Nurse midwife Michelle Barcus demonstrates the use of nitrous oxide.

Nitrous Oxide Another Option for Coping With Labor

By on 09/11/2019

Candace Hager was determined to have her first baby without medications.

She didn’t want intravenous opioids that might make her groggy. And she didn’t like the idea of losing feeling in the lower half of her body, so an epidural injection around the spine was out.

Hager’s mom and sister had managed to deliver without drugs, and she wanted that experience, too.

But somewhere around her 16th hour of labor, with “horrible pain,” she started to waver.

That’s when nurse-midwife Ronni Rothman, CNM, “got a little tough with me, which was a good thing,” Hager recalls. “And she said, ‘You know, this isn’t what you wanted, you didn’t want the medication. We only have a few more hours left.’”

Fortunately, Rothman had another option to offer, one that was brand new for Einstein Medical Center Montgomery: nitrous oxide, the same short-term, relaxing gas that’s used by many dentists. Einstein is one of only three hospitals in the area that offer it.

Not Laughing, But Relaxed

Nitrous oxide, sometimes called “laughing gas,” doesn’t affect the baby. It doesn’t numb a woman’s body or make her sleepy. It just helps her relax.

It turned out that was just what Hager needed.

“So they brought in the machine,” she says. “They explained to me that I basically administer it myself. And then with each contraction I would breathe into the mask that I put over my mouth and nose. I would breathe in through the contraction.

“About an hour into it I was feeling a little bit calmer. I wouldn’t say it helped with the pain at all, but it helped me stay focused. It helps with your mental state to a point where you can power through the pain and make it a little bit more manageable.”

About three hours later, Haydn (pronounced Hay-den) was born. And like most mothers, Hager promptly forgot about all that pain to marvel at her new baby son.

Low-Risk and Low-Tech

And that’s just the kind of result that Einstein Montgomery nurse-midwife Michelle Barcus, CNM, was aiming for when she applied in 2018 for a grant from the Albert Einstein Society. This organization funds innovative projects in the Einstein Healthcare Network.

“I was looking for something else for first-off options for birth and birth pain management for patients, things that are low-risk and low-tech that aren’t going to have such huge significant impacts on the patient or baby,” she says.

 “Nitrous oxide has been widely used throughout Europe and Australia and New Zealand, for years and years and years,” Barcus says. “It fell out of favor in the U.S. in the ’70s when the epidural came about as a different form of pain relief.”

“Nitrous oxide gas helps to decrease anxiety and helps kind of create the sense of euphoria and calm,” Barcus says. “And so by doing that, it helps to improve coping through the contractions. You know, pain is very subjective. There is this component of anxiety and fear that leads to greater pain. So if you can decrease some of that fear-anxiety-pain cycle, you can help improve pain outcomes.”

Alternative to an Epidural

An epidural, the form of pain relief during labor most widely used in the United States, is a type of regional anesthesia, numbing the body from the waist down. It is administered with a needle into the space around the spinal cord.

An epidural is generally very safe, but it can cause a sudden, temporary drop in the mother’s blood pressure that can slow down the baby’s heart rate, Barcus says. It also requires the woman to stay in bed while in labor.

“While epidurals have been really useful and revolutionized pain management in labor, there is a place for the nitrous gas where some folks don’t want something as invasive as an epidural, and they want something sort of middle of the road,” she says.

 “We appreciated the versatility of using nitrous oxide in labor compared to traditional IV medications and epidurals,” says Cheung Kim, MD, MPH, Chief of Obstetrics and Gynecology at Einstein Medical Center Montgomery. “Nitrous is a great option in most situations.”  

Only Short-Term Effects

Unlike other drugs used in labor, nitrous oxide leaves the body quickly. “It takes 45 seconds to a minute to really just blow off,” Barcus says. “All you have to do is just take a nice deep breath of regular old room air and you exhale nitrous oxide. So it doesn’t have long-term effects on the fetus or the newborn baby. You can really use it right up through delivery without any adverse effects to the baby.”

The grant from the Albert Einstein Society allowed Einstein Montgomery to buy equipment for the nitrous program, including the nitrous oxide gas, oxygen, a blender machine to mix them, masks, hoses and adapters. After receiving all approvals, the program was introduced in December. Since then, more than 100 women have used it during labor, Barcus says.

The introduction of nitrous oxide “aligned seamlessly with our goals of providing a low-intervention and safe labor experience for our patients, and contributes to our low cesarean and high satisfaction rates.” Dr. Kim says. “The successful implementation of nitrous oxide at Einstein Montgomery was due to the engagement of the nurses, midwives and doctors.”

Plans for Philadelphia Campus

Nitrous oxide currently is available only at the Montgomery campus. However, Einstein Medical Center Philadelphia plans to introduce it as a pilot project in October, says David Jaspan, DO, Chairman of Obstetrics and Gynecology for Einstein Healthcare Network.

Hager apparently was the first patient to use nitrous at Montgomery. “My nurse manager knew that I was totally excited about it,” Rothman says, “and she came running over to me and said, ‘We got the [approval] form and you have everything set now. Is your patient interested in nitrous?’ And I said, ‘Yeah, she totally talked about wanting to do it.’”

Rothman explained that there could be some side effects, such as a headache or lightheadedness after using it, but Hager wanted to go ahead. As it turned out, she had no side effects. Hager says she stopped using nitrous when it was time to push, which lasted about two hours.

The later stages of labor are a great time to use nitrous oxide, says Rothman, part of a private practice of three midwives who deliver babies at Einstein Montgomery.

In the first six months after the program started, “our practice probably has used it maybe 15 times,” she says. “My general thought is that it works best for people who have had babies before and are handling everything pretty well and then right around transition time they hit that really hard stage where everybody starts to panic and think, ‘I can’t do it,’ when your cervix is seven or eight centimeters dilated,” not quite enough for the baby to come through.

Reducing Anxiety in Late Labor

By that point, Rothman says, the nurse-midwives will have tried a variety of things, such as having the woman take a shower, to help her relax and power through the last stages of labor.

For women who don’t want an epidural, nitrous “works best for them to decrease anxiety and help them get through that little last bit, which is pretty short for them,” she says. “It’s going to be an hour long probably. We’ve had really good success with that.”

Nitrous oxide also allows women to be alert and to move around during labor, Barcus says. This can help to reduce the chances that labor will stall or the baby will poorly positioned for birth. Either of these problems can lead to cesarean section instead of a vaginal birth.

Einstein Philadelphia and Einstein Montgomery are both part of an American College of Nurse Midwives program that employs a variety of strategies to reduce C-sections.

Nitrous oxide is one of many ways to reduce anxiety and help labor, Barcus says. “Anxiety and fear is a powerful drug internally. It releases high cortisol levels, which can inhibit labor.

“If we can optimize how Mom is coping, keep her as relaxed as possible, help her actively participate in managing her pain through position changes and activity, then hopefully that’ll decrease the C-section rate.”

It worked for Hager, who has nothing but praise for her birth experience with nitrous oxide.

“It is a drug, but if you’re looking to have an unmedicated birth – and I mean no epidural, no narcotics – I recommend it,” she says. “It helps you focus through the pain and manage it. I would definitely recommend it.”

Learn more about Einstein obstetrics and gynecology services.

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