- N2O use provides a safe option for pain relief in

labor
-N2O administration is noninvasive and does not
carry the serious (although rare) risks associated
with regional analgesia
- Access to this therapy in the United States is
surprisingly limited, so, an increase for access has
been proposed
- Environmental pollution is common during inhaled
anesthetic administration, and health care workers
exposed to inhalational agents where scavenger systems
are not simultaneously used are often exposed to levels of
N2O in excess of occupational exposure limit
-Test your knowledge!

1. The precise effects on brain development in human fetuses

exposed to N2O or other anesthetic agents in utero remain
largely unknown. True/False?
2. The American Association of Anesthesiologists defines N2O
as moderate sedation/analgesia. True/False?

1. TRUE!
2. FALSE! It is minimal sedation with
normal response to verbal stimulation,
and unaffected airway, spontaneous
ventilation, and cardiovascular
function- Moderate sedation is
conscious sedation, remember?

-Why was this topic chosen?

Because as noted in our labor and delivery rotations, women experience great
deals of pain during the progression of labor. We believe it is important to help
our patients to relieve pain by any safe and effective method possible.
-Primary, secondary, and tertiary prevention are not applicable to this topic.
Why is nitric oxide (N2O) use a concern for this population?
-Because pain is a major factor of how a woman experiences labor, and requires
interventions. Inhaled N2O has a long history of use in pregnancy, and provides
a safe option for pain relief in labor.

-Currently, access to this therapy is limited in the United States, and a necessity
for increased access has been proposed.
-In patients where regional analgesia is not feasible, N2O may be the only
alternative choice available for pain relief.
-The improved availability of N2O for labor analgesia would increase options
for pain management for laboring women.
Health needs:
-Although an FDA advisory issued in 2007 recommended no change in
anesthetic practice for children or fetuses, the precise effects on brain
development in human fetuses exposed to N2O or other anesthetic agents in
utero remain largely unknown.
-The American Society of Anesthesiologists stated that N2O, when used at
concentrations of < 50% and as a sole agent, is defined as analgesia minimal
sedation.

-Assuming the patient is responsive and airway, ventilation, and cardiovascular

function remain unaffected, the use of pulse oximetry is not required.
-With intermittent use, room air entrainment will result in fluctuating N2O
concentrations of < 50%. If N2O is used by the patient continuously or is used
intermittently in conjunction with intravenous or intramuscular narcotics, pulse
oximetry should be used.

Problems:
-Environmental pollution occurs frequently during inhaled anesthetic
administration, and health care workers exposed to inhalational agents where
scavenger systems are not simultaneously used are often exposed to levels of
N2O in excess of occupational exposure limit. For this reason, FDA

requirements necessitate the use of a blender device with a scavenger, which

provides superior environmental hygiene
-Ingestion of modest amounts of clear fluids during uncomplicated labor appears
safe. Although, research specifically examining oral intake and safety of N2O
use has not been undertaken. N2O analgesia should not be a gateway for altering
an institutions existing guidelines for oral intake during labor.
-Laboring women who have experienced nausea prior to beginning N2O therapy
may benefit from prophylactic antiemetics prior to initiation of N2O therapy.

Risks:

-N2O administration is noninvasive and does not carry the serious (although
rare) risks associated with regional analgesia.
-The use of N2O as a labor analgesic in a study conducted in the United
Kingdom revealed a long track record of safe outcomes for both mother and
child.
-Although short duration and modest concentrations of such analgesics would be
expected to have insignificant effects, concentrations < 50% nitrous and 50%
oxygen for prolonged periods may be harmful.

References
Adams, M. P., & Urban, C. Q. (2013). Pharmacology: Connections to nursing practice
(2nd ed.). Boston, MA: Pearson.
Bon Secours. (2015). Nitrous Oxide Policy. Richmond, VA.
Collins, M.R., Starr, S.A., Bishop, J.T., Baysinger, C.L. (2012). Nitrous oxide for labor
analgesia: Expanding analgesic options for women in the united states. Reviews
in Obstetrics and Gynecology 5(3-4), 126-131. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3594866/
Lowdermilk, D. L., Perry, S. E., Cashion, K., Alden, K. R., & Olshansky, E. F. (2016).
Maternity & womens health care (11th ed.). St.Louis, MO: Elsevier.