Mom's Choice: Nitrous Oxide at D-H
December 18, 2013
Childbirth is a unique experience for each woman. With this in mind, Dartmouth-Hitchcock is now offering an additional pain relief option to help women during labor: nitrous oxide.
Nitrous oxide has been the standard of care for decades in Europe; however, in the U.S., pain relief choices have been limited. Until now, women primarily had two options during labor: opioids delivered through an IV, or an epidural catheter infusing medicine to the nerves of the spinal cord. "Epidurals are great for some women, and extremely safe; so are opioids. But nitrous is the middle ground between the two, and may be all that some women need," explains Benjamin Morley, MD, Director of Obstetric Anesthesia at Dartmouth-Hitchcock.
"The main thing I think a patient will appreciate is that it is under her control," says Suzanne Serat, MSN, CNM, who was instrumental in bringing nitrous oxide to D-H. "It's the only pharmacological thing that affords women that level of empowerment. The woman simply holds the mask to her face and takes the breath when she needs it. We teach her in advance how to use it, but it's patient-controlled analgesia." Morley adds: "The most attractive aspect of nitrous is the rapid onset and offset. It reaches peak effect within a minute, and it's completely gone from the system within a few minutes from the last inhale. Other analgesics that we could offer—like opioids—are in the system for a longer time."
Within a few breaths after stopping nitrous a woman can be fully functional and rational. Unlike an epidural, nitrous does not change the course of the labor or the baby's heartbeat, explains Serat, nor does the baby need to be continually monitored. "I also think women will like that there is nothing invasive about nitrous," says Morley. There are no needles or catheters; a woman only has to hold a mask to her face and breathe. "It gives them a sense of empowerment and control with their labor experience. Other options are being administering to them."
"The use of nitrous as a labor analgesia is relatively uncommon in the U.S.," explains Morley, "but it has a long history of widespread use outside of obstetrics, so we have a lot of experience using it safely." Nitrous oxide is often used as a supplement to general anesthesia in the operating room, and in emergency rooms for potentially painful procedures like IVs for children, says Morley. "It's also used widely for dental procedures," and often called 'laughing gas.'
However, the fragrance-free gas is used differently in obstetrics, explains Serat. "The mixture is 50/50 nitrous and oxygen. That means that women are receiving more oxygen than they would just breathing room air." It was in 2011, that Serat attended a midwifery conference and listened to speaker, Judith Rooks, a major proponent of nitrous use for labor. "I knew after listening to her that it was something that would be beneficial to D-H patients.
"Nitrous oxide had been used for childbirth in the U.S. in the 1940s and 50s, but it fell out of favor when it was incorrectly associated with 'twilight sleep,'" explains Serat. Twilight sleep was entirely different. It was a combination of morphine and scopolamine that "made women amnesic. They often became disinhibited or out of control to the point where they had to be strapped down. It was just not a respectful way to treat people and handle a women's labor. So they moved away from it." Although there was nothing wrong with nitrous, this erroneous association practically eliminated its use in the U.S. Yet, many other countries continue to use it to this day without ill effect. It was only early this year that suitable equipment became available in the U.S. with the appropriate mixture and delivery system for obstetrics use.
Morley and Serat agree it was a "collaborative effort between the departments of Anesthesia and Obstetrics that made offering this option possible." Nitrous oxide use in obstetrics was also quickly sanctioned, and fully supported, by D-H leadership. "It's good for our patients because it gives them more options," says Morley. "We are focused on patient-centered care and empowering patients. This is just one more tool that allows women to decide what's best for them."