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Nitrous Oxide for the Management of Labor Pain Executive Summary

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Nitrous Oxide for the Management of Labor Pain Executive Summary Comparative Effectiveness Review Number 67 Effective Health Care Program Nitrous Oxide for the Management of Labor Pain Executive Summary Background Effective Health Care Program More than 4 million births occur in The Effective Health Care Program the United States each year; in 2008, was initiated in 2005 to provide valid there were 4,247,694 births.1 The most evidence about the comparative commonly used labor pain management effectiveness of different medical method in the United States is epidural interventions. The object is to help analgesia (hereafter epidural).2 Use of consumers, health care providers, and inhaled nitrous oxide is a common option others in making informed choices for labor pain management in several among treatment alternatives. Through countries outside the United States, its Comparative Effectiveness Reviews, including the United Kingdom, Finland, the program supports systematic Sweden, Canada, Australia, and New appraisals of existing scientific Zealand. Only five centers in the United evidence regarding treatments for States are known to currently provide high-priority health conditions. It nitrous oxide as an option for labor pain also promotes and generates new management: the Birth Center at the scientific evidence by identifying gaps University of California San Francisco in existing scientific evidence and Medical Center; the University of supporting new research. The program Washington Hospital in Seattle; St. Joseph puts special emphasis on translating Regional Medical Center in Lewiston, ID; findings into a variety of useful Okanogan Douglas Hospital in Brewster, formats for different stakeholders, WA; and Vanderbilt University Medical including consumers. Center in Nashville, TN (which began offering nitrous oxide in June 2011 after The full report and this summary are this review was under way). A significant available at www.effectivehealthcare. barrier to use in the United States is ahrq.gov/reports/final.cfm. limited availability of equipment to blend and deliver a mixture of nitrous oxide and oxygen for self-administration by laboring Nitrous oxide, sometimes called “laughing women. gas” because it can produce euphoria, is Effective Health Care 1 an inhalational anesthetic and analgesic gas. Nitrous oxide stimuli via descending spinal cord nerve pathways. Nitrous has been used in dental care since the mid-1800s3 and is oxide does not completely relieve the pain of labor but commonly used for this indication today. Use of nitrous creates “diminished pain, or a continued awareness of pain oxide during labor began in the late 1800s, and equipment without feeling bothered by it.”5 Nitrous oxide also has an for self-administration was introduced by Minnitt in antianxiety effect, which may be helpful if laboring women England in 1934.4 are restless and doubt their ability to cope, emotions that The mechanism of action of nitrous oxide is thought to be are not uncommon, especially during transition (see an increased release of endorphin, dopamine, and other Figure A for an overview of the stages of labor). natural pain relievers in the brain, which modulate pain Figure A. Stages of labor First Stage • Uterine contractions cause dilation Second Stage (opening) and effacement (thinning) Third Stage • Begins when cervix is of the cervix • Begins when the baby is born completely dilated (10 cm) and and ends with delivery of the • Often divided into early labor (0 to ends with the birth of the baby 4 cm dilation), active labor (4 to 8 placenta • Uterine contractions continue cm dilation), and transition (8 to 10 • Uterus contracts • Woman pushes to help the fetus cm dilation) • Woman may need to push to move down and out of the birth • Contraction frequency, duration, assist removal of the placenta canal and intensity increases as first stage progresses The most common concentration of nitrous oxide Although nitrous oxide would not be expected to be administration for labor pain management in the as effective for analgesia as an epidural because of the biomedical literature and in current clinical practice is differences in their mechanism of action, nitrous oxide has 50 percent nitrous oxide in oxygen, which can be mixed other benefits, including its lower cost and less invasive from two separate gas sources with a blender device nature. Nitrous oxide has a rapid onset and end of action. (e.g., Nitronox®) or premixed in a single cylinder (e.g., Thus women who do not like nitrous oxide or find it Entonox®). Nitrous oxide is usually self-administered inadequate for pain management can easily discontinue via a facemask or mouthpiece on an intermittent basis, its use and switch to another