Call It A Comeback? The Many Faces of Nitrous Oxide For Labor Pain Relief

Jill–Unnecesarean

A long-neglected drug for relieving pain in labor may be making a comeback in the United States.

Twenty-five years ago, Evan McAllister tried to bring Entonox, a premixed gas blend consisting of 50 percent nitrous oxide and 50 percent oxygen from the U.K. to the United States under the name Dolonox. McAllister, a respiratory therapist with a background in anesthesiology, hit a roadblock with the Food and Drug Administration, who denied the application for what he calls “compliance reasons.”

The U.S. FDA grandfathered in older medical gases, including nitrous oxide and oxygen shortly after the turn of the century. A blend of these two medical gases is treated as a new drug, which requires extensive (and expensive) research to be approved.

Determined to make nitrous oxide available in the U.S., McAllister designed a device to blend pure oxygen with pure nitrous that could be self-administered by the patient. The device was in production until about 20 years ago, when sales dropped off and McAllister stopped making them.

As a result of recent interest in nitrous oxide as a labor analgesic, McAllister and his company, Nitrox, Inc., designed a more compact version of the decades old blending unit, which they are actively marketing.

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Said McAllister, “I’ve had it all shut down for 25 years and it’s all coming back.”

Nitrous oxide for labor?

Unlike women in Canada, the U.K., Scandinavian countries, Australia and elsewhere, women of childbearing age in the United States are likely to have never heard of the use of nitrous oxide for pain relief in labor. Only three hospitals in the U.S. offer the option of self-administering nitrous oxide during labor: University of California, San Francisco (UCSF), University of Washington Medical Center in Seattle, and St. Joseph Regional Medical Center in Lewiston, Idaho.

Dr. Mark Rosen of UCSF conducted a systematic review in 2002 to determine the efficacy and safety of nitrous oxide for labor analgesia. While nitrous oxide is not a potent labor analgesic, Rosen concluded that “it is safe for parturient women, their newborns, and health care workers in attendance during its administration” and effective enough for many women.

The 50/50 mixture of N2O with oxygen used in hospitals is eliminated through the lungs, not the liver, making it a safe option for mother and baby if self-administered properly. Rosen was quoted in a 2007 article in the Journal of Midwifery & Women’s Health saying “We’ve never seen a groggy baby from inhalation of 50% N2O. It just doesn’t happen.”

McAllister’s blending unit limits the upward amount so a woman cannot overdose, taking pure oxygen and pure nitrous, blending them 50/50, and putting them it into a system where the patient can breathe on demand through out her labor. Said McAllister, “Wherever the woman is at, she’s in total control.”

An epidural monoculture

In a comprehensive interview on childbirth education organization, Lamaze International’s blog, Science and Sensibility, in April 2010, Judith Rooks discussed the roadblocks encountered in trying to make nitrous oxide available in U.S. hospitals. While lack of equipment has been problematic, fear of competition and potential loss of revenue have held progress at bay. Rooks told Science and Sensibility’s Amy Romano:

Epidurals are big money makers for hospitals and, of course, for anesthesiologists, whereas nitrous oxide is an old, off-patent, cheap drug that can’t compete as a money- maker…Profit is a powerful force in American health care. If no one is making a profit, no one is pushing for a product to have a place on the shelf, whereas those who are making big profits are always trying to push the product that is not profitable off the shelf.

According to Rooks, the drive of anesthesiologists, obstetricians and hospitals is to maintain what she labeled in a previous article, an “epidural monoculture.” If a hospital is to promise women that they can have an epidural during labor, this service must be available 24/7 every day of the year, since any women may go into labor on any day before or after her “due date.” More than 5 full-time anesthesiologists or nurse anesthetists would be required, and making their salaries justifiable to the hospital depends upon a high percentage of women getting epidural anesthesia.

Additionally, some obstetricians and hospitals are reluctant to use it because of perceived risk of environmental contamination, even though modern nitrous oxide units scavenge the unused gas. Rooks calls this concern a red herring, as hospitals are filled with many types of potential occupational hazards and safety programs are put in place to train staff accordingly.

Nitrous oxide is notoriously bad-mouthed, called old-fashioned, dangerous and a revenue reducer, an attitude partly stemming from what Rooks describes as “a desire to avoid the need to provide the time-intensive care needed by women who are experiencing some degree of pain.” Rooks cites her personal experience with an obstetrician who “banned continued use of nitrous oxide analgesia in an major university hospital when he went there to head the department of obstetrics and gynecology during the 1990s,” finally admitting to Rooks that he prefers the use of epidurals because he is uncomfortable seeing women in pain, favoring a quiet labor ward.

