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No laughing matter: Nitrous oxide gains acceptance in NC’s delivery rooms

A woman's pregnant torso poses in the light. This photo is used to illustrate perinatal depression and maternal health and use of nitrous oxide in childbirth.
Photo credit: Flickr creative commons.

By Yen Duong

If you’ve ever had a wisdom tooth out or dental surgery, you may have used laughing gas to take the edge off the pain. Across North Carolina, women now have the option to use the same nitrous oxide to get through childbirth.

The mix of nitrous and oxygen has been used for childbirth across the world for about a century, but it’s only recently started catching on again in American hospitals. University of North Carolina – Chapel Hill Women’s Hospital was the first in North Carolina to offer it in 2013. This month, Atrium Health’s main Charlotte hospital, Carolinas Medical Center, joins the trend.

“It’s a unique tool; we didn’t really have anything else like it that really worked with a woman who’s coping but is getting to a phase of her labor where that intensity has ramped up,” said certified nurse-midwife Meg Berreth of the UNC School of Medicine. “You can stop using it and you don’t have any effects still lingering. You can use it straight through pushing.”

Pain management during labor

In childbirth, women often manage the early stages of labor at home. As contractions become stronger and closer together, many women head to hospitals or birthing centers, which turn to medicated pain measures: intravenous narcotics such as Demerol or Stadol, local anesthetics such as epidurals, and now nitrous oxide.

“Women between eight and 10 centimeters, whether they want an epidural, or whether they want to have a delivery with no medication, everybody wants something at that point,” said Dr. Leslie Hansen-Lindner, who spearheaded the effort to bring nitrous to CMC. “At that point, you can’t get narcotics because it’s too close to delivery and narcotics affect the baby’s ability to breathe.”

For women who don’t want, or can’t have an epidural, which limits one’s ability to move around during labor, or IV pain medication, which can cause drowsiness and other side effects, nitrous oxide offers a welcome alternative.

“As a nurse-midwife, I do get a lot of patients that want to do natural childbirth or childbirth without an epidural,” said nurse-midwife Hallie Lyon, who worked with Hansen-Lindner to bring nitrous to CMC. “Plus we have patients sometimes that can’t get an epidural for other reasons, and it gives them something else to use.”

For instance, women with low platelet counts or who were recently on blood thinners can’t get epidurals, as the needle can cause bleeding near the spinal cord, Hansen-Lindner said.

Opting for nitrous oxide

Nitrous oxide has fewer restrictions than epidurals, Hansen said. It also acts quickly: women feel its effects within one or two breaths. Because of its short half-life, it also leaves the body quickly after women stop using it, unlike epidurals or IV pain medications.

“It doesn’t make you not feel the pain of the contraction, it just helps you to process it a little bit differently,” Hansen-Lindner said. “Every time the contraction comes, [when] you start to feel like you’re losing your ability to cope, the nitrous helps you think ‘I can manage this.’”

Nitrous was popular in the U.S. in the 1950s and 60s, but then epidurals took over in the 1970s. New technology and patient interest have helped bring back laughing gas. Unlike at the dentist, a woman controls the nitrous oxide herself during labor by holding a mask to her face and breathing in and out of it.

“A former issue was the gas going out in the room and hitting providers or family members. Also overdosing,” Hansen-Lindner said. “But the new system means you can’t get too much. You’ve got to hold the mask on your face and if you’re starting to get loopy, your hand comes away.”

The nitrous oxide machine is small and has wheels with two metal bottles dispensing laughing gas and oxygen.
The nitrous oxide machines consist of one tank of oxygen, one tank of nitrogen, a ‘blender’, and a mask and tubing system. Photo credit: Yen Duong.

While it was rare for patients to get enough nitrous oxide to cause serious side effects, medical providers who were often exposed to any gas in the room were at risk for difficulty breathing, choking, seizures and other negative effects. New “scavenging” systems which pull excess gas from rooms are now common practice, according to reader Mike Civitello from manufacturer Porter Instrument, which makes nitrous oxide medical equipment.

Like over half of Americans, I chose an epidural for my first two births. I needed it for that first 26-hour labor so I could take a nap without the contractions waking me up, even though that meant I could no longer move around, squat or bend over in labor positions which might help the baby come. If nitrous had been available, I would have tried it for my second delivery, which was only five hours and much easier.

“The downside of nitrous is that it doesn’t get you any rest because you have to self-administer it,” Barreth said. “It can be relaxing, but for a woman with a long, drawn-out labor who has been at it for a while, sometimes she just needs to sleep … it is not as ideal for that.”

While more hospitals and birthing centers have been offering nitrous lately, the trend has been slow to pick up: a national survey found that in 2002, only 2 percent of women had used nitrous oxide during labor. By 2013 that number increased to 6 percent. A California-only survey in 2018 showed 8 percent of women used the gas.

Bringing nitrous to hospitals

The nitrous oxide machines at CMC join the ones at Novant Health Presbyterian within the limits of Charlotte, the most populous city in the state, though Novant Health Huntersville Medical Center, Novant Health Matthews Medical Center and Atrium Health Pineville also offer the gas. Earlier, Charlotte moms could access nitrous oxide at a Baby & Co. birthing center, but all three locations in the state closed last year after some newborns died.

[Read more: https://www.northcarolinahealthnews.org/2018/04/12/22416/ ]

After tracking patient use from the past few years, UNC now has three nitrous oxide machines for their 15 labor and delivery rooms. CMC is starting with two machines for their 23 rooms but are open to buying more machines based on usage.

When nitrous first came up at Atrium, Hansen-Lindner and Lyon ran into pushback from anesthesiologists who were wary of introducing the gas. When Atrium switched to a different anesthesiology practice in summer 2018, the providers found a more open group that had previous experience with nitrous, and the ball started rolling. Today, providers order the nitrous oxide just as they do IV pain medications, Hansen-Lindner said.

Some NC hospitals which offer nitrous oxide for labor. Light green (UNC Chapel Hill Women’s Hospital) was first to offer in 2013; dark red (Atrium Health Carolinas Medical Center) is the latest to join. Darker colors indicate later years of first offering nitrous. Map credit: Yen Duong.

Know of another North Carolina hospital that offers nitrous oxide for childbirth? Let us know at yduong@northcarolinahealthnews.org.

At UNC, nitrous oxide is ordered and billed through anesthesiology. Barreth said that in the past, the UNC midwives and obstetricians had also run into concerns from anesthesiologists, as about half of women who use nitrous then go on to get an epidural.

As a result, she said that the anesthesiologists had considered the nitrous a failure.

“I said ‘Listen, if I rub a woman’s back for two hours and then put her in the tub, and then she wants an epidural, it’s not because I’m not a good masseuse, or because the tub wasn’t a great option, it was just that it’s not enough now,” she said. “We helped them understand that it is another tool to have in the toolkit.”

How we reported this story: I heard about nitrous oxide coming to CMC during my hospital tour in preparation for the baby. Fun fact: I knew about it before some of my midwives and nurses did. Interviewed sources by phone and in person, and I did research into nitrous oxide with some journal articles, linked in the story. I’m looking forward to trying it in a few weeks.

Note: This story has been corrected to reflect that laughing gas as used medically is a mixture of nitrous oxide and oxygen, and clarify what “overdosing” means per a reader email. It has also been updated to reflect the correct last name of Dr. Leslie Hansen-Lindner, not Hansen.

After publication, Novant Health reached out to us to inform us that Novant Presbyterian Medical Center, which is in Charlotte, recently also started offering nitrous oxide for childbirth. 

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