Nitrous Oxide for Labor Analgesia

Transcription

1 Provider order required? [ X ] Yes [ ] No TITLE: STATEMENT: Nitrous Oxide for Labor Analgesia Nitrous Oxide May be used safely for analgesia during labor. It may be initiated by anesthesia, self-delivered by the patient, and the care may be managed by qualified Labor and Delivery Nursing staff. The increased involvement of the patient in managing her own discomfort/pain helps lead to a more satisfying birth experience. PROTOCOLS: I. Nitrous Oxide for Labor Analgesia SCOPE: RELATED DOCUMENTS: DEFINITIONS: St. Luke s Boise and Meridian Medical Centers NA EFM: Electronic fetal monitoring N2O: Nitrous oxide AUTHORIZED BY: Original signed by Stacy Seyb, MD OB/GYN, Department Chair Stacy Seyb, MD AUTHORIZED BY: Original signed by Robert Centeno, MD 11/18/15 Department of Anesthesia, Chair Robert Centeno, MD AUTHORIZED BY: Original signed by Cynthia (Cy) Gearhard, RN, MSN 11/29/15 Vice President, Patient Care Services/CNO West Region If this is a patient care policy, the information contained herein is used to provide guidance in the care of patients, but should not, and does not replace or preclude the use of clinical judgment. FOR OFFICE USE ONLY Originator: Women s Services Original : 06/30/14 Revised : 11/18/15 Effective : 11/30/15 Page 1 of 5

2 Provider order required? [ X ] Yes [ ] No PROTOCOL I: CRITERIA FOR INTERVENTION: Nitrous Oxide for Labor Analgesia Mothers in labor, with no contraindications to the use of nitrous oxide, may safely selfadminister inhaled nitrous oxide as ordered by their provider. INTERVENTION: I. Nitrous Oxide (N2O) for labor analgesia: A. General Information: 1. Nitrous Oxide is a colorless, odorless, tasteless, nonflammable gas that is liquid at room temperature 2. Nitrous Oxide provides a modest level of analgesia, but less analgesic potency than narcotics, epidural or Remifentanil. It is thought to stimulate endogenous endorphin release and possible corticotrophins and dopamine release. 3. Commonly used in: a. Emergency medicine (in the field and in hospitals) b. OR s to augment other anesthetic gases c. Dentistry 35% use it, commonly with children Most common way people in US have used it d. Used in L&D since 1934, extensively in Canada, UK, Australia, New Zealand, Norway and Finland, but less in US once epidural analgesia became popular. 4. N2O is inexpensive and provides an alternative to persons who are not candidates for labor epidurals. 5. The combination of 50 % nitrous 50% oxygen used in labor is considered analgesia, or minimal sedation (not anesthesia) according to the American Society of Anesthesiologists (ASA). B. Women who may be candidates for Nitrous Oxide analgesia 1. Highest priority: those who are NOT candidates for neuraxial/epidural analgesia (When a patient with contraindications to epidural analgesia is laboring, the N2O will be kept available for that patient, unless she is sure she does not want to use it, if the quantity of equipment is limited.) 2. Patients progressing rapidly through Stage 1 labor, or who need a little analgesia at the end of Stage Patients requiring mild analgesia for vacuum or forceps assisted delivery, laceration or episiotomy repairs, or manual removal of retained placenta 4. Patients who desired a home birth, avoiding IV and bladder catheterization. 5. Anxious patients needing IV start, pelvic exam or epidural placement. 6. Patient experiencing an external cephalic version (ECV) C. Nitrous Oxide use is contraindicated for women who: 1. Cannot hold the mask with good seal 2. Have impairment of consciousness/intoxication 3. Have documented B12 deficiency (may lead to megaloblastic anemia) 4. Have potential for trapped gas (pneumothorax, intraocular surgery, bowel obstruction or middle ear surgery) 5. Hemodynamic instability and/or impaired oxygenation Effective : 11/30/15 Page 2 of 5

3 6. Increased intracranial pressure, increased intraocular pressure, or pulmonary hypertension. D. Initiation of Nitrous Oxide 1. May be ordered by physician or CNM 2. Initial patient set up can be done by an RN. a. Bedside nitrous oxide blender is attached to wall suction to scavenge any excess N2O. b. Blender delivers only a 50:50 mixture (nitrous and oxygen) 3. Patient and family education must be provided prior to initiation and the patient will sign that she understands the information. 4. L&D RNs may manage the care and monitor use of nitrous oxide. Consultation is provided, as needed, from OB or anesthesia providers. E. Patient Self-Administration 1. Patient holds the mask or mouthpiece herself and maintains a tight seal. It is not to be held for her by staff or family/visitors. 2. Self-administration is self-limited as patient becomes mildly sedated. 3. Medication flow is initiated by inhalation strong enough to open the one-way valve and stops when no longer inhaling due to the demand valve. 4. Continuous pulse oximetry, continuous EFM, IV and bedrest are not required. 5. Can be administered safely over several hours. F. Patient Safety/Side Effects 1. Studies and experience have shown Nitrous Oxide has No effect on: a. Uterine tone b. Maternal laryngeal reflex (aspiration risk not increased) c. Progress of labor/ability to push d. APGAR scores e. Cord gases f. Risk of maternal nausea (minimal) g. Breastfeeding 2. Rapid onset and rapid offset - doesn t build up in mother or fetus 3. Patient may be able to postpone or avoid narcotics 4. Most common side effect is maternal drowsiness or possible dizziness. 5. To prevent falls or slips, attentive supervision is necessary when patient is squatting, sitting on birth balls, standing in shower, or sitting in tub. 6. Minimal to mild potential for maternal respiratory depression: Pulse oximeter will be used during initial 15 minutes of use to rule out response of respiratory depression. G. Nursing Assessments and Documentation 1. Vital signs should continue based on the patient s risk status and stage of labor. 2. If maternal or fetal well-being is thought to be compromised, follow all usual guidelines for notification of OB and anesthesia providers, performing required intrauterine resuscitation nursing interventions (e.g., maternal position changes, oxygen administration, obtaining IV access, discontinuing nitrous oxide administration) as appropriate to Effective : 11/30/15 Page 3 of 5

