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Field Trial of Methoxyflurane, Nitrous Oxide, and Trichloroethylene As Obstetric Analgesics Br Med J: First Published As 10.1136/Bmj.3.5665.263 on 2 August 1969

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Field Trial of Methoxyflurane, Nitrous Oxide, and Trichloroethylene As Obstetric Analgesics Br Med J: First Published As 10.1136/Bmj.3.5665.263 on 2 August 1969 BRITISH 2 August 1969 MEDICAL JOURNAL 263 Field Trial of Methoxyflurane, Nitrous Oxide, and Trichloroethylene as Obstetric Analgesics Br Med J: first published as 10.1136/bmj.3.5665.263 on 2 August 1969. Downloaded from M. ROSEN,* F.F.A. R.C.S.; W. W. MUSHIN,t F.R.C.S., F.F.A. R.C.S.; P. L. JONES, F.F.A. R.C.S.; E. V. JONES§ British Medical Journal, 1969, 3, 263-267 ummary: In a field trial of 1,257 patients receiving Nitrous-oxide/oxygen (50% /50% v.v.) was given by the methoxyflurane, trichloroethylene, and nitrous- Entonox apparatus, trichloroethylene (0-5% and 0 35 % v.v. in oxide/oxygen for the relief of pain in labour methoxy- air) by the Emotril and Tecota vaporizers, and methoxyflurane flurane has been shown to have certain advantages which (0-35% v.v. in air) by a modified Tecota, also known as the support its use in midwifery practice. The trial confirms " Cardiff " inhaler. The calibration of each vaporizer was our objective method for screening an inhalational agent checked before the trial by gas chromatography and again at as an obstetric analgesic. intervals during the trial. The midwives were instructed to use inhalation analgesia in their usual manner. No restrictions were on the use of Introduction placed other drugs such as pethidine. After the trial was completed another questionary was sent Methoxyflurane has been shown by a comparison with by post to each of the participating midwives, in order to get trichloroethylene (Major et al., 1966) and with nitrous oxide a picture of the practical experience of the midwives and of (Jones et al., 1969a, 1969b) to have certain advantages over their final opinions about methoxyflurane. them as an obstetric analgesic. During each of these trials an anaesthetist was present continuously as an assessor. His presence may have affected the results, though it is hoped Results equally for each drug being compared. It is still necessary, therefore, to show whether the differences which emerged from Randomization these trials are still present if methoxyflurane were used in A total of mothers were studied general midwifery practice. In addition it is to 1,257 (Table I). The com- important bined number of determine whether any advantages which methoxyflurane might trichloroethylene and nitrous oxide patients is to have would be sufficient to make the drug especially attractive similar that of methoxyflurane patients, because the mid- for use by midwives. wife was allowed to use either trichloroethylene or nitrous oxide as an alternative to methoxyflurane. The difference in number between nitrous oxide and trichloroethylene is partly due to the Method rearrangement of the trial at the beginning. Trichloroethylene had a slight start over nitrous oxide. A field trial was conducted in eight maternity units in South Wales. The plan was discussed thoroughly with the medical TABLE I.-Distribution of Cases and nursing staff in each hospital before the trial began. The No. of Methoxy-| Trichloro- Nitrous http://www.bmj.com/ trial was carried out under the supervision of a consultant Cases flurane ethylene Oxide anaesthetist in each hospital. Originally it was intended to Total .1,257 598 394 265 compare methoxyflurane and trichloroethylene. Shortly after starting we Multiparae .. .. 703 347 (58%*) 226 (57 5%) 130 (49%/0) the trial felt it desirable to include nitrous oxide Assisted deliveries 144 68 (110%) 46 (11*5%) 30 (11°') because of parallel detailed studies in this department (Jones Caesarean section .. 8 5 (1%) 3 (0-8%) 0 et al., 1969a, 1969b). Furthermore, we sensed that some mid- * The percentages are of each agent. wives were disinclined to use trichloroethylene. The trial was There are significantly fewer multiparae in the nitrous oxide group than in the methoxyflurane group (P < 0-02) or in the trichloroethylene group (P < 0-05). therefore rearranged to compare methoxyflurane with a free choice of either trichloroethylene or nitrous on 30 September 2021 by guest. Protected copyright. oxide. The day The number of multiparae in the nitrous oxide group is on which either methoxyflurane or the choice of nitrous oxide significantly lower than in each of the other two. A detailed or trichloroethylene could be used was randomized on a calendar examination of individual hospital results shows that when this which stood in the labour room. On Sundays the midwife difference is taken into account it does not affect had an open choice of agent. the results of the midwives' assessment of pain relief or restlessness, the The data were entered by the midwife on a self-coding chart mothers' opinion of pain relief, or any of the other results suitably arranged for transference to Hollerith cards. Besides reported in this paper. There is no significant difference recording personal details and data about complications of between the groups as regards mode of delivery and the dura, pregnancy, this dealt with details of the anaesthetic inhaled; tion of the various stages of labour. The primiparae in the other drugs given; the duration of labour and method of methoxyflurane group had shorter first stages than those who delivery; the condition of the baby; the midwife's opinion on had the other agents. the mother's condition during labour; and the mother's opinion Other Drugs (Table II).