Nitrous Oxide for Labor Pain

Nitrous oxide (also called “laughing gas” or “gas and air”) has long been in common use for labor pain in other countries, being used by more than half of laboring women in such countries as England, Finland, Sweden, and Canada. It has not been common in the United States in recent decades (it was only available at 5 hospitals in 2012); however, its popularity is now increasing as equipment becomes more widely available, and may soon be seen in more hospitals and out of hospital birth centers. This online article is intended as a supplement to chapter 13 of the 2016 edition of Pregnancy, Childbirth, and the Newborn which does not cover nitrous oxide.

How Administered

Nitrous oxide is a gas. It is mixed 50/50 with oxygen, and inhaled through a mask. (Note: If you’ve had nitrous at the dentist, that’s a 70/30 or 80/20 mixture. So the dose given in labor is lower than the dose at dental procedures, and has a milder effect.) The laboring mother holds the mask to her face whenever she wants a dose. The gas only flows when she inhales. When she moves the mask away, the medication stops. (To see what the equipment looks like in use, do an online image search for “nitrous oxide in labor.”)

The peak pain relief effect kicks in about 50 seconds after you start inhaling. But the peak intensity of contraction pain tends to be 25 – 45 seconds into a contraction. That means you need to start inhaling 30 seconds BEFORE the next contraction is expected so the gas is in full effect when the contraction pain peaks. It can be tricky to get timing just right.

Benefits

Nitrous oxide stimulates the brain to release endorphins and dopamine, hormones that help to reduce pain. Nitrous oxide does not completely relieve labor pain, but women are less bothered by the pain. It reduces anxiety, and can cause a mildly euphoric feeling. Women describe themselves as feeling relaxed and calm while using it. Women report that they liked the fact that they had control over the administration. (To learn more about the laboring person’s experience of nitrous, watch this video from Vanderbilt at https://www.youtube.com/watch?v=lPyuerAoKg8)

Other benefits are that it’s inexpensive (at some hospitals, there’s no extra charge – it’s included in room cost), it takes effect quickly, and if you stop using it, the effects fade quickly (it has a half-life of 3 minutes) rather than remaining in your system for a long time. That means that if you decide nitrous does not provide enough pain relief, it’s easy to move on to other options, such as epidural analgesia.

Effectiveness

One study (Pasha, 2012) found that 92% of women had less pain with nitrous than without. They were also less likely to have severe pain. On nitrous, 41% reported severe pain and 10% reported very severe pain. In the no-nitrous group, 55% had severe pain and 27% had very severe pain.

It’s important to note that nitrous oxide is a mild pain reliever. You should not expect it to take away all your pain. An epidural is much more effective at that; however, an epidural also has more tradeoffs and side effects, so you may choose to start with nitrous and see if that offers enough relief. Some nurses describe the choice to have nitrous as “why not try it and see if it helps.”

Rather than thinking of nitrous as pain relief, it may help to think of it as a ‘coping boost.’ One study showed that it did not reduce the intensity of pain much (as measured on a visual analog pain scale), but after the study period, when given the option to stop using it, women wanted to continue using it anyway. (Carstinou, 1994) The unpleasantness of the pain was reduced, and seemed more manageable. Another study found that 98% of users were satisfied with the experience of using nitrous oxide. (Pasha, 2012) Studies also show that women say they would use it again in a subsequent labor.

Tradeoffs

Unlike epidural analgesia, nitrous does not require extra procedures or extra monitoring. You will not need an IV or continuous fetal monitoring. You are also able to stand, move, and change positions. (If the oxygen comes from a portable tank, you can move around with it, but if the oxygen is piped in from the wall, you’ll need to stay near the bed.)

Possible Side Effects

Side effects on mother and baby are minimal, and less than those experienced with epidural analgesia and with IV / IM narcotics. They can include nausea, dizziness, drowsiness and a hazy memory of events. There is a small chance you could lose consciousness, but if you do, you drop the mask away from your face, and quickly recover. Nitrous does not slow labor and does not affect your ability to push. It does not appear to affect baby at birth. The portable pump is loud, but nurses report this does not seem to bother the user.

Nitrous is contra-indicated if you have persistent anemia / vitamin b12 deficiency.

Timing in Labor

Can be used at any time in labor, except you cannot have nitrous if you have had narcotics in the past two hours. You must wait for them to wear off.