4 situation. 3. Document patient s nitrous oxide use similar to other analgesic methods in labor, including time of initiation, patient s response, any side effects or complications, end time and reason (e.g., when patient no longer desires, requests to discontinue due to side effects, or wishes to change to an alternate, or medical, pain management technique). H. Patient/Family Education Points 1. Assure patient/family education. 2. Only the patient may hold the mask or mouthpiece. Support persons CANNOT assist. When the patient has physiologically reached her limit of N2O intake, she will no longer be able to hold the mask to her face, thus self-regulating the intake, a safety mechanism. 3. Placement of the mask or mouthpiece to create a seal. 4. Timed breathing (starting 30 seconds before regular contractions or at the onset of awareness of a contraction) provides the maximum effect. 5. Inhaling slowly and deeply enough to open the demand valve and start the flow. 6. Exhaling back into the mask or mouthpiece. 7. Breathe room air between contractions. 8. What to expect: a. Variable pain relief, but usual response within seconds b. Sense of not caring about the pain c. Feeling of euphoria d. Decreased anxiety 9. ONLY the laboring patient may use the N2O. NOT for support persons. 10. Conversion of the patient to epidural is NOT a failure of the modality I. Nitrous Oxide Safety for Staff and visitors: 1. Pregnancy Precaution: It is recommended that women trying to become pregnant or in the first trimester not be in the patient s room. Although the evidence is weak, one study implicated there may be a decrease in fertility with excessive exposure. 2. No harm when used at analgesic levels, intermittently with a. Scavenging equipment b. Demand valve c. Proper instruction and use 3. These safety measures limit exposure of others in the room 4. Environmental exposure standards: a. OSHA: developing safety requirements for medical personnel b. NIOSH: limit to 225ppm time over 8 hr time weighted average c. Dosimetry badges can be utilized 5. When blender is not in use, it must be kept in a secured area, and treated as any other medication. Any abuse or diversion would be addressed according to institutional policy. 6. Nursing scope of practice issues: a. Nurses are not administering the nitrous oxide; the patient administers it to herself. b. Nursing s role includes: 1) Reinforcement of patient/family education, Effective : 11/30/15 Page 4 of 5

5 J. Miscellaneous 2) Perform and document nursing assessments, 3) Prepare equipment and set up for patient use, 4) Monitor patient relief and side effects response, 5) Guard the patients physiologic safety. 1. Equipment: Nitronox machine and Nitrous tanks will be stored in the Anesthesia room or other designated, locked area. Also, it is recommended that the nitrous tank be changed when it gets just below 750 psi. 2. Nitrous Oxide has been used in Labor & Delivery and throughout the hospital, especially Emergency Department, at St. Joseph s Regional Medical Center in Lewiston, Idaho, without incident since1980. Summary of Interim Change(s) / Annual Review Author / Title The following list of supporting references is attached to the foregoing policy for the convenience of staff. This list is not part of the foregoing policy and may not include all resources that were used to research the subject of the policy or prepare the content of the policy. St. Luke s process for developing policies and the content of policies is proprietary business information and may only be shared outside of St. Luke s with permission from a St. Luke s Director, Vice President or CEO, or as required by law. Clinical References (Level all clinical references) Strength Quality Baysinger C. (Sept 2012) Nitrous oxide for labor analgesia. Society for Obstetric Anesthesia and Perinatology Newsletter; p. 11. Likis F, et al. (2014) Nitrous oxide for the management of labor pain: a systematic review. Anesthesia & Analgesia;118: Wong C (2010) Advances in labor analgesia. International Journal of Women s Health. 1: Tekoa K. (Jan 2014) Nitrous oxide for labor pain: is it a laughing matter? Anesthesia & Analgesia (International Anesthesia Research Society); 118:1, p High Directions for using Johns Hopkins Evidence-based Practice Rating the Evidence Scale: Research Evidence Appraisal (e.g., experimental study, meta-analysis, quasi experimental, non-experimental, qualitative study, meta synthesis) Non-research Evidence Appraisal (e.g., systematic review, clinical practice guidelines, organizational, expert opinion, case study, literature review) Copyright Approval Granted by The Johns Hopkins Hospital/The Johns Hopkins University KEYWORDS: analgesia, anesthesia, labor, alternative, nitrous, nitrous oxide, nitronox, inhaled analgesia Effective : 11/30/15 Page 5 of 5