Nitrous - PowerPoint Presentation

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Nitrous Oxide for Childbirth

Larry Leeman MD MPHRobyn Lawton, CNM Laura Migliaccio, CNMSlide2

Objectives

Participants willUnderstand role of nitrous oxide for labor analgesia and historical contextUnderstand research regarding safety and efficacy for labor analgesiaBe familiar with new UNM Labor and delivery guidleline for nitrous in laborSlide3

Disclaimers

NoneNitrous equipment is FDA approvedSlide4

Special Thanks to……

Amanda Holbrook, RNTrisha Mondragon, RNSharon Phelan, MDEva Szabo, MDBeth Brown, RNSteve Villescas (Safety)

Adda Garcia McDonald (Quality)Slide5

Why Introduce Nitrous Oxide for labor ?

Increase women’s options beyond epidural, parenteral opiates and “natural” childbirthNow in use in many medical centers- University of Colorado, UCSF, University of Washington, Brigham and Women’s’Increase patient satisfaction with labor and delivery experienceAttract new patients and increase volume of births Slide6
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Agenda: Nitrous oxide for childbirth

HistoryReview of research and side effectsClinical implementationUNMH guidelineSlide8
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History

1772-First synthesized 1881-Klikovich (Poland) first studied for labor 1934-Minnitt (England) invented “gas and air” apparatusSlide10
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Current Nitrous Oxide Use Around the World

Canada 40-45%Finland 60%Sweden 65%UK 50-75%US <1%Likis 2014Slide13

How it Works

Mechanism poorly understoodWorks in gray matter of midbrain, induces endorphin, corticotropin, and dopamine release, modulating pain stimuli by way of descending spinal cord nerve pathways, changing perception of the pain.

Rosen 2002; Maze 2000Slide14

Research(Likis 2014)

“Literature addressing nitrous o

xide use in labor includes few studies of good or fair quality”

“Further research is needed across all areas examined including effectiveness, satisfaction, safety and adverse events” Slide15

Lack of STUDY Standardization

Differences in concentrations-30-80%Differences in inhalation methods (mouthpiece vs mask, continuous vs intermittent)Comparison groups using other agents (inhaled, opiates) vs no

nitrousUse of different pain measures, most often retrospectivelySlide16

Cochrane Review (2012)

26 studies (2959 women)9 of the 26 studies compared nitrous with placebo or no treatment Women reported less pain intensity (30-50% less) in nitrous vs placebo groups

More nausea, dizziness and drowsiness reported in nitrous groupSlide17

Nitrous oxide efficacy

N= 26 women in early labor, RCT, double-blindCompared air with 50% nitrous/50% oxygenIntervention used for 5 consecutive contractionsAlmost no difference in pain scores, yet…Majority of the nitrous group wanted to continue using it once study period over

Carstinou et al. (1994). Anesthesiology 80: 30-5Slide18

Maternal Expectations and Experiences

N=98 multips in active laborRCT, N2O vs no N2OResults: Nitrous oxide reduced severity of pain98% of intervention group satisfied with method80% would request it again

Pasha et al. 2012Slide19

Safety Outcomes-Review

No differences in:Cord blood gasesApgar scoreNICU admission

FHRBlood loss at deliveryUterine contractions or labor progressMode of deliveryNo report on bonding, breastfeeding, and long term infant outcomes

Klomp et al (2012)Cochrane Database of Systematic ReviewsLikis et al (2014) Anesthesia and AnalgesiaRooks, J. (2011). J. Midwifery & women’s HealthSlide20

Obstetric pain relief and its association with remembrance of labor pain at 2 months and 1 year postpartum

