TO: Jessica Hanon, RN, CNM FROM: Marissa Dunn, RNDATE: March 7, 2019 RE: A proposal to implement a program that facilitates the inclusion of nitrous oxide as an option for labor analgesia.PURPOSEI propose that our Labor and Delivery unit initiates a program that facilitates the inclusion of nitrous oxide as an option for labor analgesia. The experience and response to labor pain is highly individualized. Women should have a variety of options for managing their labor pain. Our current practice offers labor analgesia with intravenous Dilaudid or placement of an epidural. Our unit works closely with midwives and their patients. Nitrous oxide allows women to avoid interventions associated with epidurals such as, intravenous access, bladder catheterization, continuous fetal monitoring and confinement to bed.PROBLEMOur unit consists of multiple certified nurse-midwives. Their patients are usually dissatisfied with the labor analgesia options we offer, intravenous dilaudid or an epidural. Dilaudid provides short-term labor analgesia, with a half-life of two hours. Increased risk for fetal respiratory depression and the need for neonatal resuscitation at the time of delivery deter many patients from this use of dilaudid for labor pain relief. This is a problem because many women, especially midwife patients, do not want to have an epidural during labor. For reasons such as, immobility, risks, and difficulty bonding with their baby after delivery. On our unit, women can either receive an epidural or dilaudid for labor analgesia. SOLUTIONMy recommendation would be to initiate a nitrous oxide program on our unit. This will increase patient satisfaction, decreased opioid use, and decrease cost compared to regional anesthesia.Nitrous Oxide in labor is a 50/50 blend of oxygen and nitrous. This is different than the highly concentrated “laughing gas” used in dental offices, which is 70/80. Obstetric use of nitrous does not allow the provider or patient to alter the ratio of gases. The Obstetric apparatus delivers gas only on inhalation, not continuously.Nitrous oxide works by increasing the release of endogenous opioid polypeptide compounds (endorphins), corticotropins and dopamine that are produced in the mother’s brain. It is an analgesic, not anesthetic. Research shows an increase in patient satisfaction scores when nitrous oxide was providedSafety and Use4342946232555200Nitrous oxide is safe for women to use during the entire labor process. Nitrous oxide’s rapid onset of action and quick clearance prevents accumulation in maternal or fetal tissues.The demand valve in the apparatus ensures the gas mixture only delivers with inhalation. On exhalation, the flow of gas ceases completely. Nitrous oxide devices have scavenging capabilities. Expired nitrous oxide is gathered into a scavenger interface connected to the breathing circuit. The expired gas is vented outside through the facility’s vacuum system. Dosimeter badges measure the ambient nitrous oxide concentration. These Can be worn by providers. Acceptable ambient levels were set at 25 parts per million (ppm) by National Institute for Occupational Safety and HealthyTo use nitrous oxide, the patient breathes the gas through a mask or mouthpiece. The patient holds her own mask, increasing sense of control and autonomy. The patient starts to breathe in gas mixture about 30 seconds before a contraction starts which allows nitrous oxide to best most effective at the peak of a contraction. The patient can put mask or mouthpiece down between contractions or use it in-between contractions, too.EducationPatient safety is a key component of nitrous oxide use in labor. Since it will be self-administered, initial and repetitive education to the patient and support person is required. It must be clear that only the laboring woman may administer nitrous oxide to themselves. If staff notes a support person is using the nitrous oxide, they should be removed from the patient’s room.Some woman may experience side effects such as vertigo and unsteadiness. It is important to educate the patient and support person on possible side effects. The woman must be up with assist to ensure her safety will moving around the room.Patient monitoring will be comparable to an epiduralized patient. The nurse must continuously assess the mother and fetus through the labor process. Vital signs should be in accordance to current policy, based on risk status and stage of labor.743975084200Nurses must have thorough education and demonstrate competency before providing care for women using nitrous oxide. I propose that nurses are required to view a presentation by the leaders of this proposed nitrous oxide initiation program. Then, staff will be required to pass a test regarding the information from the presentation. Documentation of core competency will be obtained.Documentation is similar to that of any analgesic method used in labor. Nitrous oxide documentation should include time of initiation, patient’s response and any side effects. End time with indication for termination of use is also documented.BenefitsOne benefit of Nitrous oxide’s rapid onset and elimination is that the woman will begin to feel effects within 2 to 3 inhalations. Nitrous oxide is eliminated from the lungs within a few breaths. Nitrous oxide not only promotes comfort during labor but can also be used during procedures such as painful sterile vaginal exams, external cephalic version, placement of IV and foley balloons for cervical ripening, manual