Expanded Discussion of Nitrous Oxide for Labor Pain Relief

By Rachel Walden |

Last week’s post questioning why nitrous oxide isn’t more widely available to women in labor generated a lot of discussion, so we’ve decided to dedicate today’s post to exploring the issue further.

One commenter posted a response from her anesthesiologist friend, who discussed his concerns about the safety of nitrous oxide for both the laboring woman and other people in the room exposed to the gas. After reading the anesthesiologist’s concerns, Judith Rooks, a nurse-midwife, epidemiologist, and Our Bodies, Ourselves contributor, felt compelled to respond. She sent us a long, detailed email breaking down his concerns one by one, and addressing what she believes is misinformation about what is known about nitrous oxide and the risks of epidurals. We’ve decided to post the entire email here (with permission). The original comments are posted in bold, with Judith’s response immediately following.

“Nitrous oxide in trace amounts is considered a biological hazard. It must be scavenged, which is difficult to impossible for someone who has just been taught to self-administer while in labor.”

Yes, nitrous oxide (N2O) is a biological hazard, but not all biological hazards are equal. Nitrous oxide is produced by trees, among other sources, so some of it is a natural part of our environment. I mention this just so that no one thinks it is like Sarin, e.g., which is a very deadly gas even in minute quantities. N2O has been used as a component of anesthesia for more than a hundred years, and as an analgesic for women during labor for nearly a hundred years. It is the most widely used labor analgesic in the UK, Sweden, Finland, and many other countries. It is also widely used for analgesia during dentistry in this and other countries. American dentists find it particularly useful for children, and it is often used by pediatricians during necessary procedures on children.

Like all effective drugs, N2O can have ill effects, but only as a result of large doses, with dose being the product of three factors: (1) concentration, (2) duration of exposure, and (3) time for restitution between episodes of intermittent exposure. For instance, it can affect vitamin B12 metabolism resulting in health problems due to impaired cell division. But, because the effect is dose-dependent, problems are usually associated with chronic recreational abuse (addiction to recreational use of N2O) or inborn vitamin B-deficiency disorders. Healthy women using 50/50 mix of N2O & O2 during contractions are not at risk of this effect.

But it was thought to increase the incidence of infertility and spontaneous abortions among female physicians, dentists, midwives, dental hygienists and nurses exposed to N2O that leaked or was exhaled into the ambient air by patients who were using N2O. The anesthesiologist referred to a 1970s study of its effects on dental assistants. In this case, the high dose was due to prolonged and repetitive exposure to low doses. This problem has been addressed by anesthesiologists, other physicians and dentists, as well as by the National Occupational Safety and Health Agency (OSHA) by mandating the N2O only be used in well ventilated buildings (virtually all US hospitals meet this requirement) and use of scavenging equipment, which sucks nitrous oxide that is exhaled by the patient back into the equipment. (For more information, see the American Academy of Pediatric Dentistry’s policy on minimizing occupational health hazards associated with use of N2O, an American Society for Anesthesiology newsletter that reports their findings regarding occupational risk from trance anesthetic gases, and the OSHA guidelines for use of N2O .)

In 2002 Dr. Mark Rosen, an obstetric anesthesiologist at the University of California in San Francisco published an extensive review of the risks, benefits and effectiveness of nitrous oxide for analgesia during labor. The following is a quote from that paper:

“Some have suggested that occupational exposure of healthcare workers (nurses, midwives, etc.) to nitrous oxide for labor analgesia renders it an unsafe or unfeasible technique. Although the actual risks associated with occupational exposure to nitrous oxide are not precisely known, there is a very low or nonexistent causal effect of exposure to nitrous oxide or isoflurane and mutagenic, teratogenic or carcinogenic effects (62). Epidemiological studies performed in the 1970s suggested that trace levels of waste anesthetic gases, as found in operating rooms, delivery rooms, and dentist offices were hazardous. These studies were retrospective, mail questionnaire designed studies that did not provide quantitative information about exposure, or verify adverse outcome. Further, a meta-analysis of those studies concluded that they did not establish the alleged association (63), and because the studies were inconclusive about outcome and waste gas levels, they could not be used as the basis for setting occupational health standards. Further, the studies that had suggested an association were conducted before scavenging excess gas was a common practice. On the labor ward, excess gas scavenging reduces pollution to recommended limits in the majority of cases (64, 65). Health care workers in labor rooms without scavenging systems are at risk for excessive occupational exposure (66). In the U.S., hospital rooms are well ventilated and Nitronox machines have an active scavenging device.” (Rosen MA. Nitrous oxide for relief of labor pain: A systematic review. Am J Obstet Gynecol 2002;186:S110–126.)

 

 

“There is a tremendous abuse potential for N20, and perhaps other countries do not seek to control access, but the US does. Dentists often abuse N2O, resulting in neuropathy. N2O cylinders sitting around would be likely to be abused.”

There is potential for abuse of N2O in hospitals, just as there is potential (and actual) abuse of almost all drugs that are used for pain abatement. But N2O canisters are not just sitting around in those hospitals in which it is used. (FYI, it is used not only in surgery and labor, but in many emergency rooms, and in many women’s health care centers, where it is used during procedures.) Hospitals have to control many substances, including blood, bacterial contamination, radio-active substances, and all pain medication, among others. No US hospital would just let any of those materials “sit around” without control. Nitrous oxide is not, however, the substance which provides the biggest risk of abuse in the US, and to the extent that N2O is abused, there are many sources easier to access than a hospital. Canisters of it have traditionally been thrown from floats during Mardi Gras parades, and somehow or other, teenagers seem to be able to get it for getting happy (it’s called “laughing gas”, after all) during rock concerts. It is also sold in every can of fake whipped cream; push the button and the fake cream gets fluffed up by N2O. Some tattoo parlors also use it. The possibility of abuse is not an acceptable reason to fail to provide a service or product that is needed for serious purposes.

“Nitrous can be administered in a “safe” 50% mixture with O2, but the results can be highly variable and are unpredictable. Some patients get little relief, while the same inhaled concentration could render others unconscious.”

Dr. Rosen described it as “safe for parturient women, their newborns, and health-care workers in attendance during its administration.” He has provided it to women during labor for more than 30 years and has never seen either a woman or a baby be harmed as a result. It is true, however, that the effectiveness of nitrous oxide analgesia is unpredictable. Although about two-thirds of women find it to be effective “enough” and are satisfied, a few women report that it was not helpful. A consumer oriented book co-authored by Dr. William R. Camann, Director of Obstetric Anesthesia at Brigham and Women’s Hospital in Boston and a past president of the Society for Obstetric Anesthesia and Perinatology (Easy Labor: Every Woman’s Guide to Choosing Less Pain and More Joy during Childbirth. New York: Ballantine Books; 2007) noted that “The gas can cause nausea and vomiting in some women” and that “Very rarely, if too much gas is inhaled, it can result in a loss of consciousness.” But that does not happen if the rule of self-administration is followed, as it would be in any setting that provides careful care to women during labor. As Dr. Camann noted, “The mask will not be attached to you while you inhale the gas. This is intentional and will prevent you from inhaling too much gas at once. If you become too drowsy as a result of the gas, you will no longer be able to hold the mask or mouthpiece to your face.” He also noted that there are no known clinical side effects to impact the newborn.

