Laughing Gas Gives Women Another Option To Manage Labor Pain

Nov 7, 2016
Originally published on November 15, 2016 2:52 pm

Since the mid-1800s, laughing gas been used for pain relief, but these days it's usually associated with a visit to the dentist.

In the early 20th century, women used laughing gas to ease the pain of labor, but its use declined in favor of more potent analgesia. Now a small band of midwives is helping to revive its use in the U.S.

One hospital in Rhode Island, South County Hospital in South Kingstown, has just added nitrous oxide, the formal name for laughing gas, to its menu of pain relief options for labor.

Amy Marks jumped at the chance to use it because she wanted to avoid an epidural — an injection near the spinal cord that blocks feeling below the waist. Now she sits with her son, Ethan Thomas, barely a day old, snug in the crook of her arm.

"When the contractions started getting pretty intense, I was like, wow, this is pretty bad," says Marks, who is 31 and lives in Wakefield, R.I. "So they brought it in and it really took the edge off."

If you've been through labor, you know it hurts. Is taking "the edge off" really enough? It was for Marks, once she got the hang of breathing in the gas through a face mask, timing it to anticipate the peak pain of a contraction by 15 to 30 seconds.

"You're going through the contraction, you're breathing in and out, maybe do five, six breaths, get to the peak of the contraction, and I kind of didn't really need any more, I could bear the rest of the contraction," she says. "I was giggly. But only for like 15 to 30 seconds."

Marks' nurse-midwife, Cynthia Voytas, says Marks was breathing a mixture of 50 percent nitrous oxide and 50 percent oxygen.

"It gives you this euphoria that helps you sort of forget about the pain for a little bit," Voytas says.

"Absolutely. That's exactly what happened," says Marks.

Voytas shows me a little cart stocked with two gas tanks. It's mobile, so nurses can roll it up to the woman's bedside. There's a hose with a breathing mask. When she wants a little gas, a woman can just pick up the mask and breathe. Voytas says it gives a mom more control over her pain relief.

Until 2011, only a couple of hospitals in the United States offered nitrous oxide to women in labor. Today, it's in hundreds, according to the two main manufacturers of nitrous oxide systems. One of those manufacturers, Porter Instrument, maker of Nitronox, says nearly 300 hospitals and birth centers use the option for pain management.

Michelle Collins, a professor and director of nurse midwifery at Vanderbilt University School of Nursing, is helping lead the charge to bring back nitrous oxide as one of several options women should be offered for pain relief during childbirth. She sees the effort as being in line with what midwives have always done: advocating for women to have more control of the experience of giving birth.

Prior to the 1950s, Collins says, nitrous oxide was commonly used in labor. But then doctors started using more powerful anesthetics. Women would go to the hospital, be completely knocked out, and wake up with a baby in their arms. Epidural anesthesia, which came on the scene in the 1970s, gave women the possibility of a pain-free labor while awake. But it came with trade-offs: epidurals can make it difficult to move around, and can prolong the second stage of labor.

Women want more options, Collins says. They want to be more involved in the birth of their baby. "Now women are more informed, and they're demanding that their voices be heard, which is a really great thing in my book," she says.

Nitrous oxide has continued to be used regularly in Europe for labor pain, so there's data that shows it's safe, especially in smaller doses. It doesn't reduce pain, like an epidural. Rather, it induces a sense of euphoria or relaxation.

"For some women, the epidural is going to be their number one choice. For other women, they want to be unmedicated and have nothing and that's their choice. For other women, nitrous oxide is a viable choice," Collins says. "It's seen somewhat like a menu and for everything that's safe, it should be on that menu and available to the woman."

Another leader of this mini-revolution, retired nurse midwife and epidemiologist Judith Rooks, says the gas leaves the body in seconds.

"It does pass the placenta and go into the fetal circulation, but as soon as the baby takes a breath or two, it's gone," Rooks says.

The American College of Nurse Midwives came out with a position paper in 2011, saying it's important for midwives be aware of nitrous oxide as a good option for women in labor and get trained in how to administer it.