removal of placenta, laceration repair and epidural or spinal placement.Nitrous oxide has no adverse effects on uterine activity. It does not decrease frequency or intensity of contractions. Since nitrous oxide has no regional anesthetic effects, the women is able to push effectively.Table 1.0 compares Nitrous Oxide and an epidural in the management of labor pain:Inhaled Nitrous Oxide EpiduralNoninvasive InvasiveVariable pain reduction Dense pain reliefSignificant anxiolysis No sedative effectNo serious side effects or risks Serious side effect and risksWoman retain mobility Woman is bed boundDoes not require IV access Requires IV accessDoes not require urinary catheter Requires urinary catheterNot possible for to use alone for cesarean anesthesia Can convert to anesthesia if neededNo oversight by anesthesiologist is required Oversight by an anesthesiologist is requiredTable 1.0ContraindicationsNitrous oxide is contraindicated in women with conditions that may create space for the collection of gas. These conditions include recent pneumothorax, gastric bypass surgery, and inner ear surgery. Nitrous oxide is also contraindicated in women with known B12 deficiency because of the relationship between nitrous oxide and cobalamin binding. Other contraindications include pernicious anemia, impaired consciousness, increased intracranial or intraocular pressure, pulmonary hypertension, and inability to hold the mask or mouthpiece.Neonatal EffectsIn one study, there were no significant differences in Apgar scores or special care nursery admissions. In this particular study, no newborns had an Apgar score less than 7 at 5 minutes. Nitrous oxide has no effect on maternal-infant bonding or early breastfeeding.After speaking with the hospital’s Infant Special Care Unit (ISCU) Neonatologists, they approve the use of nitrous oxide for management of labor pain. The mother using nitrous oxide during labor does not require ISCU to attend the delivery.CostAfter carefully reviewing the cost of this proposal, the nitrous system cost is $5,000 per machine. At most, the cost per patient after initial investment in nitrous system is less than $25.The cost breakdown is as follows:$8 for 3-4 hour use per patient (average time used by patients)$2-$5 per face mask$15.50 for scavenger hose, specific to the machineImplementationAll labor and delivery staff will participate in a Nitrous Oxide training session which will include patient assessment, benefits and risks, setup and use of equipment, protocol for machine checkout, patient monitoring and education, potential side effects, and patient support. This training must be completed before administering nitrous oxide. Training certificate will be documented through DevelopU, our online learning and development. This competency will be reevaluated on an annual basis, to ensure continued competence.I suggest a formal policy that will be written by the implementation team. All providers are required to carefully review and follow policy guidelines.Documentation will include date, time of initiation and discontinuation. Every 15 minutes you will document the patient’s response with pain scale and any side effects experienced. The policy will outline documentation requirements in more detail.A consent must be signed prior to administration. In the consent, the patient must understand that nitrous oxide may not remove all discomfort. It will include risks, potential side effects, instructions for use, and agreement not to allow anybody else to hold or use the mask. The patient will sign the consent, as will the provider. This consent will be scanned into patient’s chart after delivery.CONCLUSIONOur labor and delivery unit should implement the use of Nitrous Oxide for pain management. It will benefit this organization as it cuts cost and increases patient satisfaction scores. Using nitrous oxide will decrease recovery time due to mobility that the patient doesn’t have with an epidural. It will help with patient to nurse staffing ratios as the recovery time will be shorter before the patient goes up to the postpartum floor. Nitrous oxide is a safer alternative for pain management, it decreases opioid use, provides the patient with a sense of control, and will save our unit money. Implementing Nitrous Oxide on the unit is key to our success.ReferencesBishop, J. T. (2007). Administration of nitrous oxide in labor: expanding the options for women. The Journal of Midwifery & Women’s Health, 52(3), 308-309.Collins, M. (2018). Use of nitrous oxide in maternity care: AWHONN practice brief number 6. Nursing for women’s health, 22(2), 195-198.Collins, M. (2015). A case report on the anxiolytic properties of nitrous oxide during labor. Journal of Obstetric, Gynecologic & Neonatal Nursing, 44(1), 87-92.Likis, F. E., Andrews, J. C., Collins, M. R., Lewis, R. M., Seroogy, J. J., Starr, S. A., . . . Mcpheeters, M. L. (2014). Nitrous Oxide for the Management of Labor Pain. Anesthesia & Analgesia,118(1), 153-167. doi:10.1213/ane.0b013e3182a7f73cRichardson, M. G., Raymond, B. L., Baysinger, C. L., Kook, B. T., & Chestnut, D. H. (2018). A qualitative analysis of parturients’ experiences using nitrous oxide for labor analgesia: It is not just about pain relief. Birth.Rooks, J. P. (2007). Nitrous Oxide for Pain in Labor‐‐Why Not in the United States?. Birth, 34(1), 3-5.Stewart, L. S., & Collins, M. (2012). Nitrous oxide as labor analgesia: clinical implications for nurses. Nursing for women’s health, 16(5), 398-409.