Questions & Answers
Do you have any references on the use of Nitrous Oxide in Labor and Delivery?
1) References for use of nitrous oxide-
ACOG- Not recommended in combination with sedatives/opioids
2) ASA- Also not recommended in combination with sedatives/opioids. Side effects can include dizziness and nausea (nursing implications- increased fall risk)
3) ASA- Management of Nitrous Oxide in Laboring women and
Nitrous Oxide in labor requires an order and consent and is this is usually per anesthesia although some organizations allow OB/GYN to order.
“The safe and proper use of N2O for labor analgesia requires multi-disciplinary involvement (anesthesiology, obstetrics, neonatology, nursing, risk management, facilities management, etc.).(30,31) Success increases when all stakeholders are involved in the discussion and development of local policy and protocol. However, CMS designates the Chief of Anesthesiology as ultimately responsible for all anesthesia/sedation policies, and thus requires their final approval. Local policy or protocol development may allow for labor nurse or midwife initiated N2O for labor analgesia with obstetric provider orders (50% N2O without co-administration of other analgesic/sedative agents typically produces an effect, defined as normal response to verbal stimulation, that qualifies as minimal sedation).(32)” (See reference link above)
Staffing Considerations-
“Use of 50% N2O for labor analgesia as the sole agent with no other sedative or analgesic medications should produce an effect that is designated as “minimal sedation,” and administration does not require patient oversight by an anesthesiologist.(34) Labor and delivery staff need training and education on N2O use, knowledge of their local policies, proper administration, importance of scavenging, patient monitoring, and potential for exposure of health care workers.(35) Some hospitals require 1:1 nursing/midwife care:patient staffing for N2O usage, while others allow the labor nurse to leave after the first 15 minutes of 1:1 supervision. N2O dosimetry badges may or may not be required for staff and local policy determines how environmental exposure will be monitored”
Storage- Should be considered as possible risk of diversion or abuse and therefore securely stored according to organization policy
“Other public health risks include potential diversion or abuse, including health care professionals who have access and are familiar with its clinical use. (49) Although N2O is a weak anesthetic, it has some abuse potential. N2O is also available from other sources including as a propellant for pressurized cans (e.g., whipped cream). Acute inspiration of 100% N2O can lead to addiction, cerebral hypoxemia, asphyxiation and death. (11) Repeated chronic abuse over several months to years can lead to irreversible peripheral myeloneuropathy with the potential for permanent neurologic disability.(48,49) In a 2016 literature review(50), nitrous oxide abuse strongly correlated with low vitamin B12 and included 72 cases of neurologic sequelae including myeloneuropathy or subacute combined degeneration and 29 cases of death due to nitrous abuse. Because of the potential for abuse, the delivery system should be regulated in a controlled environment and stored appropriately. (48)”
