Officially referred to as dinitrogen monoxide by IUPAC, nitrous oxide which is an oxide of nitrogen is an inorganic chemical molecule identified with the formula N2O. Commonly, it is identified as laughing gas, nitro, nitrous, NOS, nitrogen protoxide, sweet air as well as hyponitrous oxide. N2O is colorless at room temperature, non-flammable and has to some extent sweet taste and odor. N2O is used by medical specialists in dentistry and surgery due to its analgesic and anxiolytic effects. It is a weak anesthetic and overall is never used as a sole agent; however, it is usually combined with oxygen as a carrier gas. It is euphoric in nature, thus it is called laughing gas, a component that that resulted into its recreational usage as dissociative anesthesia. Further, it is used in industries as oxidizer in auto racing and rockets to increase the power output of engines. N2O is a forming agent used in food industries to can whip cream.
This assignment highlights the recent data on the safety and risks of the consumption of N2O for both anesthesia as well as lose-dose N2O/O2 combination (50 percent NO2/O2). The information is important for analgesia as it stresses on the issues that are mostly applicable to impacts on labor, breast-feeding, birth, the mother’s and neonate’s wellbeing, and probable risks of occupation for persons caring for women at labor times.
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Proposal for the Implementation of N2O as Labor Analgesia
The proposal for the implementation of N2O as labor analgesia is to provide analgesia through self-administration of inhaled N2O delivery system for women in the immediate or intrapartum postpartum period. The usage of N2O as an analgesic is consistent with the current guidelines and practices to offer safe, standardized administration for women who need such as well as are recommended patients. This study applies to the therapeutic usage of N2O analgesia for particular clinical contexts for instance removal of placenta manually, repair of perineal that are extreme as well as other painful procedures.
Problem Statement
N2O is one among other many categories of drugs responsible for decreasing the brain cells excitability. Doses of anesthesia can at some point lead to unconsciousness by depressing the central nervous system. However, inform of inhaled weak anesthetic, N2O is usually combined with strong agent for consumption for the purposes of anesthesia (Judith, 2011). The effectiveness of analgesia is thought to be out of the increase of endogenous dopamine, endorphins as well as other natural brain opioids and neuromodulators found in spinal cord. In addition, it increases the production of prolactin while decreasing the production of cortisol, thus lessening hormonal reaction to stress. Consciousness effects entail dizziness, detachment, fatigue, euphoria, hallucinations, nightmare, headache, relaxation, pleasure, sedation and blurred memory of occurrences, as well as sense of warmth.
There is a variation on the women percentage who report blurred memory of labor, however, women report blurred remembrances of giving birth rarely than they report on labor. Exceptional features of N2O/O2 labor analgesia are accountable for several of its safety merits. N2O in the body is discharged through human lungs (Judith, 2011). At most, 1 percent of N2O is broken down and it is not stored in the body whereas more than 99 percent is breathed out unchanged. Laboring women regulate N2O/O2 dose through their inhalation mechanisms and mostly on the basis of period they use it. The period could be continuous such as during birth process as well as contractions or recurrently in a minute, previous and during contractions though not amid them. Nevertheless, nitrogen oxide is not a strong analgesic at the dosages offered in labor. It is accountable for women relaxation and provides women a sense of control while reducing pain but they are still aware of the presence of pain. The effects differ from one woman to another. Some women are opposed to the way analgesic makes them feel while others require stronger analgesic.
But, N2O/O2 is efficient enough for several women since it can meet the needs of labor analgesia. Safe practices for N2O/O2 labor anesthesia necessitates that the N2O is applied with O2 and N2O concentration and should not be past 50 percent (Judith, 2011). In addition, it should be self-administered where the woman in labor holds the mouthpiece or mask without any assistance. Further, the N2O/O2 equipment of delivery should use a demand valve to cut off the supply when the woman has ceased inhaling and utilizes the scavenging equipment to hold N2O that has been exhaled. The proposed measures assist in ensuring the laboring woman using N2O/O2 analgesia do not overdose and become hypoxic. It also important in protecting health care providers from getting exposed to contaminated air.
Needs Assessment
There is the need for more access to labor analgesia and to a wider variety. Several women are unable to access reasonable efficient means of labor analgesia at their times of need. In 2008, 61 percent of women diagnosed with singleton due to virginal births in 27 States where data was collected on birth certificate based on labor analgesia in the US contracted neuraxial analgesia (Judith, 2011). A section of women do not want or need an epidural whereas others need or want an epidural. Though, these women cannot access epidural at the time they need assistance due to where they live, the day and time of the week, the hospitals they access and the competing desires for the amenities of anesthesia professionals.