-Over half of the patients received of the pain relief. The mother was questioned by her midwife pethidine within four hours of the beginning of inhalation, but immediately after delivery and again by the ward sister two days later. there is only a negligible difference between the groups. Of those mothers who had pethidine, 5-7% had had more than Each hospital was visited by us at about weekly intervals, not only to ensure smooth running of the trial but also to TABLE II.-Distribution of Administration of Drugs ensure that the trial was being conducted so far as possible in No a uniform manner. Comments by the midwife were Drugs Pethidine Others noted, Agent Total though special care was taken not to influence these. No. % No. 'IO No. % Methoxyflurane.. .. 238 40 333 56 27 4 598 *Consultant Anaesthetist. Trichloroethylene .. 151 38 228 58 15 4 394 t Professor of Anaesthetics. Nitrous oxide .. .. 87 33 166 63 12 4 265 Research Registrar. Research Fellow. 476 38 727 58 54 4 1,257 Department of Anaesthetics, Royal Infirmary, Cardiff CF2 1SZ. No significant difference between agents. C 264 2 August 1969 Obstetric Analgesics-Rosen et al. MEDICALBRM JOURNALSr 150 mg. within four hours of inhalation. Other drugs such as Midwives' Opinion (Table V).-The midwives considered morphine were given to only a very small number of mothers that more patients who had methoxyfIurane (14%) were excel- Br Med J: first published as 10.1136/bmj.3.5665.263 on 2 August 1969. Downloaded from in each group. lent than were those who had nitrous oxide (7%) (P<001). Duration of Inhalation (Fig. 1).-The duration of inhalation The number considered excellent and good is also significantly of methoxyflurane is shorter than that of nitrous oxide more for methoxyflurane (53%) (P<001) and for trichloro- (P<0 02) and of trichloroethylene (P>03). This relates to the ethylene (49%) (P<002) than for nitrous oxide. shorter first stages of the primiparae in the methoxyflurane group. TABLE V.-Midwives' Opinion of Pain Relief Excellent Good Adequate Inadequ 14 No. % No. % No. % No. mnethox'jflurane 12 Fn trichlorcethylene nitrous oxide 10' Mean du-7-on methoxyflurcrie1 rn n. V0 iP<002 40 8 ni trous oxide ....... 103 4 min. trichloroethylene Nausea and Vomiting -' 97 5 min. 0 Immediately after delivery 23 % of the methoxyflurane patients, 22% of the trichloroethylene patients, and 19% of the nitrous oxide patients said they felt sick. Of these, 7-5% of the 4. methoxyflurane group, 6% of the trichloroethylene group, and 7-5% of the nitrous oxide group vomited. There is no signi- 2 ficant difference between the agents for any of these figures. U j. Duration of inhalction ( hours) Restlessness FIG. 1.-Distribution of duration of inhalation. Midwives' Opinion.-There is no significant difference between the results for the three agents (Table VI). Never- theless, when those who had not had pethidine are considered Pain Relief (Fig. 2) there is significantly less restlessness with methoxy- flurane than with nitrous oxide (P<005). Where pethidine Mothers' Opinion (Table III).-There is no great difference had been given there is no difference between the agents. If between any of the drugs. Thirty-five per cent. of all the the methoxyflurane patients are considered alone, those who the mothers changed their mind at the second questioning, but did not have pethidine were significantly less restless than those http://www.bmj.com/ changes in either direction made little difference to the results. who did (P<0-01). Trichloroethylene patients showed a similar difference (P<O01). Nitrous oxide patients had the TABLE III.-Mothers' Opinion of Pain Relief same degree of restlessness whether pethidine had been given Complete Considerable Slight None or not. Agent .Total No. % No. 1 % No. % No. % TABLE VI.-Midwives' Opinion of Restlessness Methoxy- flurane .. 69 11-5 352 59 154 26 23 3 5 598 Never ShortPeriods Long Periods Trichloro- Total Agent _ on 30 September 2021 by guest. Protected copyright. ethylene 47 12 235 60 98 25 14 3 394 No. % No. % No. % Nitrous oxide 29 11 161 61 66 25 9 3 265 Methoxyflurane .. 242 41 310 52 46 7 598 145 11-51 7*8 59 5 318 25-51 46 3-5 1,257 Trichloroethylene .. 153 39 206 52 35 9 394 Nitrous oxide .. .. 95 36 157 59 13 5 265 No significant difference between agents.
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