Obstetricians don't have an official position on use of nitrous oxide, says Dr. Laura Goetzl, a professor at Temple University's Lewis Katz School of Medicine in Philadelphia and a member of the American College of Obstetricians and Gynecologists. She helped draft the College's 2002 guidance about analgesia for labor, which, she says, "did not discuss nitrous oxide as an option since its use in the U.S. was exceedingly rare at the time." She adds, "However, I can speak as an expert on obstetrical analgesia that it is a safe and reasonable option. We are actually currently trying to add a service to our hospital."

The American Society of Anesthesiologists reviewed research on nitrous oxide in May 2011, and said that there needs to be more studies, and more rigorous studies, on its safety and effectiveness — much of the research is decades old. They also warn that facilities should have a good system for capturing any gas that escapes into the air, so those nearby don't breathe it in. But they also say its use in Europe shows "good safety outcomes for both mother and child."

Nitrous oxide is less expensive than an epidural by hundreds, sometimes thousands of dollars. Collins says the disposable patient breathing circuit and mask cost about $25 and the gas alone might cost about 50 cents an hour. Porter Instruments, which manufacturers the Nitronox system, says the equipment itself will cost a hospital or facility just under $5,000. An anesthesiologist does not need to administer it — that can be done by a nurse midwife or other trained medical staff. Though hospitals are having a hard time figuring out the billing because it's so new, says Collins.

"The interesting thing is that there's not a charge code for this particular use of nitrous oxide in labor," she says. "So places around the country are being very creative in how they're approaching the charge portion of it."

One insurer in Rhode Island covers it as it would another painkiller. Some hospitals, says Collins, just swipe a patient's credit card, or don't charge at all.

This story is part of a reporting partnership with NPR, local member stations and Kaiser Health News.

Copyright 2016 Rhode Island Public Radio. To see more, visit Rhode Island Public Radio.

RENEE MONTAGNE, HOST:

Today in Your Health, we're going to take a look at nitric oxide - otherwise known as laughing gas - and childbirth, yes, childbirth. Laughing gas has a long history. Since the mid-1800s, it's been used for serious pain relief and sometimes a little comic relief, such as the 1976 movie "The Pink Panther Strikes Again."

(SOUNDBITE OF FILM, "THE PINK PANTHER STRIKES AGAIN")

PETER SELLERS: (As Chief Inspector Clouseau) Nitrous oxide.

HERBERT LOM: (As Dreyfus) What's that?

SELLERS: (As Chief Inspector Clouseau) That is the anesthetic, you know.

LOM: (As Dreyfus) Oh, good.

SELLERS: (As Chief Inspector Clouseau) Yes, it is good, yes.

MONTAGNE: Peter Sellers, posing as a dentist who samples the gas before giving it to his patient. And that's how most of us think that nitrous oxide is used. But this morning we're going to hear from Rhode Island Public Radio's Kristin Gourlay about its use in childbirth.

Good morning.

KRISTIN GOURLAY, BYLINE: Hello, Renee.

MONTAGNE: So you're here to talk to us about laughing gas and childbirth, which is - I have to say, I have never put those two together.

GOURLAY: Yes. It used to be really common, but it actually fell out of favor. And to see it back in use, I visited South County Hospital in North Kingstown, R.I. Amy Marks has just given birth. Her son, Ethan Thomas, is barely a day old. He's snug in the crook of her arm as she receives visitors.

This small hospital in southern Rhode Island has just added nitrous oxide - or laughing gas - to its menu of pain relief options for labor. Marks jumped at the chance to use it because she wanted to avoid an epidural. That's an injection in the spine that blocks feeling below the waist.

AMY MARKS: When the contractions started getting pretty intense, where I was like, oh, this is really bad, I think I might want an epidural. Somebody reminded me, no, remember, you wanted to try the nitrous. I said, oh, yeah. So they brought it in and it really took the edge off.

MONTAGNE: If you've been through labor, you know it hurts. Is taking the edge off really enough? Well, it was for Marks once she got the hang of it.

MARKS: So you're going through the contraction and you're breathing in, breathing out, you know, maybe do five, six breaths and then you get to the peak of the contraction. And I kind of didn't really need anymore. I could bare the rest of the contraction. You know, the contraction went away and I'm just kind of like, giggly, but only for like, you know, 15 to 30 seconds.