Difficulties in introducing nitrous oxide to the U.S. market have a nearly century-old history. In a 1922 New York Times article about nitrous oxide for laboring women, the doctor interviewed (who specifically asked that his name not be printed) spoke to similar challenges as to why the nitrous oxide was not regularly used instead of chloroform and ether.

“The first answer is that the medical profession is the most conservative of bodies. The second answer is concerned with economics. I told you that I believe that a doctor must be present while the gas is in use, which is for the duration of ten or twelve hours possibly—used periodically, remember. And remember also that some of my colleagues do not agree with me on that point. I have a wife and four children to support. I am an attending physician at three hospitals. If I stayed ten or twelve hours with each patient I could not make a living for my family unless I charged a fee far beyond the means of the average person. The presence of a professional anesthetist would, of course, make my presence unnecessary until the very last stage, but it would add materially to the cost as far as the patient was concerned.”

Consumer interest

Joyce Moxley Thomas, a midwife and advocate for nitrous oxide in Chino, California, believes that nitrous oxide is not available in U.S. in part because the FDA’s classification of the premixed gas as a new drug and the expense associated. Thomas became aware of the benefits of nitrous oxide while working with U.K. midwives, whom she feels take its availability for granted.

“To get a drug approved by the FDA takes years and costs millions,” said Thomas, “which BOC/Linde Gas is not interested in paying.”

Thomas is convinced that the middle ground of using nitrous oxide will be widely appealing to U.S. women.

“I think when American women realize that since the 1950s women worldwide have had access to [nitrous oxide] and expect to have it there for their births– that we have been deliberately deprived of a safe, effective “gas and air” that is not narcotic, that didn’t hurt our babies, and allowed us to give birth normally — I think American women will start demanding it,” said Thomas. 

Laughing Gas for Labor? I’ve Been There

Robin Marty

One publication asks why more women in the United States don't have access to laughing gas during labor. 

Nitrous oxide for labor?  Common Health asks why the drug, which is so readily used in other countries, is no where to be found in labor and delivery rooms in the United States.

Why don’t women in the U.S. have access to nitrous oxide, a safe, inexpensive and fairly simple option for alleviating pain during labor, when women in almost all other developed countries use it widely?

A small band of midwives, doctors and mothers are trying to find out.

Sure, nitrous oxide (aka laughing gas, like you get in the dentist’s office) doesn’t have the super-pain-relieving magic of an epidural. Instead, it offers something closer to an elixir of dulled pain tempered by nonchalance, says William Camann, chief of obstetric anesthesia at the Brigham & Women’s Hospital and the co-author of the book “Easy Labor.” “The pain may still exist for some women but the gas may create a feeling of, ‘Painful contraction? Who cares?’”

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So, while nitrous oxide is used by about 50% of laboring women the United Kingdom; 60% in Finland and widely in Canada, according to a published review, it’s available only in two U.S. hospitals.

It seems like the major roadblock is just that since we’ve never used it, it never occurs to the U.S. medical system to try.

However, hospitals to occasionally use laughing gas during births, as I can attest.  During my own extended labor we discovered that each epidural “boost” was becoming less effective, including the one that was given to me prior to my emergency c-section.  When the final injection wore off during the middle of my surgery, I was given the option of total anesthesia, which I knew would make me unconscious for hours, or the use of laughing gas to get me through the final removal of the placenta and the subsequent sewing up. 

I chose the nitrous oxide, knowing that it meant I would be awake, mostly alert and able to move around more quickly during my post-op recovery.  I most definitely felt the pain, but it tempered it enough to get me through surgery, which was all I wanted at that point.

Could laughing gas be a viable option for the actual act of labor?  I’m not sure, but it will be difficult to ever know if we aren’t given an option to try it.

Roundup: Choosing Gubernatorial Candidates Not Always A Great Choice

Robin Marty

We're now entering the countdown to election day, and in some states the candidates show clear differences on abortion.  In others, the choices are exactly the same.

In Minnesota, the day after Labor Day means two things: school is starting, and the political season is officially in high gear. 

In New Mexico, abortion has become a key differentiator between two gubernatorial candidates, as the Santa Fe New Mexican Reports:

Neither gubernatorial candidate has spent much time discussing abortion. But both are supported by organizations on opposite sides of the issue.