 

Dr. Camann described the effectiveness as “a kind of strange sensation of feeling the pain while at the same time feeling a sense of bliss. So, the pain may still exist for some women, but the gas may create a feeling of: “Painful contraction? Who cares?!”

“Disinhibition regularly occurs (it was described in the demonstration that gave W.T.G. Morton, one of the founders of surgical anesthesia, the idea) and can lead to dangerous behavior, such as excitation and pulling out IVs. People can have amnesia from N2O; while receiving it they can be screaming in pain, but later not remember.”

Nitous oxide used to be used in much higher concentrations—70 or 80% or even more, compared to just 50% now, so Dr. Morton was responding to something very different from modern day use of a 50/50 standardized ratio of N2O versus oxygen. This anesthesiologist may also be confused between the disinhibition that was associated with “twilight sleep” and other mixtures of drugs including scopolamine, which were still being used when I was a nursing student at the University of Washington in the very early 1960s. Screaming, swearing women were being tied to their beds in disgraceful and humiliating states of disinhibition. I got to know Dr. John Bonica, one of the giants of anesthesia, while I was there. He was a wonderful man. Perhaps he invented obstetric spinals and epidurals in response to the terrible conditions during labor in most American hospitals at that time. But this does not occur with a 50/50 mixture of N2O and oxygen when the rule of self-administration is followed. The anesthesiologist’s statement seems more consistent with the effects of “twilight sleep”, which caused women to have no memories of giving birth.

“The patients and nurses at my hospital would not accept what N2O has to offer.”

With all due respect, I wonder if any one person can really speak for all of the nurses and patients at any hospital, especially if they had access to unbiased information and were able to observe and talk with women using nitrous oxide during labor. Epidurals are very popular and appreciated by many, indeed probably most women giving birth in the US, and I am grateful that most women who want an epidural can have one. But some women don’t want an epidural, and they should be offered a safe and reasonably effective alternative. I doubt that women who give birth in the hospital in which this anesthesiologist practices are offered an alternative. If N2O were offered, I doubt that most women would choose it. But a few would, especially after they learned more about it and after it had been used by a few other women in that community. Nitrous oxide is widely used and appreciated by women in many other countries—including countries in which medical science and care are at least as advanced, if not more so, than in the U.S. Virtually all of these countries have better pregnancy outcomes than we do.

My interest in expanding access to N2O as an analgesic for women during labor in the US is not for the purpose of diminishing use of epidurals. There will always be a big, important place for epidurals during labor. But not every woman wants the same thing, and nitrous oxide has some benefits and characteristics that make it very attractive to some women:

  • Because the laboring woman administers N2O to herself, she has complete control over the frequency and dose used, when it is started, and when it is put away. This gives her a sense of control over herself and over her pain.
  • N2O enters the woman’s body quickly through her lungs. Pain relief begins in one minute or less. If N2O equipment is available in the room—as it is in almost every hospital in the United Kingdom (UK), Sweden, Finland, Australia, Israel, etc., nitrous oxide can be started easily and simply and become effective in a minute. There is no need to call and then wait for an anesthesiologist or nurse anesthetist and set up for and conduct a sterile invasive procedure.
  • It is eliminated just as quickly, also through her lungs. Women who use nitrous oxide during labor can pick it up and put it down—start and stop at will. A woman who needs help during a particularly intense part of labor can start it when she needs it but stop the effect completely in order to experience and participate fully in the act of giving birth. A couple breaths of room air and the effect is gone.
  • The ease and quickness with which N2O can be started is an important benefit when an emergency that requires a painful procedure occurs, such as the need for forceps.
  • Nitrous oxide may make it possible for women who do not want an epidural or narcotics to manage their labor pain so that they can achieve their goal.
  • N2O may help women endure the period between when they ask for and when they receive an epidural.
  • Because N2O doesn’t cause complications that affect the woman’s vital functions, it’s not necessary to use continuous electronic fetal monitoring or start an IV. It doesn’t interfere with her ability to walk or control her bladder; she can get up and walk to the bathroom. Since there’s no tube leading from her back into tissue near her spinal cord, she can take a bath without danger of infection. Hospital maternity units and freestanding birth centers in the UK have portable nitrous oxide equipment that women use while relaxing in a bath.
  • Dr. J. Whitridge Williams, who was one of the leading obstetricians in the US during the early nineteen hundreds, headed the department of obstetrics at Johns Hopkins and wrote the most influential obstetrics text book—Williams’ Obstetrics—praised nitrous oxide because it doesn’t diminish the force of contractions or have any other negative impacts on the physiology of labor.

None of these attributes is true of epidurals. Women often have to wait before an epidural can be started.

Once an epidural has been placed, it is pretty much on board for the duration of the labor. A woman who really only needed help during a specific phase of labor, has to wait for the epidural to “wear off.”

Most women who have had an epidural are not able (or allowed) to get out of bed. They will have to use bedpans, and many of them cannot urinate spontaneously and therefore need to have a catheter placed in their bladder.

Women who have epidurals are at increased risk of a number of complications and therefore need to be monitored more closely than is necessary for women who don’t have epidurals. They can expect to have an IV, not be allowed to eat, have continuous electronic fetal monitoring, et cetera.

Although very rare, some very serious—even disastrous—complications can occur due to trauma, bleeding or infection at the site of an epidural. Deaths are exceedingly rare, but have occurred.

One to three percent of women who have epidurals during labor experience intense post-dural-puncture headaches during the postpartum period. Although these headaches can be effectively treated with another procedure, they occur during a precious period of time during which women want to be able to spend concentrated time breastfeeding and bonding with their newborn.