There are increasing shortages of both nurse anesthetists and anesthesiologists more so in rural areas. An estimated 18 percent of the entire United States births take place in rural areas. According to Finnish anesthesia professor, on evaluation of labor analgesia, there are several parturient gains from neuraxial analgesia intended for labor, whereas there are exceedingly most of individuals who are choice-less for varied reasons. Thus, they require an alternative means to release labor pain. N2O can assist in addressing the uneven access to labor analgesia in the US. The main advantage is the ease of its use. An anesthesia professional and a sterile field are not required. N2O labor analgesia is safe as well as lacks the negative impacts on labor physiology. To widely increase access to labor analgesia in the US, nurses and midwives have to be trained to provide as well as monitor the consumption of N2O/O2 analgesia for laboring women (Judith, 2011).
Literature Review
Judith P. R., (2011). Safety and Risks of Nitrous Oxide Labor Analgesia: A Review. Journal of Midwifery & Women’s Health, 6(56), 557-565.
This review article examines the effects of N2O when provided in anesthetic doses. The resultant effects on cobalamin also known as vitamin B12, homocysteine and methionine synthase are hyperhomocysteinemia as well as cardiovascular disease vulnerability. In addition, it results in neuro-apoptosis and neurotoxic effects.
Findings of the Article
The article highlights that, N2O/O2 is used in several health care contexts, for instance, N2O affects many key hormones that are significant during labor as well as birth incorporating endorphins, cortisol, prolactin, and norepinephrine/epinephrine. However, it has no decreasing effect on the release or efficiency of endogenous oxytocin. It has no effect on the contraction of uterine and labor development (Judith, 2011). A further and major risk that was identified in any inhaled analgesic or anesthetic is aspiration of stomach composition caused due to loss of laryngeal reflexes which is important for protection during unconsciousness.
Most frequent side effects of nitrogen oxide/oxygen labor analgesia are vomiting and nausea. Vomiting is recurrent during labor and more common in women consuming N2O/O2 at labor times than among patients consuming it due to other reasons (Judith, 2011). It is as well more frequent in persons who have used it for surgery as opposed to those who have not, and among women inhaling N2O/O2 analgesia constantly other than intermittently. There were also alterations in consciousness incorporating sedation and dizziness. Also, N2O may result in emesis in a portion by fluctuations in the middle ear due to diffusion of nitrous oxide.
The effects of N2O when administered in anesthetic doses to laboring women result in hyperventilation apnea, oxygen desaturation and diffusion hypoxia. Since fetus is dependent on maternal oxygen, a reduction in oxygen concentration in the blood of a laboring woman raises alarm. There are no negative effects of N2O/O2 on newborn, fetus and breastfeeding (Judith, 2011). Research have reliably established that there is no negative impact on Apgar as well as neonatal-neurobehavioral neonates’ scores open to nitrogen oxide during birth whether it was consumed by the mother for five minutes or five hours. The half-life of nitrogen oxide in the neonate after birth is at most three minutes. There are no severe effects on breast suckling behavior of neonate when subjected to it during birth.
When considering occupational risks, dose becomes the main determinant. Exposure to nitrogen oxide, however, higher occupational exposures such as 1000 parts/million are considered low percentages, for instance, 1/10 percent of ambient air. But, due to possible health risks due to occupational subjection to anesthetics inhalation, the national as well as the provincial occupational exposure was created for particular anesthetics. Majority of US facilities are well ventilated. Scavenging ability is designed into multi-purpose equipment that is meant for N2O/O2 labor analgesia throughout the US. That is to say, equipment providing NO2/O2 to laboring women, as well offer a stable pressure that is negative to seize the woman exhalation and suck them both out of the room and hospital (Judith, 2011). The method necessitates the woman to breath into the face mask or mouth duct for many inhalations every moment she stops to inhale N2O/O2. The inactivation of the synthesis of methionine is a major cause of occupational health risk. But, with low exposure generally the only significant anxiety is conceivable effect on reproduction of human (Judith, 2011).
Baysinger, C. (2016). Nitrous Oxide. American Society of Anesthesiologists . Retrieved from https://www.asahq.org/resources/resources-from-asa-committees/nitrous-oxide.
The article informs readers that techniques effectiveness employed in labor analgesia are challenging to plan. Most patients undergo serious pain at particular state during labor, though with varied intensities that is dependent on factors of maternity, size as well as fetus presentation, or whether labor is bigger or impulsive, cervical dilation at the initial stages or parity. Also included are psychological factors.
