be Used
According to Dr. Ronald Jaekle, fetal medicine specialist and professor at the University of Cincinnati department of obstetrics and gynecology, which he said is working to get funding for the equipment to offer nitrous oxide to laboring women: “Nitrous oxide comes into play for those patients who are not candidates for regional anesthesia [i.e., an epidural]; for patients who have been on blood thinners and epidural anesthesia is not an option; or patients who discover after trying to go natural at the very last minute that it’s just not working for them and they need something [a painkiller] when it’s really too late to get regional anesthesia.”
Why nitrous fell into disuse in this country is a matter of debate. The more powerful pain-killing of epidurals is one reason. Another is the discovery that the nitrous oxide exhaled by patients was unhealthy for health care workers.
“Nitrous oxide is a danger to health care workers if it’s not controlled,” said Jaekle. “So they needed to come up with a technology whereby patients could inhale the nitrous oxide and then breathe it out into the environment, so that not everybody working in labor-and-delivery got exposed. It’s a very safe system,” for patients, Jaekle said. “It’s very rapidly metabolized, so basically as soon as you start breathing again [without the gas] it gets out of your system.”
But nitrous oxide, without proper capture of exhaled gas, “is great for the patient, not safe for the [attending] employees.”
Making It Safe For Health Workers
According to the Centers for Disease Control and Prevention, side effects of secondhand nitrous oxide could include dizziness, fatigue, nausea, headaches, and liver and kidney disease.
The Journal of Obstetrics and Gynecology reported in 2012 that “One major barrier to implementation of N2O [nitrous oxide] services in the United States has been the limited availability of N2O delivery equipment.”
In 2011, the FDA approved a rolling cart that could be used for nitrous oxide in childbirth. The cart includes apparatus for oxygen and nitrous oxide canisters, as well as a tank for capturing spent gas. Since then, the number of hospitals nationwide offering the nitrous option in childbirth has increased.
This is the cart Mercy is training its staff in using now and which Jaekle says his department is seeking to purchase.
Goal Is To Relieve Urgent Pain
Holden said the option of nitrous oxide in childbirth does not preclude use of an epidural: a mother could start with nitrous oxide and later opt for an epidural – but not too late. Once a mother is in the final phases of delivery, an epidural can no longer be initiated. In other words, a patient could potentially use both methods, and nitrous oxide could be used throughout the course of labor.
But Jaekle said nitrous oxide is best for patients for whom an epidural was not used at all.
Still, he said, epidurals should not be dismissed as an option.
“So many patients,” he said, “have this perception that epidural is bad and harmful and terrible and causes problems. But the reality is there is not any evidence that epidurals increase your C-sect rate; increase your risk for complications with your labor course. But there is every reason to suspect since we use nitrous oxide as a means of relaxing the uterus that if you try to use it for a whole labor instead of using an epidural, you’re going to have a longer labor and a higher likelihood of C-section those kind of things. So it is really to take the urgent pain away, not as a means of constant pain relief in labor.
“For the vast majority of patients where pain relief is a goal, we have epidural anesthesia that has an extraordinarily long track record of efficiency, efficacy and safety.”