method, unlike epidurals and beginning about 30 to 60 seconds before each contraction.6 systemic opioids, which diminish gradually over a much A variety of pain management methods were described longer period. Mobility and options for positioning are in studies in this review (Table A). Epidural analgesia not limited and nitrous oxide does not require additional is the most commonly used method in the United States monitoring and potential anesthesia-related interventions and may block pain entirely. Although epidurals are more (e.g., bladder catheterization). Women self-administer nitrous oxide, which allows them to control the amount effective for pain relief than other pain management 8 methods, epidurals are associated with increased risk of they need. Nitrous oxide may not be an ideal method assisted (vacuum or forceps) vaginal birth, use of oxytocin, for women who want maximum pain relief, but it could maternal hypotension, motor blockade, urinary retention, be preferable to other pharmacologic pain management maternal fever, and cesarean for maternal distress.7 Women methods for women who want increased mobility with who have epidurals must have additional monitoring and less intervention and monitoring. Nitrous oxide might also may need confinement to bed, which limits mobility and be useful when a woman wants to delay use of epidural options for positioning, and placement of a Foley catheter. anesthesia until later in labor, when epidural anesthesia is not immediately available (e.g., in hospitals that do not have in-house anesthesia staff and must call in an 2 anesthesia provider), when a woman arrives at the hospital others present for labor. Equipment capable of scavenging too far along in labor to allow for an epidural to be placed provides constant negative pressure so that the woman’s and take effect, and when a woman finds epidural analgesia exhalations, which contain nitrous oxide, are captured and ineffective or inadequate. removed from the room and facility.6 One concern with nitrous oxide use is the potential for the Finding the appropriate measure of effectiveness on gas to escape into the room and potentially affect health which to assess nitrous oxide with other pain management care workers as well as other individuals present with methods is challenging. Nitrous oxide is not intended to laboring women. For this reason, multiple organizations provide the extent of pain relief expected with epidural. are responsible for regulating the use of nitrous oxide, Therefore, rather than a direct comparison of effectiveness, and factors other than clinical outcomes are important the more important questions are whether women are to decisionmaking about its use (Appendix F). Room satisfied with the use of nitrous oxide for labor pain ventilation systems and scavenging systems that remove management and if it is safe for the woman and her fetus/ waste gases are used to reduce exposure to caregivers and newborn. Table A. Labor pain management methods used in studies included in this review Timing and Frequency of Method Description Administration Nitrous oxide • Anesthetic and analgesic gas usually • Can be used for first- and second-stage inhaled intermittently via a facemask or labor pain mouthpiece, can be given continuously • Self-administered between and/or during via nasal cannula contractions • Reduces the perception of pain, alters • May be continued into third stage if consciousness, decreases anxiety procedures, such as perineal repair or manual removal of the placenta, are needed Other inhalational anesthetic gases • Anesthetic gas usually inhaled • None is used currently used for (desflurane, sevoflurane, isoflurane, intermittently via a facemask or management of labor pain in the United enflurane, methoxyflurane, mouthpiece, can be given continuously States trichloroethylene, cyclopropane) via nasal cannula • Desflurane, sevoflurane, and isoflurane • Reduces the perception of pain, alters are used for other types of anesthesia in consciousness the United States Epidural • Injection of medications (usually a • Initiated during first stage of labor with combination of local anesthetic and infusion usually continuing into second opioid) into the epidural space around stage the spinal cord • May be continued into third stage if • Blocks pain in lower half of body procedures, such as perineal repair or May partially or fully block voluntary manual removal of the placenta, are motor control in lower half of body needed Opioids (for example, pethidine/ • Medication given intravenously or by • Used during the first stage of labor meperidine) intramuscular injection Administered at regular intervals as • Provides some relief of labor pain and needed for pain (usually every 1 to 4 causes sedation, which can also alter hours depending on specific medication) perception of pain • Opioids commonly
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