 

Epidurals do affect the physiology of labor, decreasing the effectiveness of contractions, relaxing the muscles of the pelvic floor, and—due to lack of sensory feedback to the woman—making it difficult or impossible for the woman to use positioning and purposeful efforts of her voluntary muscles to augment the efforts of her body that are not under her control. In most cases it’s necessary to give a lot of Pitocin, but even then, labor is usually somewhat longer. Relaxation of the muscles of the pelvic floor seem to make it harder for the baby’s head to rotate into the optimal position for birth (Liebermann E, Davidson K, Lee-Parritz A, Shearer E. Changes in fetal position during labor and their association with epidural analgesia. Obstet Gynecol 2005;105-974-82), increasing the proportion of babies who need either a cesarean section or use of forceps or vacuum to achieve a vaginal birth The rate of spontaneous vaginal births is significantly lower for nulliparous women who have an epidural during labor (Lieberman I, O’Donoghue C. Unintended effects of epidural analgesia during labor: A systematic review. Am J Obstet Gynecol 2002;186:S31–68.) The only two alternatives to a spontaneous vaginal birth are an operative vaginal birth or a cesarean delivery. Operative vaginal births are responsible for increased rates of many serious complications for both the mother and the baby, including, for the mother, a high incidence of lacerations that extend from the vagina to the anus or even into the rectum. Either alternative to a spontaneous vaginal birth is something to avoid.

“A properly done labor epidural allows the mother to be fully sentient with well controlled pain and the ability to cooperate.”

Properly administered and monitored use of N2O also allows the mother to be fully sentient. Although the effectiveness of nitrous oxide is variable and less than the effectiveness of epidurals, it is effective enough for about 2/3rds of the women who try it. Some women do not want complete obliteration of their pain. “The experience of labor pain is . . . complex, subjective, multidimensional” and “occurs in the context of an individual woman’s physiology and psychology, and the sociology of the culture surrounding her. That culture . . . includes the beliefs, mores and standards of her family and community.” (Lowe, NK. The nature of labor pain. Am J Obstet Gynecol 2002;186(5):S16–24.)

 

Women who have been using N2O during labor but have not had an epidural are better able to cooperate if they need to change their position in order to facilitate a maneuver during, for instance, an unanticipated vaginal breech birth.

“N2O has some analgesic properties, but they only come with a clouding of the sensorium and risks such as combativeness, loss of consciousness, and pulmonary aspiration.”

I don’t know where the idea about combativeness comes from. If the rule of self-administration is followed, a woman who was getting too drowsy would stop pushing the button to keep the gas turned on and let her hand fall away from her face before she would lose consciousness. This extreme example might have happened some time in the past, when higher concentrations were used, scavenging wasn’t used, and the rule of self-administration was not adhered to. I won’t bother to give extreme examples of damage and deaths caused by epidurals, except to say that they happen but are rare.

A couple of years ago I exchanged emails with the chief of obstetrics at a well-respected university hospital that stopped offering nitrous oxide to women during labor during the early 1990s. The main people providing nitrous oxide to women during labor at that hospital at that time were midwives. There had been a very high level of patient satisfaction among women who chose this method of analgesia, and the midwives knew of no complications associated with use of nitrous oxide during the years it had been used at this hospital. When this option was withdrawn, some women who had used it during a previous birth and returned to the hospital for their next birth were shocked and disturbed to find out that it was no longer available and made their feelings known. One woman was so angry and adamant that the chief of obstetrics finally let her labor in a cesarean section room, which had piped in nitrous oxide.

 

When I asked him why he had removed the N2O equipment and banned its further use for women during labor in that hospital, he gave several reasons, including advice from the Obstetric Anesthesia Service, liability concerns from institutional leadership, and “a few scary anecdotal stories”. In fact, however, he had never seen a bad outcome associated with use of nitrous oxide, although he’d heard a story about a woman whose husband strapped the mask to her face and she vomited and aspirated some of the vomit. He didn’t recall the source of the story. I, in contrast, personally knew a midwife who had seen a woman almost die from an epidural. He’d heard a rumor about something bad that might have happened; if so, it was the result of poor practice. Bad things do happen when hospital staff do not provide a high standard of care. In addition, bad things happen as a result of unnecessary cesareans and operative vaginal deliveries even when they are performed correctly, and epidurals result in increased need to use one or the other of those means to achieve delivery.

“If one wants analgesia free of risks of inhaled vapors, one can use injections of demerol, morphine, etc. These make the baby a little sleepier, but not critically so unless used in large and repeated doses.”

I think that this anesthesiologist is unduly worried about occupational risks that have been dealt with and require only proper equipment and diligence, and that he is reacting to protect or create the work environment that he prefers, without consideration for offering any choices to women. Our Bodies Ourselves is and has always been committed to providing women with the fullest, most accurate information possible so as to empower and enable them to make knowledgeable choices.

Most women’s natural inclination is to avoid unnecessary pain, so epidurals are very popular. Epidurals are an excellent method for many women—not only the best method, but truly essential for some. But this is America! Some women, relatively few but some, really don’t want an epidural. They should be offered an alternative that does not depress the newborn’s respirations and can be used right up to and during the actual birth, if that is what the woman wants. Nitrous oxide is a safe, inexpensive, simple to use, reasonably effective labor analgesic that is widely used by women in many other countries but was arbitrarily withdrawn from use in all but two West Coast academic hospitals when anesthesiologists began to offer obstetric epidurals.

Now epidurals are so popular that anesthesiologists and nurse anesthetists are having to really stretch to provide them and cannot provide 24 hour/7-day-a-week coverage for every hospital in the country. This relative shortage is likely to get worse as baby-boomer doctors and nurses retire and the number of babies born in the U.S. continues to rise. The situation is worst in rural areas. The number of births to white women who are not Hispanic is slowly declining, while the number of births to Hispanic women and women of all races other than white are increasing. We all like to eat, and it is important for any civilized country to be able to provide proper maternity care to women who live in the parts of the country that produce our food. Anesthesiologists should be more concerned that all women have access to safe and reasonably effective pain relief during labor instead of disdaining a safe and reasonably effective method of analgesia that they perceive to be less good than the one that they alone can provide.

Epidurals are not only popular among women, they are also popular among many anesthesiologists, obstetricians, family physicians, nurses, and midwives. Taking care of a woman who is experiencing labor without an epidural, even if the edge has been taken off of her pain, is very different from taking care of a woman who may not be in any pain and is chatting calmly or watching TV. Women who have epidurals during labor are at risk for a number of serious complications, have to be monitored more closely than women having normal labor, need a lot of treatments, and may need some kind of emergency response. But for the most part these are technical aspects of care—not the much more intimate and intensive kind of care required by a woman who is much more thoroughly engaged with giving birth. Once doctors and nurses—and even midwives—get used to a quiet labor unit, with all or virtually all of the women on epidurals, the whole ambience of the unit and flow of the work change, and they may not want to work with women who don’t have an epidural.

But there are some serious ethical issues in this scenario. One is the quality of informed consent obtained for epidurals. Few women are told the whole story about the risks. In addition, women in most hospitals are not offered any really viable alternative to an epidural. Having a baby is not like having an appendectomy. In a study in which a researcher asked women in a nursing home to describe the single day that they remember most strongly as a very important and memorable day, most of them remembered the experience of giving birth (Simkin P. Just another day in a woman’s life? Women’s long-term perceptions of their first birth experience. Part I. Birth 1991; 18:203-10). Giving birth is an important event in women’s lives; they deserve some choices. Is it ethical to not even offer another way to help them cope with pain? If a safe, simple, inexpensive, reasonably effective method that is used and appreciated by the majority of women in many other countries is shut out of almost all hospital completely, then women aren’t even offered a choice. And the decisions that result in that lack of choice are driven by factors that have nothing to do with safety.