Some cases where it might be especially helpful: during transition, during anxiety provoking procedures (such as vaginal exams, IV starts, stitches for a tear), for women who arrive at the hospital in heavy labor and need quick relief, and at any time by someone who wants to delay getting an epidural. Birth center midwives also report using it when a mom is considering a transfer to the hospital for pain medication. Anecdotally, they say that about half the time it has allowed the client to remain at the birth center.

Comparison to Other Methods

On page 211 – 212 of the book, we offer a chart called “Nonmedicated Labor versus Medicated Labor” that compares what labor is like if no pain medications are used, or if IV narcotics or epidural analgesia are used. Here is that same information for nitrous oxide, so you can easily compare and contrast to the other options.

Pain-Relief Option Used Nitrous Oxide
How it affects your experience of pain Increases pain-relieving endorphins, eases anxiety or fear, and enhances your mood. Small decrease in pain intensity, but makes pain less unpleasant. Can boost your ability to cope.
Feedback from women who used it “Labor was still intense, but it took my fear away and helped me calm down. It made it seem like coping with the pain was doable.”
How it affects your mental state You’re relaxed, calm, may be drowsy or light-headed.
How it affects your mobility You can walk, move around and change positions. If the equipment is hooked up to the wall (rather than being on a mobile cart), you will have to stay close to the bed.
What you’ll need from your support people You’ll still be experiencing pain (though you’ll be less distressed by it). You’ll still want support with comfort techniques and emotional support. Also, they can tell you when a contraction is about to start so you can begin inhaling. (Nitrous oxide is most effective if you start 30 seconds before the contraction.)
Equipment and precautions required You’ll hold the mask that dispenses the nitrous, inhaling from it as desired. Some women need an oxygen sensor on their fingers.
Impact on labor progress Does not affect labor progress.
Timing Can be used at any time, especially during anxiety provoking times in labor.
Availability Very limited availability in the U.S.
Possible risks to you Minimal. (See above.)
Possible risks to baby No apparent risks
Cost Inexpensive
Best option for you if… You just need a little boost to your ability to cope, or need to reduce your anxiety.

For more information:

Source for study data cited: Pasha, et al. Maternal expectations and experiences of labor analgesia with nitrous oxide. Iran Red Crescent Medical Journal, 2012. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3587869/

 

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Labor Hormones in under 10 minutes

Note: this page is about how professionals can TEACH this concept to expectant parents. If you’re an expectant parent looking for info on labor hormones, their effect on labor pain, and what your partner can do to help you have a shorter and less painful labor, click here.

In my childbirth classes, and with doula clients, I want them to understand that our emotions, and the support we receive, absolutely affect labor on a physiological basis, by influencing our hormones. The big message is that fear and anxiety slow labor down and make it more painful. Support and feeling safe make labor faster and easier. I have simplified the complex details into a simple stick figure drawing that takes 5-10 minutes.

Before I talk about my teaching method, let’s start with a basic summary* of hormones

Hormone What Does It Do What doesn’t help What does help
Oxytocin Causes labor contractions that dilate cervix Anxiety, bright lights, feeling observed, feeling judged

Pitocin – if have synthetic oxytocin, make less hormonal oxytocin

To increase oxytocin: Skin-to-skin contact.
Nipple stimulation, making love.To increase endorphins: social contact and support from loved ones.To increase oxytocin and endorphins and to reduce adrenaline: create an environment where we feel private, safe, not judged, loved, respected, protected, free to move about.(So, partners, if you remember nothing else about labor support, remember that if she feels safe, loved and protected her labor will be faster, and less painful)
Endorphins Relieve pain, reduce stress (cause euphoria and feelings of dependency) Stress, lack of support

Narcotics (if you have an external opiate, your body will start producing less internal opiate… even after the narcotics wear off, you’ll have less endorphins)

Catecholamines (adrenaline, etc.) In early / active labor: slow labor down(Imagine a rabbit in a field. If it doesn’t feel safe, it wants to keep baby inside to protect it)

In pushing stage: Make you and baby alert and ready for birth, give you energy to push quickly.
(If the rabbit is about to have a baby, and something frightens it, it wants to get the baby out as quickly as possible so it can pick it up and run with it.)

Stress / anxiety / fear

Lack of control

Feeling trapped

Hunger, cold

 

So, in class how do I convey these ideas in just a few minutes, so it’s easy to understand and to remember?

