Bring Me the Gas!

Nitrous oxide in the delivery room? Yes, please.

Happy mother with newborn baby

This may be possible with a little help from nitrous oxide soon enough.

Photo by Mikhail Tchkheidze/Thinkstock

Labor is no laughing matter, at least not in the U.S. Today, most women in the U.K., Canada, Australia, and Scandinavia use laughing gas (otherwise known as nitrous oxide) for pain relief during childbirth, but for years it has not been available for labor in the U.S. beyond a few lucky maternity wards—until now.

Just in time! I’m pregnant and planning for an unmedicated delivery. The thought of having a catheter placed into my epidural space (and subsequently my urethra) and then being confined to a bed doesn’t appeal to me. But, having never experienced labor, I would like to have an option to take the edge off that doesn’t take away control of my body.

I learned about nitrous oxide not from my doctor or WebMD, but rather by watching PBS’s Call the Midwife. The show is based on the memoir of a 1950s midwife and her team in London. In one episode, a patient pleads with the midwives to “bring me the gas!” A midwife runs to the car and grabs a tank and mask, and after a few puffs the woman in labor looks euphoric. My first thought was they’re going to kill the baby! Unable to cope with the suspense I immediately Googled “gas during labor.” The search results revealed that I was watching my ideal analgesic: nitrous oxide, commonly referred to as “nitrous.”

Nitrous does not eliminate pain, as an epidural does; generally women report that nitrous makes them care less about the pain. “I felt the pain but I was able to distance myself from it,” is how Shauna Zurawski, a new adopter who used it during the birth of her son last year, described it to me.

Because it doesn’t block pain, nitrous allows women to maintain control during labor. “You can still move around, you can also use it in a tub,” says Fletcher Wilson, obstetrician at Monadnock Community Hospital (MCH) in Peterborough, N.H., which recently started offering the gas to obstetric patients. Other plusses: Nitrous has not been associated with prolonged labor, it can be used at any time during labor, it does not require an IV or urinary catheter, and there are no serious side effects to mom or baby. According to a 2012 review of 26 studies on the safety and efficacy of nitrous, it’s safe. Basically, it’s everything I want during childbirth, but until recently, due to a mix of cultural taboos and lack of equipment, had no hope of getting.

Now two companies are making nitrous oxide delivery equipment for maternity wards and birthing centers here. Porter Instrument relaunched the Nitronox system in the U.S. in January 2013, after its last manufacturer was liquidated in the mid-2000s. Since then, 12 hospitals and 20 birthing centers in the U.S. have begun using the Nitronox system and Porter says it has “several trials in progress and many others scheduled to start after the new year.” In July, the FDA approved CAREstream Medical’s Pro-Nox system, previously available in Canada and Europe.

Though nitrous has been used in U.S. dental offices for years, the gas delivery system for dentistry is different—it’s a continuous flow system while “the gas mixture [for labor] only flows to the patient when she holds the mask to her face and inhales,” Mike Civitello, a product sales manager at Porter Instruments, told me. “The system is controlled by the patient when she wants and needs pain relief.” This patient control also prevents a woman from getting too much nitrous; if she starts to get too drowsy from it, her hand and the mask will fall away from her face.

I was eager to hear more about the nitrous experience from Zurawski, especially because she had something to compare it to. The 30-year-old mother of three used nitrous only during her most recent birth at Vanderbilt University Hospital. For her first birth she had an epidural, but “with the epidural I couldn’t really tell when I had a contraction and I felt like I was driving blind,” Zurawski said. So for her second, she opted to go without medication. But during that birth, she said, “right at the end, the contractions seemed almost unbearable. By then I wasn’t doing well dealing with the pain.”

Zurawski’s midwife, Michelle Collins, told her that nitrous would have been perfect to get her through those last few contractions, if only they had it. Shortly after the birth of Zurawski’s second child, Vanderbilt became one of the first in the country to offer nitrous in January 2011.

When Zurawski became pregnant with her third child, she planned for another unmedicated birth but her labor stalled when she was 5 centimeters dilated. In anticipation that she might need to augment labor with Pitocin, which can cause especially painful contractions, Zurawski asked for an analgesic, so Collins brought in the nitrous. After just one breath, Zurawski says she “felt so relaxed, and so relieved. My anxiety was gone.”

Zurawski credits that relaxation with helping her labor progress; she went from 5 centimeters dilated to 10 in just 15 minutes with nitrous and without Pitocin—although of course there’s no way to know how things would have gone without the nitrous. Still, who can argue with feeling relaxed? “One of the hidden nice effects of nitrous oxide is that it not only relieves pain but it decreases anxiety,” Zurawski’s midwife Collins told me.

Still, nitrous isn’t for everyone. If you are looking for a stamp of approval from the American Congress of Obstetrics and Gynecologists, you won’t get it. When I reached out to the ACOG for comment on nitrous oxide, they responded in an email with only this: “ACOG is reviewing this issue, but at this time does not have guidelines or recommendations on the use of nitrous oxide during labor.” Nitrous can produce mild side effects like nausea, drowsiness, and dizziness, and some women find the dissociative feeling disconcerting. Zurawski’s sister-in-law didn’t like it because “it made her feel too loopy,” Zurawski said. But, says Dr. Wilson, “what I love about nitrous is that if you’re that person who doesn’t like it, you stop breathing it in and 30 seconds later it’s out of your system.” “There is nothing else that we can offer women that gives them that much control,” Elizabeth Kester, MCH’s Nurse Manager of Obstetrics and Women’s Health, told me. “It’s awesome.”

I talked to Kester about my hope that a nitrous-assisted labor would help me stay off the epidural. “Nitrous is not an anti-epidural movement,” she warned, adding that “they actually work quite nicely in conjunction with each other. Many women who use nitrous go on to have an epidural. It’s not supposed to be one or the other.” Basically: Nitrous is one more option for dealing with the pain of childbirth—and options are good.

Thoroughly convinced, I asked my midwife if there was any hope of having nitrous at my D.C. hospital when I’m due. She told me she had fought that battle a while back and lost. But in researching this article, I learned that there will be nitrous in the D.C. area soon, at MedStar Washington Hospital Center. Now I’m faced with the decision of staying with a practice I love, or transferring for the gas. Hopefully in a few years most women won’t have to choose.