 

Is that ethical? And is that what we are willing to accept as the standard for maternity care in the USA?

Our thanks go to Judith for furthering this discussion.

Update: Judith requested that that we make several small corrections; the changes were made on May 16.

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26 Comments

  1. Deanne Williams says:

    Thank you Judith and thank you OBOS for providing this information. It will no doubt come as a shock to many well meaning anesthesiologists and nurses who do not have access to current information on this topic. It is painful to realize that US medical schools do not teach accurate information and to worry that information is being withheld or altered in order to promote the staus quo or to fulfill profit motives. Hoefully Judith’s work will bring informed conversation about nitrous oxide back and women will have more options.

  2. Lisa Caruolo says:

    I am 27 weeks pregnant and am making my birthing plan. This is my 6th pregnancy and I have experienced quite wonderful births. Painful yet pleasant… I had epidurals for two of my labors and in two of my labors I was given something IV, I cannot remember what it is called, that helped eleviate pain and somewhat was sedating. Both of those deliveries were preterm and my babies were taken and rushed to Children’s Hospital for respiratory distress. I have not been able to get the idea out of my mind that the medication was the cause – however they were early – 36 and 35 weeks.

    I do not want another edipural since they tended to slow down contractions and inhibit labor – was fully dialated with NO contractions for several hours – and also had the feeling I had no control. Some pain for me is needed so I can push through it and use it as a focal point.

    I’ve been frantically searching for alternatives and I hope the use of N2O is something my OBGYN is on board with.

    I would like to learn more about the RISKS involved in using N2O so that I might be able to have a clear cut BENEFITS/RISKS in front of me so that I can make the best decision possible. Any other information you might have would be greatly appreciated.

    Sincerely,

    Lisa Caruolo

  3. Judith Rooks says:

    Dear Lisa,

    It sounds to me that nitrous oxide would be the perfect analgesic for you. Nitrous oxide is a gas. It is mixed half and half with pure oxygen and provided to a women during labor through a mask or tube that she holds and controls. She breathes it in when she needs some help during a painful contraction–or during the birth itself, but stops when the pain has eased. The laboring woman has complete control of when and how much she uses. If she doesn’t like the effect, she can stop and the affect on her perception of pain stops almost immediately. Many women like yourself, who feel that they push better with some degree of pain, use it until they feel the urge to push, and then put it down and concentrate on pushing. Some other experienced women (like yourself), have very fast 2nd-stages of labor (the pushing part); when the “expulsion” phase of labor is very fast, it can be very painful. So some women don’t even start using it until then. Every woman’s labor is different, and every woman has unique needs related to the pain she experiences during labor and her attitude and concerns about use of analgesia. (Drugs administered intravenously, as you had for two of your births, do cross the placenta and affect the fetus. When those drugs are used, it is not unusual for the newborn to have respiratory problems.)

    Nitrous oxide becomes effective (not as effective as an epidural, but effective enough for most women) in less than a minute after the woman starts to use it and is completely gone from her body–and the body of her baby–within a couple of minutes after she stops using it. Two-thirds of the women who give birth in the UK and almost all women who give birth in Sweden (as well as many other countries) use it, and no baby or mother has been harmed by nitrous oxide as it is currently being used by millions of women in Canada, Europe, Israel, Australia, etc. Any stories about complications related to use of nitrous oxide during labor originated from incidents that occurred many, many years ago, when it was used in much higher concentrations than are used today. I have talked with obstetricians who are leery of it because they heard a story about a woman vomiting and inhaling the vomit under the influence of nitrous oxide. When I hear such a story I always ask the doctor about his (usually) personal experience with it, and although many older obstetricians who are still practicing in the US used it many years ago and have heard tales of women vomiting, none of the ones I’ve talked with about it have had any first or second hand experience with such a situation. Instead, it was always a story that someone else told them, not something that had experienced directly. At the same time, the two most commonly used analgesic and anesthetic methods currently used by women during labor in US hospitals both have well-known complications, such as labor slowing down or stopping after an epidural and respiratory distress in whose mothers were given “opioid” drugs. Many women accept these drugs without having been given complete information on possible problems. Nitrous oxide, in contrast, does not have any negative effect on either the baby or the normal physiology of labor, and does not result in any increase in the need for forceps, vacuum or cesarean sections to deliver the baby. The biggest problem with nitrous oxide is that is it only available in a few hospitals. Please tell me where you live, Lisa, and I will tell you if it is available in a hospital near you. Some other hospitals are considering starting to provide it. If you live near one of them, you might be able to persuade the doctors at that hospital to accept it and provide it to you.

    If you want additional information, you might want to look at any or all of the following sources.

    (1) Dr. Mark Rosen, who is chief of obstetric anesthesia at the University of California’s Moffitt Hospital in San Francisco, conducted a very thorough review of use of nitrous oxide for relief of labor pain, which was published in the American Journal of Obstetrics and Gynecology in 2002 (Rosen MA. Nitrous oxide for relief of labor pain: A systematic review. Am J Obstet Gynecol 2002;186:S110–126).

    (2) I published an editorial entitled “Nitrous oxide for pain in labor–why not in the United States?” in the international journal Birth: Issues in Perinatal Care, in 2007 (Rooks JP. Nitrous oxide for pain in labor–why not in the United States?. Birth. 2007;34:3–5).

    (3) Dr. William Camann, Director of the Obstetric Anesthesia Service at the Brigham and Women’s Hospital (affiliated with Harvard Medical School) in Boston, summarized information about use of nitrous oxide during labor in Easy Labor: Every Woman’s Guide to Choosing Less Pain and More Joy During Childbirth, a book he co-authored with Katherine Alexander, which was published by Ballantine Books in 2007.

    In addition, I manage an invitational Internet listserv for people who want to increase access to nitrous oxide for women during labor in the US. Members of the N2Oduringlabor listserv can access a treasure trove of information about nitrous oxide analgesia during labor. If you would like to become a member, submit a comment in which you say so and include your name and email address. I will send you an invitation. Please also feel free to use the Our Bodies Ourselves blog to ask any other specific questions about use of nitrous oxide during labor. And let me know where you live. I hope that you—and any other pregnant woman who would like to have access to this option for pain relief during labor—will also discuss it with your/her physician or midwife. Nitrous oxide is not widely available in the US because epidurals are more effective, and when they were introduced, hospitals wanted to offer them and decided it would be easier to just offer one kind of effective pain relief to women in their obstetric service. But more and more women feel as you do, Lisa, that you want another option. If all of those women would speak up, we could begin to make this safe, inexpensive, woman-controlled, “old fashioned” labor pain control method—which is used by the majority of women giving birth in many other countries—available to women in the US too!