According to the author, there have not been recent assessments on the safety and appropriateness of N2O used for labor analgesia. Thus, in its findings, there is a lack of clear quantitative substantial proof that N2O analgesia is efficient.
Further findings when comparing N2O effectiveness with other approaches of labor analgesia show that alternative volatile substances offer analgesia in similar standard or superior than N2O when administered solely or together with N2O, however by compromising maternal sedation. The finding states that there is a single study that has compared the effectiveness of N2O to the administration of intravenous opioid.
Some of the side effects incorporate depressant of the respiratory system, increased rates of oxygen desaturation of the mother amid contractions on labor. Increase in the hypoxemia of the mother can be as a result of extra administration of systematic opioid. However, regarding gases of vein blood and umbilical artery or and the measurement of Apgar score, there is no research indicating serious effects of neonate.
Discussion and Recommendations
There has never been widespread usage of N2O/O2 labor analgesia in the US in contemporary years; several studies have been conducted elsewhere. However, interest in the consumption of N2O during labor is developing thus requiring research. Although, it received some opposition to being introduced in the US hospitals from the anesthesiologists due to its hyperhomocysteinemia linked to its usage (Judith, 2011). The impact of nitrogen oxide on homocysteine concentration in plasma is due to overdose than those consumed during labor, although they take place temporarily. There is no much investment in providing N2O/O2 labor analgesia in training and new equipment. It is suggested that university hospitals providing it should carry out prospective research to measure the concentration blood-plasma homocysteine of women prior to their consumption of N2O/O2 during labor. Also, measurement should be done before discharge from hospital and to measure the concentration of N2O in the umbilical cord blood of neonate at birth.
Studies are, however, carried out to elevate people’s understanding regarding apoptotic destruction to the fetus and young child’s brain as a result of general anesthesia. Since the link between dosage and harm due to exposure to N2O is definite, the concern has severed weak applicability to the safety of nitrogen oxide/oxygen labor analgesia (Judith, 2011). It is, therefore, important for the experts on N2O/O2 labor analgesia to come together when there is need for research to save the brains from being subjected to drugs alleged to increase the vulnerability of neuro-apoptosis at the synaptogenesis period. Further, studies are reqired based on risks of occupation of offering maintenance to women consuming N2O/O2 labor analgesia in aired facilities and birth facilities with active scavenging constructed into the apparatus that supply the mixture of gas to women. Studies are also required to establish the quantity of inhalations a woman consuming N2O/O2 labor analgesia occasionally requires to breathe out into the scavenging machine after every terminated contraction.
The outcome of a dose-dependent link between intra-partum subjection to N2O and addiction of amphetamine as an adult is worrying; however, many mothers of amphetamine addicts in the research consumed 100 percent of N2O (Judith, 2011).
Project Activities
The project activities include setting up and administering N2O which involves the following steps in the implementation process (Starr, Collins, & Baysinger, 2011).
Pre-treatment Assessment
First, evaluation of patient suitability as well as nonexistence of contraindications is carried out. Second, essential symptoms such as heart rate, saturation of oxygen, blood pressure and the heart rate of fetus are documented in a GasChart before the start of therapy.
Set-up of Equipment.
A team of anesthetists validates if the equipment is properly installed, operating and is well attached to disposable circuit intended for single use.
Preparation of Patient.
First, anesthetists establish the patient’s informed consent such as probable side effects for example fatigue, dizziness, vomiting and nausea. Second, the patient is provided with counseling therapy as well as assured that they will move only with the help of N2O therapy. Third, the patient form of consent is signed and identified in chart. Fourth, anesthetist guides the patient on self-administration of N2O that includes: Placing of mask to create a seal, keeping time of breathing for maximum effect of analgesic and the patient being responsible of holding her mask throughout.
Procedure.
First, the patient is required to hold mask over their nose as well as mouth, to create enough seal which is responsible for activating a second phase regulator to allow flow of NO2 up to 50 percent in concentration of nitrous and at least 50 percent in concentration of oxygen. Second, continuous patient guidance and help with the timing of breaths parallel to contractions is offered by a team of anesthetists with the continued emphasis on nursing as well as obstetric provision that is needed. Third, the patient is guided to start inhaling immediately awaiting contraction is realized so that therapy is optimized. Fourth, Labor nurse is directed and orders recorded that no extra opioid administration is accepted without direct supervision of anesthesiologist while the patient is using N2O.
Treatment Termination
The usage of N2O is terminated when the patient wishes so or there is no need for analgesia.
Monitoring of Fetus
This as well includes monitoring heart rate of fetus.