GOURLAY: It doesn't obliterate the pain like an epidural.

MARKS: I was, like, I'm just happy. I was, like, really tense and, like, oh, like - and now I was able to relax my body and my mind.

GOURLAY: Breathing in the mixture of 50 percent nitric oxide and 50 percent oxygen produces a kind of temporary euphoria. Up until 2011, only a couple of hospitals in the United States offered nitrous oxide to women in labor. Today, it's in the hundreds. Dr. Michelle Collins teaches nurse-midwifery at Vanderbilt University.

MICHELLE COLLINS: It started in Europe. It's been used in labor and birth for over 75 years.

GOURLAY: But she says it fell out of favor in the U.S. when epidurals became popular around the early 1970s. Now midwives are convincing a new generation of doctors and hospitals the option is safe and women want it.

COLLINS: For some women, the epidural is going to be their number one choice. For other women, they want to be un-medicated and have nothing and that's their choice. For other women, nitrous oxide is a viable choice. So for many of us, it seems somewhat like a menu. And for everything that's safe, it should be on that menu and available to the woman.

GOURLAY: Another advocate, nurse-midwife and epidemiologist Judith Rooks, says the gas is safe because it leaves the body in seconds.

JUDITH ROOKS: It does pass the placenta and go into the fetal circulation. But as soon as the baby takes a breath or two, it's gone.

GOURLAY: What's more, nitrous is cheaper than an epidural by hundreds, sometimes thousands of dollars. For one thing, you don't need an anesthesiologist to administer it. Though hospitals are having a hard time figuring out the billing because it's so new, says Vanderbilt professor Michelle Collins.

COLLINS: Right now there's not a charge code for - particularly for using nitrous oxide for labor and birth. So places are having to sort of write their own page, if you will, as to how to charge for this.

GOURLAY: One insurer in Rhode Island covers it as it would another painkiller. Some hospitals, says Collins, just swipe a patient's credit card or don't charge at all because the gas is so cheap. At a time when giving birth in a hospital has gotten pretty expensive, that might be music to some women's ears.

MONTAGNE: And that was Rhode Island Public Radio reporter Kristin Gourlay. And Kristin is with us now. You know, I did not hear any critics there.

GOURLAY: Well, you're right. There's just a lot of safety data on nitrous and all of it is really pretty good. Some people say, you know, you've got to make sure there's a system for capturing any gas that escapes into the labor and delivery room, you know, so staff don't breathe it in.

Also, women have to be taught how to use it because there's a delay in its effect, you know, you have to anticipate your contractions a little bit and breathe it in about 15 to 30 seconds before. But midwives and some doctors are really trying to make nitrous oxide another common option for women in labor.

MONTAGNE: And you mentioned midwives leading the way here?

GOURLAY: That's right. You know, midwives have always advocated for women to have more control of the experience of giving birth. When epidurals came on the scene, you know, for many years people just saw them as this incredible new option that could give a woman a completely pain-free birth. You know, that was something unimaginable, Renee, a hundred years ago. But epidurals come with a price, you know. For one, you can't move around once you've gotten it. Moving around can actually help speed up labor. Epidurals have been known to slow labor down. Nitrous oxide doesn't have that effect.

So midwives are part of this movement toward a more patient-centered childbirth. I don't just mean, quote, "natural childbirth," where a woman doesn't use any drugs. But, you know, one in which a woman has more options, let's say, and is in more control of the experience of giving birth.

MONTAGNE: We've heard about safety then just now. But how easy is it to use?

GOURLAY: Well, pretty easy. Midwives showed it to me in Amy Marks's hospital room, she's the woman who had just given birth in the piece we just heard. It was just a cart with a couple of gas tanks on it. And nurses just roll it up to the woman's bedside. There's a hose with a breathing mask. And when she wants a little gas, a woman can just pick up the mask and breathe.

MONTAGNE: Kristin Gourlay is a reporter with Rhode Island Public Radio. She's part of a reporting partnership with NPR, local member stations and Kaiser Health News. Thanks very much.

GOURLAY: Thank you so much. Transcript provided by NPR, Copyright NPR.