    I look forward to hearing from you!

    Sincerely,

    Judith Rooks, CNM, MPH

  4. Lisa Caruolo says:

    Hello Judith!

    Thank you so very much for resonding and getting me more information on the use of Nitrous Oxide during labor and delivery. I am writing out my birthing plan and am trying to find out if the hospital I plan on giving birth in (Calvert Memorial Hospital, Prince Frederick, MD) participates with using N2O. It is a very small county hospital so I am not sure how up-to-date they are with reference to the knowledge of N2O.

    I live in Owings, Maryland, Calvert County. I am not totally “married” to the idea of keeping my current OBGYN or the hospital and might be willing to change to a new OB or even a midwife.

    Is N2O available to me to purchase and use on my own during labor and delivery or does it have to be provided by the hospital and monitored?

    Please let me know what I can do to help myself and this cause.

    Thank you again

    Lisa Caruolo

  5. Judith Rooks says:

    Dear Lisa,

    Thanks for writing back. I’m sorry it took me so long to respond. I needed to give it a lot of thought and find out some things about the hospital you’re planning to use. Also, I was impressed that you asked me to let you know what you can do to help both yourself and “this cause”. Although I doubt that you will be able to use nitrous oxide for this baby, I want to give you very full information so that you can perhaps help to make it available to women who go to Calvert Memorial Hospital in the future, after your baby has been born. I’m sorry to start off a little bit negative, but I think (hope) you’ll find this all to be of interest.

    Let me begin by answering your last question. Nitrous oxide is a legally regulated drug. You cannot buy it over the counter, although it is apparently available on the “black market”, as are many other drugs that provide analgesia and, in this case, feelings of euphoria, “bliss”, etc. All such drugs are abused by some people. The companies that make and sell nitrous oxide (abbreviated as N2O) cannot sell it to anyone without a prescription written by a physician or dentist. (It’s used in about one-third of all dental care settings in this country.) So you can’t buy it and bring it to the hospital with you. This is a good thing, as using it may affect a person’s judgment; it should always be used in a health care setting with oversight and monitoring provided by a well-trained, knowledgeable professional, who takes responsibility for its safe use. Nevertheless, N2O is not only used by approximately two-thirds of women who give birth in hospitals in the United Kingdom (UK), it is also used in community-based birth centers in the UK, and British midwives can stop at a hospital or birth center to pick up a canister of N2O and the equipment for its use during labor on their way to a home birth, which are much more common in the UK than in the US. N2O used by a woman who is under the care of a midwife does not cause any serious complications and thus is safe for home births. This is unlike epidurals, which can cause serious complications that require medical intervention; it is not safe for a woman who is laboring at home or in a birth center to have an epidural.

    I doubt that any hospital in your area is offering nitrous oxide analgesia to women during labor at this time, although most, if not all of them probably use nitrous oxide somewhere within the hospital. N2O has been used as one component of a mixture of volatile anesthetics that are given together to produce anesthesia for surgery for more than a century. I think that it’s easier for people to come out of anesthesia if N2O was part of the drug “cocktail”, and that they are less likely to have memories of the surgery. Nitrous oxide has been so widely used in surgery that it is a common commodity in American hospitals that do surgery, even though some hospitals are probably using it less and may soon stop using it for surgery based on research has shown important benefits (better wound healing and less infection) from administering 100% oxygen to patients during surgery. New anesthetics that can be administered intravenously have made it possible to give 100% oxygen to patients during surgery now; as a result, use of N2O during surgery will probably decline.

    But nitrous oxide is also used as an ANALGESIC—i.e., not as an ANESTHETIC—in other units within some hospitals, including emergency departments, where it is used to provide quick pain relief for people being treated for some kinds of painful injuries and during painful procedures, such as suturing wounds for people who will go home after being treated in the ER. The ability of nitrous oxide to be started quickly, have an almost immediate effect, ease pain without causing unconsciousness, and have no hangover effect on the patient are important advantages. It is also used for some dental procedures that are performed in hospitals and in some hospital-based outpatient clinics, especially during some gynecologic procedures. N2O may be used somewhere within Calvert Memorial Hospital, even if it is not available to women during labor.

    Although I hope you will tell your doctor that you want to use nitrous oxide during your upcoming birth, I doubt that any of the obstetricians who deliver babies at Calvert currently offer N2O to women during labor, and I assume that the hospital is not set up to provide it to women during labor. I only know of two hospitals who are doing so currently—the University of California at San Francisco (UC/SF) Moffitt Hospital in San Francisco and the University of Washington Hospital in Seattle. These are two of our country’s best academic medical centers. Even though I hope you will tell your OB that you want to use nitrous oxide during your birth, it would have to be approved by a committee or some other group within the hospital, which is usually a pretty drawn-out, multi-step process. And, even if Calvert hospital ultimately decides to begin to offer nitrous oxide to women giving birth there, it would have to buy the equipment necessary for a woman to use N2O during labor (which is different from the equipment used to administer N2O to someone during surgery, and the only company that sells it has a back log of orders for it at this time). The hospital would also need to develop procedures and train its personnel—including anesthesiologists, OBs, and nurses—in how to set it up correctly, how to teach a woman to use it effectively during labor, safe use (i.e., no one but the woman herself can hold the tube or mask), etc., etc., etc.

    Hospitals tend to be very bureaucratic, have to follow a lot of rules and regulations, and are often afraid to do something that other hospitals in the community are not doing for fear that something bad will happen and they will be sued and lose because the new practice is not “the community standard”. The “community standard” is not what really matters in a malpractice case—scientific evidence of the safety and effectiveness of a “new” practice is more pertinent in an actual malpractice trial. In addition, using nitrous oxide for analgesia during labor is not “new”, is the “community standard” if you think of the community as including all Western democracies with high medical standards, and the history of a century of safe use of nitrous oxide by tens of millions of mothers and their babies during labor provides a substantial body of evidence for its safety.

    Despite all this, I hope you will ask your doctor to ask Calvert Memorial Hospital to consider providing nitrous oxide to women like you; you would be the perfect person to make this request and be the first woman to use nitrous oxide at Calvert Memorial Hospital: You are experienced at giving birth; you are expecting your 6th child, and you have never needed a cesarean section. You expect to experience some pain during labor, and you know how to use it to help you push. Despite experiencing pain, your births have been “quite wonderful”. I looked up Calvert Memorial Hospital on the Internet. The booklet that describes the Calvert Memorial Hospital Family Birth Centers says that the hospital has “Experienced anesthesiologists to provide whatever level of pain management you need.” You think you will need nitrous oxide. You’ve already used both epidurals and opiates and have solid reasons not to want to use either of them again. You should ask the hospital to make good on their statement about providing “whatever level of pain management you need.”