Denish has received $90,000 from Emily’s List, a national organization, which, according to its website, “is committed to electing more pro-choice Democratic women to office to build a more progressive America.”

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Meanwhile, Martinez has been endorsed by The Right to Life Committee of New Mexico. This group does not directly contribute to political campaigns, executive director Dauneen Dolce said Friday. However, the group will send out mailers in support of Martinez and other candidates they support. Dolce said she doesn’t know yet how much the committee will spend on the mailers.

Few issues are more divisive in American politics, even though on a state level there’s not much that can be done either way on the matter of abortion.

Still, the issue seems to manifest every two years in the Legislature in the form of the “parental-notification” bill. Basically, this legislation does not in itself outlaw any abortions. It simply requires that doctors notify the parents of a pregnant minor before she is allowed to have an abortion.

School nurses have to notify parents before they give a student an aspirin, proponents of parental notification say. Why shouldn’t they be notified before a procedure as serious as abortion?

Opponents usually object that this is unfair to girls who come from abusive homes. Supporters of parental notification argue that the bill has a legal mechanism to allow the girl to seek intervention from a judge, who can rule that the parents can’t be notified. Opponents say it’s unlikely a scared, pregnant teenager would be able to navigate through the legal system.

Denish is opposed to parental notifications for abortions.

“Diane believes every girl should be able to turn to her parents when she needs support,” campaign spokesman Chris Cervini said in an e-mail last week. “But some are in unsafe situations, and they need to be able to exercise their rights in private without fear of abuse or retaliation.”

Martinez’s campaign did not respond to a request to discuss her position on parental notification. Her website has only one mention of abortion, and that’s to say she was endorsed by The Right to Life Committee of New Mexico “as a candidate who will stand up for pro-life principles.”

Dolce confirmed the endorsement. She declined to release a candidate questionnaire Martinez completed, but said Martinez indicated she opposes abortion “except in cases of rape or incest.” She said Martinez’s questionnaire said she supports the parental-notification law.

Of course, those of us who write about reproductive rights know that there is much that can be done on a state level about abortion, despite the reporter’s assertion otherwise. Which is why, when both candidates for governor are anti-abortion, pro-choice voters can be somewhat lacking in options.  From the Sun News:

South Carolina voters who support abortion rights have no choice in November’s gubernatorial election.

For the first time in recent history both the Democratic and Republican nominees for governor are anti-choice.

Lexington state Rep. Nikki Haley, the Republican nominee, and state Sen. Vincent Sheheen, the Democratic nominee, sparred lightly over the abortion issue recently. But there is plenty of agreement between them over abortion.

A third candidate, Morgan Reeves of the Green and United Citizens parties, is undecided.

While the state’s stagnant economy remains the top issue, the lack of choice in candidates coupled with new abortion restrictions signed into law this year are upsetting abortion rights voters.

“I’m very disappointed, and it makes me very, very nervous about the future,” said Katherine Giles, an abortion rights voter in Charleston. “Women are half the population. If [politicians] are so willing to throw away our reproductive rights, what next will they say that women don’t have the intellect to make a decision about?”

It’s not surprising that those of us who are pro-choice are slowly losing our options when it comes to political candidates.  Anti-choice politics are no longer the platform of one party, and is growing on the Democratic side as well, as Pennsylvania Senator Bob Casey discussed in a recent public appearance.  Via WDUQNews:

Democratic US Senator Bob Casey says his party has become more receptive to anti-abortion candidates since his father, Governor Robert Casey, was in office. Casey made his comments last week as part of the Pennsylvania Historical and Museum Commission’s ongoing series about former governors. Governor Casey stepped into the national lime light by not being allowed to address the National Democratic Convention in 1992 because of his prolife view. Sen. Casey spoke about his father’s book “Fighting for Life.” In the memoir, Governor Casey makes the case Democrats should be more receptive to anti-abortion candidates. Sen. Casey, who also opposes abortion rights, says things have changed over the past 14 years. “In terms of the Democratic Party nationally, my election, and others, but my election was evidence that they weren’t going to use a litmus test on abortion to prevent you – on being pro-life – from running for the US Senate. So I think there was substantial progress made on that.”

Mini Roundup: One group claims that the HPV vaccine is leading to an increase in chlamydia in Scottish schoolgirls, and the number of women getting pap smears in the U.K. seems to be on a decline due to loss of a famous spokesperson.

September 6