Wallenstrom et al 2006Slide21

Labor pain at 2 months PPWallenstrom et al 2006Slide22

Labor pain at 2 months PPWallenstrom et alSlide23

Side Effects

Nausea 5-33% Dizziness 3-35% Dysphoria 5-10% Drowsiness 0-24%

Hazy memory 0-37%Chronic occupational exposure riskSlide24

summary

Despite not being able to quantitate pain relief, many women report positive results using nitrous oxide, and most would choose it again in a subsequent labor.For some women, nitrous will not provide enough relief, but for others it may be acceptable in exchange for more mobility and less monitoring.Nitrous oxide is widely used around the world, yet we lack long term data on infant outcomes.Slide25
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Nitrous Oxide for labor analgesia

Pain reduced but still presentSignificant anxiolyticFree to move about

No IV neededQuick relief Personal controlNo impact on labor progress or pushingDoes not appear to have adverse effects on baby (

http://www.childbirthconnection.org/article.asp?ck=10188#effects)Slide27

Collaborative Guideline

Leadership from all three clinical maternity servicesObstetrical anesthesiaLabor and Delivery Nurse manager and educatorsBiomedical, patient safety, pharmacy Slide28

Panicked Newborn Didn’t Realize Breathing Would Be On Apgar TestSlide29

UNMH Nitrous Oxide Guideline

a 50/50 blend with oxygen -used as analgesiaSlide30

UNMH Indications for nitrous use

Labor pain relief

PP laceration repair

PP IUD placement

B

alloon

catheter placement

Manual

placenta removal (conscious

sedation or regional anesthesia may be

preferred)

External

cephalic version

IV placementSlide31

Precautions/Contraindications

Can’t hold own face maskOverly sedated, intoxicated or neurologically impaired Methadone/Buprenorphine users okay if not

excessively sedatedVitamin B12 deficiency (ex: strict vegan, Crohn’s disease, or bariatric surgery)(may confirm normal B12 levels prior to use)Category III fetal heart

rateSlide32

Precautions/Contraindications

Hemodynamic instability/impaired oxygenationConsult Anesthesia if O2 Sat<93%Recent head trauma (w/in 2 wks), increased intraocular pressure, pneumothorax, bowel obstruction, eye surgery, or middle ear surgery requires anesthesiology consultSlide33

NITROUS OXIDE USE WITH OTHER

ANALGESICSDo NOT administer nitrous oxide and IV narcotics concurrently(Wait 1 hour after narcotics before starting nitrous)

No delay in starting IV opiates needed after last nitrous inhalation No delay in epidural necessary after nitrous oxide unless directed by the AnesthesiaSlide34

May consider Nitrous OXIDE for

…..Concurrently with local analgesics for laceration repair

For epidural placement with anesthesia approval & managementSlide35

Patient Preparation

Handout information prenatallyAssess patientReview contraindicationsInform about possible side effects: nausea, vomiting, dizziness

Initiate Medication “Power Order”Instruct patient and support people Slide36

Before Initiating

Assess & Document Patient suitabilityAbsence of contraindications

Vital signsO2 SaturationMental statusFHT’sSlide37

Set up by Nursing

Demand Valve/Keys in Pyxis/medication roomTanks in R.T. gas roomConnect to wall oxygen and suctionConfirm mask, hoses, and clamps in place before startSlide38

Important Points…..

ONLY patient may useHold over nose/mouth to make sealInhale gas 30 seconds before contraction. Full effect takes 50 seconds. May take 3 - 4 UCs to learn the best technique.

Exhale fully into the mask for scavengingMachine makes hissing soundSlide39

May ambulate with assistance after at least five minutes if stable.