    Another possible approach is to request a consult with one of the anesthesiologists who work with women during labor. Explain your problem to her or him. If the hospital has N2O, s/he may be able to work something out for you. I know of one woman who was so alarmed that the hospital where she had used N2O during her first two births had stopped offering it to women during labor that the hospital allowed her to labor in one of the operating rooms and use the N2O supply and equipment that was available there. The hospital was part of the state university system; she probably threatened to complain to the legislature if the new chief of OB—who had “renovated” the labor and delivery suite by having the N2O supply lines and equipment torn out and adding more cesarean section operating rooms—didn’t let her use what she had used and appreciated so much during her earlier births.

    If you are inclined to ask for a consultation with an anesthesiologist, here are some tips to maximize the likelihood that you will get what you ask for: Bring a list of questions, facts and research citations; ask someone to go to the consultation with you, to be a witness and provide support; focus on what you are feeling and what you need; do NOT try to teach him or her something, but DO know what you’re talking about and take copies of the references that back up what you plan to say. (This good advice provided by Larissa Guran, a doula who also worked in hospital administration in the DC/MD area and was an active member of Birth Options Alliance in the DC area.)

    If you want to pursue this, through your OB or through a consultation with one of the anesthesiologists, or both, you should write a message in which you give permission for the wonderful women who run the OBOS blog to send me your email address. In my earlier message I told you about the listserv for people who want to expand access to nitrous oxide for women during labor in the United States—to give us as much choice for pain relief during labor as women in Canada (and many other countries) have. Members of the listserv receive information about the use of N2O during labor, can converse among themselves, and can access many of the most important scientific and other papers on the subject. The N2Oduringlabor listserv is by invitation only; if you want to join, I will invite you. Even if you don’t want to join the listserv, please let me know if you have any other questions. And I’d love to know what you end up doing.

    Also, if you find that you cannot use nitrous oxide at any hospital near Owings, and you want to try to make it through labor without either an epidural or opioids, I have some other suggestions:

    Try to find a good midwife and talk with her about your concerns about labor pain and the need for different options. I used the “Find a midwife” site on the American College of Nurse-Midwives (ACNM) website to find out about certified nurse-midwife practices within 30 miles of Owings, MD. There are 26, including one in Clinton, one in Annapolis, one in Arnold, three in Cheverly, two in Alexandria, one in Easton, one in Pasadena, one in Laurel, and 15 in Washington, DC. The Find a Midwife site is available to everyone and is easy to use. I live in Portland, Oregon, and don’t know anything about any of the practices listed on this website, but if I were you, I would want to be with a midwife. You should also check out the Birth Options Alliance in the DC area. They can tell you about local midwifery services and doulas—and probably about doctors too. I would definitely try to get a doula, whether you are with a physician or a CNM. You should ask your current OB is s/he has ever worked with a doula, and, if not, would s/he be open to it? A good doula could make an important difference in the level of pain and comfort you experience. Does the Calvert Memorial Hospital Family Birth Center have bathtubs—or even showers, although baths are best for reducing the need for pain medications during labor. Try to avoid procedures that make you stay in bed. You don’t really need an IV or continuous electronic fetal monitoring. It is very helpful to be able to get out of bed, walk around, change positions frequently, and get into whatever position feels best. And insist on being able to at least drink fluids during labor.

    Best wishes. Let me know if you want to join the N2Oduringlabor listserv. Even if the change you seek comes too late to help you; you could be a big factor in improving access to “whatever level of pain management” women in your area need during labor.

    Best wishes,

    Judith Rooks

  6. Shannon says:

    Judith,

    Thank you so much for publishing this. I thought I would offer my story to those who are considering using N2O. I gave birth 8 months ago in Norway, and am now back in the US planning on when I want to have my second child.

    When my husband and I were living in Norway and thinking of starting a family, I knew that we would be moving back home during my 5th month of pregnancy. My care and delivery would be exactly what I had heard about from friends and seemed very safe and familiar to me. So, when my husband’s contract was extended, I was scared to death of not being home in the US to deliver my son. A scared woman does A LOT of research. Thank goodness I also had many American friends over there who had delivered thier babies there and offered me all their birthing stories and opinions. I also learned that Norway had a better baby mortality rate, fewer women had c-sections. After all the research, I realized I didn’t want an epidural. Plus, my friends had told me that the epidural given wouldn’t be a “full epidural”, more like a walking epidural. And I would have to practically beg to get one. Also, I had read that epidurals tend to slow down contractions making your labor longer (longer pain) and typically they have to give you pitocin to strengthen and speed up your contractions (stronger pain). I am not a fan of pain; who is? So I thought the quicker the labor, the better. No epidural.

    My contractions were 5 minutes apart by 4am. I called the hospital at 5am to let them know they were still 5 min apart. They told me to stay home, take a hot shower, and try to labor at home as much as possible. My water broke at 7am, we were at the hospital by 7:30. By the time I got to the hospital, I was asking for that epidual. My husband let the midwife know that I really didn’t want one, and she told me to try the gas. What a life-saver!! After my first big breath, I felt the effects. She asked me if I felt a little tipsy, and really, I felt a little drunk. You know that feeling when your lips are tingly, you feel very relaxed, and you could easily just fall asleep? Once the contraction was over, and I took the mask away from my face, I was back to feeling normal. It doesn’t take all the pain away, especially those few very severe contractions toward the end, but it does take the edge off and relaxes you. I was able to sit/kneel on a stool beside the bed while my husband rubbed my back. I was never attached to any IVs and only for a short time did they hook me up to a fetal monitor. (That seemed great because then my husband could tell me when the next contraction was about to start, and I could take in the gas a little sooner.) The midwife only came in a couple times to check me, and then I had my husband get call her because I felt like I needed to push. She took the gas away (I was a little upset about that), and we started pushing. It really didn’t hurt as bad as I thought it would. My son was born at 11am. He came out with the cord wrapped twice around his neck and was purple. They told me they would have to take him away for about 15-30 minutes just to make sure he was ok. They brought him back before then because they said he was very strong and responsive. So, I don’t believe that the gas causes a baby to be less responsive after birth like some US doctors have said. He is a very smart, active, strong baby. After the birth, I felt great. After an hour, I was able to take a shower and go to the bathroom on my own. Three hours I walked over to my hospital hotel room with no problems.

    Now that I’m back in the States, I am really paying attention to my friends’ birthing stories trying to get all the details of how it works here. Let me tell you, I’m scared to deliver here! Only one of my friends didn’t have an epidural or any other drugs. What a trooper. But all of the others have had epidurals, and because of the epidural have had to have pitocin, some had to have forceps used, and a couple have had to have c-sections because the contractions just weren’t productive. So, I am now searching for a doctor/hospital in the Houston area that will allow me to use the gas. It is what I feel comfortable with.