First, I say: “In labor, our emotions and our environment effect our hormones. Our hormones have a huge effect on labor. Let’s look at a couple scenarios for labor.” [I draw two stick figures on the board.] “This one is awash in stress hormones which will make labor longer and more painful. Let’s label it adrenaline. This one is under the influence of oxytocin and endorphins. These help the laboring person shift into an altered state where labor pain is milder (less intense and less unpleasant) and also help labor progress more quickly.” [Add labels to drawings, add sad face and smiley face.]

Picture2

Then I say “So, you are all probably familiar with adrenaline. What do we call it? Yes, the fight or flight hormone. This is the idea that if an individual ran into a tiger in the woods, they would choose either to fight it or to run away. Do you know what we call oxytocin? Many call it “collect and protect” or “tend and befriend.” If a tiger is coming into our village, we gather everyone together, because we are safest together.” [I add these labels to my drawing.]  (I sometimes throw in the tidbit here that men who are not dads are more likely to release adrenaline during stressful situations; women and dads are more likely to release oxytocin – it’s the “gather the babies and protect them” response.)

Picture3

“So, what effect do these hormones have?”

“With adrenaline, all your muscles tighten. All your energy goes to your limbs in case you need to fight or run away. So, oxytocin production drops and labor slows down. (It’s hard for your cervix to open when you feel scared…)  You are also more sensitive to pain – this is useful if you’re at risk of injury – your body tells you what to move away from. But, in labor it’s not helpful – it just means labor hurts more!”

“With oxytocin and endorphins all your muscles relax. Energy is sent to the uterus and oxytocin increases. (Oxytocin is often called the love hormone, because it increases when we feel loved, and its peak levels are when we orgasm, when we birth, and when we breastfeed. It’s all about making babies, birthing babies, and feeding babies.) We also get an increased endorphin flow, which makes us less sensitive to pain, can cause euphoria, and can cause feelings of love and dependency in us… “I love you man….””

[As you talk, write the notes, and draw on the figures like this to show effects…]

Picture4

[If you teach the 3R’s method for coping with labor pain – relaxation, rhythm, and ritual, you can also add in here: If you’ve got oxytocin and endorphins flowing, you may also have more rhythm – you may rock, moan or sway rhythmically. If your partner helps to reinforce your ritual, it will help build your oxytocin and endorphins.]

“So, what causes adrenaline rushes? Fear, anxiety, feeling watched or judged, feeling like you have no control over your situation, being hungry or cold.”

“How can we tell a person in labor is rushing adrenaline? They act vigilant or panicky, have lots of muscle tension, and a high pitched voice.”

“What causes oxytocin and endorphins to flow? Feeling safe, loved, protected, having privacy, having support, eye contact, skin-to-skin contact, and love making.”

“How can we tell if someone is in an endorphin / oxytocin high? They seem open and trusting, their muscles are relaxed, and their voices are low-pitched and husky.”

[Add notes about causes and signs to your picture.]

Picture5

“So, partners, what’s the big picture summary?”

“If you remember nothing else from this class, remember this: If a person in labor feels safe, loved, and supported, her labor will be faster and less painful. If in doubt about what to do, always return to this! Anything that helps her relax, gain her rhythm and feel cared for will help her.”

More Info

* If you want a great overview of hormones in labor, read Pathways to Birth. If you want all the details on hormones in labor, read Hormonal Physiology of Childbearing. You can find them both at: http://transform.childbirthconnection.org/reports/physiology/.

To read more of my blog for childbirth educators and doulas, click here. For lots of ideas for interactive activities for childbirth education classes, click here. To learn more about any topic related to the perinatal period, check out our book Pregnancy, Childbirth, and the Newborn: The Complete Guide.

Phantom Pain Doulas

After a recent experience with phantom pain, I was thinking about how helpful it could be to have phantom pain doulas.

What is phantom pain? Phantom limb sensation is something that is experienced by amputees where it feels like the missing limb is still there.

It can be just sensation. For example, any time I talk about or write about phantom pain or about my missing leg, I feel a tingling throughout my “right leg”, even though my right leg was amputated 35 years ago – back in 1982. The tingling is similar to what you feel if your leg falls _really_ asleep, then you change position and you get that tingling / stinging sensation as the blood flow returns. It is very defined as to its location in the “limb”. I can feel the outline of all 5 toes, my heel, my calf and so on, as if my leg was still there.