Pulse Oximetry
In disparity with parenteral opioids, research on N2O for labor steadily indicates a lack of statistically vital linkage between inhaled N2O and oxygen desaturations. Women who use N2O for labor do not need constant monitoring of pulse oximetry. Maternal crucial symptoms are monitored routinely in accordance with the current policy. Anesthesia and nursing staff keep monitoring patients for symptoms of extra sedation.
Special Situations
In particular cases for example extensive repair of perineal and removal of placenta manually where the woman is likely to undergo extra stimulation over some few minutes, remifentanil administration or any other short acting agent can be used together with N2O at the will of the anesthetist on shift. In such events, provider of anesthesia maintains bedside posture to monitor and record symptoms in GasChart in consistent with required monitoring for Monitored Anesthesia Care.
If there is concern anytime for either fetal or maternal well-being, N2O therapy may be terminated at the will of the anesthesia, OB or midwife team.
IV Access
According to history of Obstetric Department, Vanderbilt has permitted laboring women the will to disallow IV access when applicable medically. With regards to the side effects, as well as the difficulties of N2O, there are no observable clinical requirements for intravenous access for the purposes of giving N2O therapy.
Labor Tub
At this stage it will be guiding principle that laboring patients who use N2O should not use labor tub at the same time with N2O.
Measures and Indicators
Some of the measures include laboring patients unable to hold their personal facemask and patients who are severely intoxicated and have impaired consciousness. In addition, patients with recorded B12 deficiency or have pernicious anemia as well as taking nutritional supplement of B12 in absence of a deficiency are not contraindicated from the therapy. Moreover, Patients with pneumothorax history, obstruction of bowel, increased pressure in the intra-cranial and intra-ocular surgery may not be patients for N2O and will be examined by a team of anesthetists for therapy applicability. Besides, the heart tones of the fetus are examined by an obstetric provider as stipulated in the policy of Fetal Heart Rate monitoring. Thus, it involves first, the effectiveness of N2O analgesia alongside heart tone category as outlined by the obstetric provider in the chart. Second, the overall steps patients suffering from category one and specific patients with category two signs will be applicable patients for N2O as indicated by the obstetric provider (Starr et al., 2011).
Indications
Indicators include women undergoing painful labor. Also, women suffering extreme repair of perineal where local anesthesia is unlikely to meet all the needs of analgesic. Further indicators are women in need of painful postpartum techniques for instance removal of placenta manually and curettage or dilation (Starr et al., 2011).
Outcomes
Efficacy as well as maternal satisfaction
There are no recent assessments regarding efficiency and safety of N2O. However, the most recent study was carried out in 2002. The study concluded the outcomes of 11 randomized controlled attempts and were only documented in 1996. The study does conclude that there is a lack of clarity on the proof of analgesia effectiveness of N2O (Baysinger, 2016) .
Conclusion
N2O has several benefits for regulating pain and anxiety due to labor, incorporating quick action as well as exit from the body (Baysinger, 2016) . N2O labor analgesia does not result in severe outcomes and complications for the neonate, fetus and mother. Since it does not diminish the release of endogenous oxytocin by pituitary gland in the mother, it does not impact on the uterine contraction; neither does it initiate the increase in the consumption of synthetic oxytocin or Pitocin. Pitocin is the drug usually linked to preventable severe perinatal results in the US. Synthetic oxytocin administered intravenously cannot replicate the efficiency as well as the safety of management of labor hormones of the mother (Baysinger, 2016) . As a result of N2O/O2 labor analgesia lacking severe impacts that could affect the safety of the mother and fetus, women who are laboring and consume it do not need stable electronic monitoring of the fetus (Judith, 2011). In addition, they do not require routine access to intravenous and other procedures which are invasive and limit the freedom of movement of the mother during labor. N2O labor analgesia is therefore safe for neonate, fetus and the mother and can further be made safe care providers.
References
Baysinger, C. (2016). Nitrous Oxide. American Society of Anesthesiologists . Retrieved from https://www.asahq.org/resources/resources-from-asa-committees/nitrous-oxide.
Judith P. R., (2011). Safety and Risks of Nitrous Oxide Labor Analgesia: A Review. Journal of Midwifery & Women’s Health, 6(56), 557-565.
Starr, S. A., Collins, M., & Baysinger, C. (2011). Policy: Nitrous Oxide Use in the Intrapartum/Immediate Postpartum Period. Vanderbilt University Medical Center. Retrieved from http://www.mc.vanderbilt.edu/dept/obgyn/LD_Policies/Nitrous_Policy.pdf.