  7. Adair says:

    I saw the use of nitrous oxide for labour on a tv show I was watching and live in the US. I was suprised to find out that it was an option for labour use. I dont believe many woman know about the option of this for pain. It is truly sad, after seeing the tv show, i did my own research on the interenet and found a lot of information that makes me prefer this method over any other, especially an epidural. Big needle in my back, NO THANKS. I believe that a lot of woman (more than you think) in the US would want the option of nitrous oxide use. The information I got from this article was very informative and made me think that woman need to be aware of this option and push to have it available to us. I was also wondering how I would be able to find a hospital that would offer this as an option to me.I am lanning on having children in the near future and would love to have the information of where this would be available to me. I live in Palmdale, CA (the L.A. county) If you can please provide me with this information or how I would easily be able to find out that information it wold be much appreciated. Thank you.

  8. Kiki says:

    hi Adair,

    I just read through Judith Rook’s comment, posted before yours, and she said that unfortunately she knows of only two two hospitals currently using nitrous oxide for births –the University of California at San Francisco (UC/SF) Moffitt Hospital in San Francisco and the University of Washington Hospital in Seattle. See also though her tips for how to possibly work with your hospital to make it available.

    Good luck!

  9. Judith Rooks says:

    Hi Danielle,

    Yes, we are behind the times, but we are working to catch up. I would like to invite you to become a member of the N2Oduringlabor listserv, but I need your email address to do so. Please send a message to Our Bodies Our Blog referring to my response to you and requesting that OBOB sends me a private message with your email address. I need your email address in order to invite you to join the N2O listserv. I will also want to know what hospital in which you plan to give birth. I would like to put you in touch with midwives in your area. The American College of Nurse-Midwives (ACNM) is just about to announce a major position statement in support of nitrous oxide analgesia during labor. Let’s see what we can all do together to help you.

    I look forward to hearing from you as soon as possible.

    Judith Rooks

  10. Judith Rooks says:

    Dear Adair,

    I would like to invite you, but I will need to have your email address. Thus I am giving you my email address, so that you can send me yours. It is jprooks1@comcast.net. I will watch for your message requesting that I invite you to join the N2Oduringlabor listserv. As soon as I receive it I invite you right away. I would also like to invite anyone else who would like to join the N2Oduringlabor listserv to send me a message. Please include brief information telling me who you are and why you are interesting in use of N2O for analgesia during labor.

    Judith Rooks

  11. Heather says:

    Please add me to your listserv…I am also interested in supportive literature if you have some to present to my Department Chair of Ob/Gyn services here at St. Joseph Medical Center in Towson, MD.

    Thank you,

    Heather Keller, RN, BSN

    Clinical Practice Specialist, L&D & Women’s Health

  12. Judith Rooks says:

    Dear Heather,

    The N2Oduringlabor is now open to anyone, no need to be invited or added by me. The website url is http://health.groups.yahoo.com/group/N2Oduringlabor/. Click on it and follow the instructions to join. When you join you will see a light blue sidebar on the left side of the website home page. Clicking on “Messages” takes you to a space where many of messages sent to members of the listserv are preserved and can be read. Some are more important than others. Mickey Gilmore, CNM, MsN, helps me with the listserv and goes through the messages from time to time to remove the less informative messages. Most of those that are available here either have some important information or are fairly new. Each message was assigned a number when it was received. Number 1 is the oldest message, number 287 was the oldest the last time I checked. But there are not that many messages there now. Although many messages that are no longer relevant and don’t provide new, interesting, or unique information have been deleted, the message that are there retain there original numbers; there are gaps in the sequence. Once you find a message that you may want to return you, note the number; that message will always have the same number. I just went through some of the oldest ones and deleted some more. I should do it again for all of them, and I will, but if you are serious about doing something about nitrous oxide, it would not be a waste of time to just click through them. Click on messages. At the top of the first message shown is a line that allows you to choose between Newest, Newer, Older and Oldest . I started with oldest, then went to older, etc. As soon as you click on one and read it, you can click on “next” to go to the next one. Some of the messages from me are sort of a compendium of information about a particular subject.

    If you click on the “Files” heading on the light-blue side bar on the home page you will enter the part of the website that has important documents. Some of them were also sent as messages. If you click on one, it will show up on your desktop.

    If you have any trouble joining or opening any of the documents, please let me know.

    Judith Rooks

  13. Marvin Will says:

    Judith, I’m glad that you posted this blog entry to clarify the issue of Nitrous Oxide during labor. It is commonly used in most medical facilities here in the country (United States). Recently, my brother was administered trace amounts by his dentist. Charleston SC and other parts of the country use this to relieve the anxiety of patients and help them relax during the procedure. Dental and other medical operations have higher success rates when the patient is in their normal state.

    Thanks for the information. I’ll definitely bookmark this for reference.

  14. Helena says:

    Thank you, thank you, thank you. I had my first child in the UK and had a beautiful, empowering experience with just N02 (we call it ‘gas and air’ over there) and the support of a talented and sensitive team of midwives. I didn’t see a doctor throughout my whole pregnancy, as I remained low-risk; in the UK, pregnancy is seen as far less of a medical event than it is here in the USA. Now I am living in NC. We want another child, but I firmly believe that if I had had my first child here in the states I would have had a cesearean (long slow labour, occiput posterior position, some concerns about fetal heartbeat due to, as it turned out, cord round the neck). I have a friend here who had a low risk pregnancy and is my age, yet she had 10 ultrasounds, an epidural, and eventually a cesearean which left her unable to stand for 2 weeks. She had wanted a natural birth. The medical profession in the USA has eroded our belief in our own bodies. We need to get NO2 into delivery rooms, and we also need to get doctors OUT of prenatal care unless there is a proven need for them to be there. thanks again for your site.

  15. Julianne says:

    Judith,

    I am currently 5 months pregnant with my first child. My husband and I will be moving near Goldsboro, NC in about a month. Not only am I nervous about giving birth for the first time, but I’m moving to a new place with only 2 months to find a new doctor and try to build a trusting relationship with him/her. I’ve always been interested in alternative methods of pain relief. I first read of the possibility of nitrous oxide about 2 months ago, but have only found 2 hospitals that offer it for laboring women (neither of which is close to Goldsboro, NC). I was wondering if you have a list of hospitals that do offer it, or even another website or source I could use? Thank you!

  16. Brittany says:

    aww this is kind of old, anyone know if nitrous oxide is readily available in more US hospitals yet? i just found out im pregnant a couple weeks ago, and when reading my first pregnancy magazine i saw an artical about this and had to google it! ive always said i wouldnt want an epidural, this would be wonderful!