Before moving wait 60 seconds after last inhalation. Slide40

Ongoing Patient Care

RN to observe/assess for first 15 minutes confirm correct usage, effectiveness, and side effectsVital Signs routine L&D orders Fetal monitoring

continuous or IA as indicatedIf maternal or fetal wellbeing compromiseddiscontinue nitrous oxide, notify providerperform intrauterine resuscitation interventions as neededSlide41

Equipment Care

Bio-Med will assess every 12 monthsFull clean/disinfect occurs after use in roomClean units will be covered in plastic in medication roomSlide42

Safety

Don’t trip on tubes!Refer to SDS if exposure occursLeaking nitrous can cause altered mental state(Scavenging system in machine & wall suction)

Share any concerns with Charge RNQA/Pt Safety Committee will review every 3 monthsSlide43

References

Barbieri R, Camann W, McGovern C. Nitrous oxide for labor pain. OBG management 2014:26(12): 10-12, 14

.Berlit

S1, Tuschy

B

,

Brade

J

,

Mayer J

,

Kehl

S

,

Sütterlin

M

. Effectiveness of nitrous oxide for postpartum perineal repair: a

randomised

controlled trial.

Eur

J

Obstet

Gynecol

Reprod

Biol.

2013 Oct; 170(2): 329-32.

Bishop J. Administration of Nitrous oxide in labor: expanding the options for women. Journal of Midwifery and Women’s Health 2007; 52 (3): 308-309.

Leeman L, Fontaine P, King V, Klein MC,

Ratcliffe

S. The nature and management of labor pain: Part ll. Pharmacologic pain relief. Am Fam Physician 2003; 68: 1115-20.

Likis

FE, Andrews JA, Collins MR, Lewis, RM,

Seroogy

JJ, Starr SA, Walden RR,

McPheeters

ML. Nitrous Oxide for the Management of Labor Pain. Comparative Effectiveness Review No. 67. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290- 2007-10065-I.) AHRQ Publication No. 12-EHC071-EF. Rockville, MD: Agency for Healthcare Research and Quality. August 2012.

Likis

FE, Andrews JC, Collins MR, Lewis RM,

Seroogy

JJ, Starr SA, Walden RR,

McPheeters

ML.

Nitrous

oxide for the management of

l

abor pain: a systematic review.

Anesth

Analg

. 2014 Jan; 118(1): 153-67

.

Rooks J. Safety and Risks of nitrous oxide labor analgesia: a review. Journal of Midwifery and Women’s Health 2011; 56(6): 557-565

.

Stewart, L.S., & Collins, M. (2012) Nitrous Oxide as Labor Analgesia: Clinical Implications for Nurses

. Nursing for Women’s Health,

2012; 16(5): 398-408.

16(

5

)Slide44

References

Carstinou, J.,

Levytam, S., Norman, P., Daley, D., Katz, J., Sandler, A. (1994). Nitrous oxide in early labor safety and analgesic efficacy assessed by a double-blind, placebo-controlled study. Anesthesiology, 80: 30-35.Collins, M., Starr, S., Bishop, J., Baysinger, C. Nitrous oxide for labor analgesia: expanding analgesic options for women in the United States. 

Rev Obstet Gynecol. 2012;5:e126–e131.Klomp, T., Poppel, M.V., Jones, L.,

Lazet

, J.,

Nisio

, M.D., &

Lagro

-Janssen, A.L. (2012). Inhaled analgesia for pain management in

labour

. Cochrane Database of Systematic Reviews, 9.doi: 10.1002/14651858.CD009351.pub2

Maze, M., &

Fucinaga

, M. (2000) Recent advances in understanding the action and toxicity of nitrous oxide.

Anaesthesia

, 55(4), 311-14.

Pasha, H.,

Basirat

, Z.,

Hajahmadi

, M.,

Bakhtiari

, A.,

Faramarzi

, M., &

Salmalian

, H. (2012). Maternal expectations and experiences of labor analgesia with nitrous oxide. Iranian Red Crescent Medical Journal, 14 (12), 792-92.

Rosen, M. A. (2002). Nitrous oxide for relief of labor pain: A systematic review. American Journal of Obstetrics & Gynecology, 186, 110-126.

Su, F., Wei, X., Chen, X., Hu, Z., &Xu, H. (2002). Clinical study on efficacy and safety of labor analgesia with inhalation of nitrous oxide in oxygen.Slide45

Thank you