Sometimes it’s discomfort – maybe in one very specific place – like the outside of “my pinkie toe”, or “my Achilles tendon”, might feel like someone’s pricking it with pins or thumbtacks.

It can also be pain. From mild to awful. Like someone is taking a sharp knife and stabbing it into my knee over and over again.

You may see articles that compare levels of pain, and they typically say that childbirth and phantom pain are at the top of the list, above broken bones, kidney stones, and tooth abscess. Having had three babies, I can definitely say that the intensity of phantom pain can be as overwhelming as labor pain.

It’s usually not that bad! For me, I’d say it only gets that bad maybe once or twice a year. (Usually when I have a fever.) But, I do have times, maybe once a month or every other month, where it’s bad enough that I have a hard time concentrating on my work or enjoying my leisure, or getting to sleep.

But, that frequency (once a month of needing attention, once a year of being overwhelming) is what I experience after 35 years as an amputee. It has become much less frequent over the years. For a NEW amputee, they can experience this pain far more often. It could be a huge help for them to have doula style support managing that pain.

What could a doula or other support person do to help with phantom pain?

Validation: Like with labor pain, one of the first steps is validation – “I hear that you’re hurting. I know it’s hard. I know you feel like you should be able to cope with it on your own, but I know it’s challenging and I’d like to help.”

Knowing about self-help techniques that help with phantom pain

  • Counter-irritants: One thing amputees may do to manage the phantom limb pain is to cause another pain somewhere “real” to distract them from this pain. This might be biting their lip, pounding their fist on the remaining limb, or squeezing their fingernails into their hands. Counter-irritants can be helpful for many pain sources, but especially for phantom pain, it can give the sufferer a sense of being in control of that pain even though they can’t control the phantom pain. An effective tool for creating this discomfort that doesn’t harm them is reflexology combs. Learn more about them and counter-irritants here. Learn more about the theory of diffuse noxious inhibitory control here.
  • Heat and massage: I find often, but not always, the cause of my phantom pain in my leg is actually tight muscles in my lower back, near my sacrum. (This usually happens when I’ve had some days of bad posture – like sitting on a soft bed and reading, which is hard on my sacral muscles.) So, heating pads and a good sacral massage can often relieve the phantom pain.
  • Other amputees find other self-help techniques helpful, such as acupressure, exercise, putting pressure on the stump – I discuss them in this post I wrote years ago: www.transitiontoparenthood.com/janelle/energy/PhantomPain.htm
  • Many of the other coping techniques doulas use in labor, such as breathing, attention focus, movement, baths, and so on can help. Phantom pain is often intermittent, coming in waves (like contractions), so support could look like labor support in early labor: sitting and watching TV or playing games for ten minutes, then helping the amputee manage a 30 second surge of pain, then returning to the movie / game.

Knowing about alternative medicine that can help with phantom pain

Knowing about medication

In MY EXPERIENCE (others may vary), here are things that didn’t help with phantom pain: Tylenol on its own, Tylenol with codeine, ibuprofen on its own, other NSAID’s, and alcohol. None of it did anything, really, so the self-help, acupressure, and energy medicine were essential to me for years.

What does help? What’s my best magic cure for phantom pain? One Tylenol and one Ibuprofen. Taken together. It’s gotta be both, or it doesn’t work. But together, it’s fabulous. No matter how bad my pain is, it’s gone in 15 minutes after I take this.

I LOVE that I discovered this about ten years ago. It gives me so much more of a sense of control over my phantom pain. I don’t take medication for mild pain – I want to go easy on my liver and taking large amounts of medication is NOT good for your liver. But it helps to know that whenever it gets too much to handle, or when I need to go to sleep or need to be at my best to teach, all I need to do is take a Tylenol and ibuprofen and it will be better in about 15 minutes and will stay better for about 6 hours. I never travel without my emergency stash of one of each pill (ever since that day in Disneyland where I had to buy one whole bottle of each at theme park prices!)

What you could do

As a doula, you know a lot about pain coping in general, and how to sit with someone who is in pain, and now I’ve given you some tips specific to phantom pain. For an “old amputee” like me, we’ve learned coping techniques that work, and we can take the occasional Tylenol/ibuprofen cocktail to manage it.

But a new amputee needs to learn those coping techniques, and they can’t be popping medications every day (because of impact on liver), so they need extra support. If you know any new amputees who are struggling with phantom pain, consider offering your support, even just a conversation about things that might help.