  17. Judith Rooks says:

    Dear Brittany,

    I believe that a company that specializes in making medical equipment
    will soon get FDA approval to begin to produce and sell a new version of
    the equipment needed to use nitrous oxide for labor analgesia. The FDA
    procedure for getting this approval is complicated and can take a long
    time, but a big company is putting substantial effort into this. They
    previously told me that they hope to have it by the end of this year. It
    could take a little longer, but new equipment should be available in time for your birth. Right now only 5 US hospitals are using it, to my knowledge. They are:

    University of California at San Francisco [UCSF] Moffitt Hospital in San Francisco
    University of Washington [UW] Medical Center in Seattle
    Vanderbilt University Hospital in Nashville
    St. Joseph Regional Medical Center [SJRMC] in Lewiston, Idaho
    Okanogan Douglas District Hospital in the Methow Valley of Washington State

    However, an ever-expanding group of hospitals are ready to buy the new equipment when it becomes available and will start using it shortly thereafter. Where do you live, Brittany? I can probably tell you if any hospital in your area is in line to buy and start using the new equipment?

    Keep in mind though that you need to know about all kinds of ways to deal with labor pain before you go into labor. Labor pain is unique to every woman. You may want to use nitrous oxide and find that you really need an epidural. Or you may find, as my step-daughter did recently, that she could get by without anything more than access to a warm tub, preparation through reading of ways to self-manage pain, and the support of her husband, a great doula, and a very good nurse, although there were a few short periods when she would have liked to use nitrous oxide if it had been available. My point is that, although you need to educate yourself and think through various scenarios, you won’t know what you need until the time comes. She was elated that she was able to give birth to her first child (at age 43) with support, her personal strength, and warm water. There are many advantages to being able to avoid an epidural if you can. You can’t count on that though, and you can’t count on a epidural either. You may have pain when it is too early to start an epidural; nitrous oxide is a good way to get through until you can have an epidural, and by then you may just want to stay with nitrous. Or you may not get to the hospital until it is really too late to have an epidural placed and begin to take effect before the baby is born. Or you could be among the percent of women, at least 10%, maybe higher, for whom an epidural isn’t really very effective for one reason or another.

    If I know where you live, and can tell you whether it is likely that a hospital near you will be using nitrous oxide labor analgesia when you are ready to have your baby.

    Congratulations on your pregnancy and your intent to learn more about labor analgesia choices.

    Judith Rooks

  18. Maura says:

    Hello Judith!

    I am so very excited to find these postings and so very thankful to you for being such an advocate.

    I am pregnant with my 7th child. The first 2 were with an epidural. Wanting a natural birth since the first child, I was determined to do it! I switched to a group of midwives with a week to go on my third child and what a difference. My last four were natural births. I know I do not want to go back to an epidural, but do need something to “take the edge off” (as I am a typical redhead in that I have an extremely low pain threshold).

    Would you be able to tell me if you have had any contact with my hospital here? I deliver at Hillcrest Hospital in Cleveland, Ohio. It is part of the Cleveland Clinic. One of my midwives has been trying to encourage N2O here and you may know her.

    I am very willing and interested in contacting the hospital hierarchy via a request letter and will ask my CNM for assistance in doing so. I will use the advice you have given here in previous posts as well.

    I am due to deliver December 5th. So I really only have 6 weeks left to accomplish this. I just hope it is not too late!

    Please advise! Would you like me to contact you on email?

    Thank you again for all your work and in advance for your support.

  19. Judith Rooks says:

    Hi Maura,

    I sent a copy of your message to a representative of a company that is in the process of seeking FDA approval for new equipment to provide nitrous oxide labor analgesia. I asked him to let me know if any hospitals or birth centers in Cleveland are in line to buy the new equipment when it is approved by FDA. I should hear from him tomorrow and will let you know. Please go ahead and ask the midwives at the Cleveland Clinic to go through their internal process of getting approvals and getting the necessary training. A review of the Safety and Risks of Nitrous Oxide Labor Analgesia is coming out in the next issue of the Journal of Midwifery & Women’s Health is available on-line in advance of publication. I can get a copy of it for you if that would help.

    Judith Rooks

  20. Maura says:

    Judith,

    You are fantastic and so wonderfully responsive! Thank you!

    I am sure my midwife (midwives) will be ready to go, if I ask. We meet again this Wednesday and I will let them know of the journal article and your suggestion to get the approval and training. Very exciting! I have so many questions I hope they can answer them. I went on-line to Anesthesiology Journal publications and found some encouraging research and articles.

    I just wish we could know the FDA timeline for approvals!!!

    I won’t give up hope that it all might be accomplished in just 6 weeks!

    Looking forward to your information. Thank you, again, Judith.

    ~Maura

  21. Judith Rooks says:

    Hi again Maura,

    Here is the answer I got from Mike Civitello, who works for a company that is in the process of seeking FDA approval for new equipment for providing N2O for labor analgesia.

    Judith

    ………

    We have several hospitals that are already using our equipment in Ohio – Pediatric though. We also have current equipment at the Cleveland Clinic being used for a clinical trial – which we are hoping gets published in the next year. They are conducting a study comparing the use of N20 versus another commonly used drug for chronic pain treatments.

    Parker Hannifin (Porter parent company) has a relationship with the Cleveland Clinic – and I’m sure we could get our new equipment to any of their affiliated hospitals. We will be looking for a few highly respected institutions like Cleveland Clinic, Vanderbilt, etc to start using the new equipment in hopes of studies and papers getting published – along with the educational opportunities that would be presented.

    New equipment is not going to be available by December 5 though.

    I’m going to try and find out more about Magee this week – will share info as I get it.

    Mike Civitello, Product Sales Manager

    Porter Instrument Division

    Parker Hannifin Corporation

  22. Randa says:

    Hello Judith,

    I am currently 3.5 months pregnant and due to give birth in August 2012. My husband and I will be moving to Washington DC in a couple of months and I am wondering if your aware of anywhere that is currently using N20.

    I was shocked to learn about N2O not being available in all hospitals in the States as I was born and raised in Sydney Australia where N2O is readily available in every delivery room and this is how my mother gave birth and how I intended on giving birth.

    I am really stressed now that it might not be an option and any help you can offer would be greatly appreciated.

    Regards

    Randa

  23. Mickey Gillmor, CNM says:

    Judith is currently traveling outside the country and has asked me to respond. We are hoping that new equipment will be available by summer, but currently on one in the Washington DC area offers nitrous oxide labor analgesia.

    To learn the latest you can join the N2Oduringlabor listserv at http://health.groups.yahoo.com/group/N2Oduringlabor/. This is an open group and anyone may join. Anyone posting anything that is not relevant to nitrous oxide in labor will, however, be denied posting rights.