Laughing Gas For Labor Pain — Why Not?

Nitrous oxide is used to ease labor pain in most developed countries -- except the U.S.

Here’s a Labor Day question:

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?’”

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.

And this at a time when the U.S. health care system is desperate to reduce costs (C-sections, now at a record high of 32% of all births, are much more expensive than vaginal deliveries) and improve quality.

Dr. Mark Rosen, director of obstetric anesthesia at University of California, San Francisco Medical Center has been offering nitrous to laboring woman for more than 30 years. (It’s also offered at the University of Washington Hospital, Seattle.) Dr. Rosen told me he believes there’s growing interest in the U.S. for pain-relief alternatives, including nitrous oxide. “It’s not a panacea,” he said. “But it would be helpful. I’m an advocate of what works, and it’s nice to have other things to offer women.”

Ania Mitros switched hospitals, and decided to travel more than an hour from home to deliver her first child at U.C.S.F. because she wanted access to nitrous oxide. She told me her experience giving birth last year was “fantastic. I’m really glad I had something to reduce the pain, and really glad it neither made me loopy like opioids nor reduced my mobility like an epidural.”

Holly Powell Kennedy, Ph.D., a certified nurse midwife and professor of midwifery at Yale University School of Nursing, says one of the reasons nitrous isn’t used in the U.S. is simply cultural. Many women make decisions about childbirth based on what they learn from family and friends, and most have never heard of or used nitrous oxide for coping with labor pain. But in the U.K, Dr. Kennedy says: “Nitrous oxide is just part of life; women expect they will have access to it. It’s in every birth room and every bathroom so women can use it and still be mobile.” In a study published this year in the Journal of Midwifery and Women’s Health, Dr. Kennedy found 49 percent of women at a large urban hospital in London used nitrous during labor.

Even though I wrote a book on birth, I only heard about nitrous oxide for labor pain two years ago, at a talk by Judy Norsigian, executive director of the Boston Women’s Health Collective, and co-author of the Our Bodies, Our Selves books. Since then, I’ve been trying to figure out why nitrous oxide is shunned here.

Ms. Norsigian directed me to the most passionate proponent of nitrous oxide for labor pain relief: Judith Rooks, a Portland, Oregon epidemiologist and certified nurse midwife who has, for years, been an activist on the issue. Ms. Rooks says for those interested in health reform and controlling costs, use of nitrous should be a no-brainer.

“Nitrous oxide has significant cost advantage,” Ms. Rooks says. In an editorial in the journal Birth in 2007 she wrote: “It is much simpler and less expensive than epidural analgesia and does not result in complications that require more treatment” and longer hospital stays.

Indeed, with C-sections and epidurals rates at an all-time high, pregnancy and delivery have become some of the most expensive “conditions” contributing to hospital costs, according to a 2006 report by the U.S. Agency for Healthcare Research and Quality. By payer, pregnancy and delivery made up the biggest cost for private insurance and Medicaid, costing hospitals about $41 billion in 2004, the report said.

Ms. Rooks says that like any drug that is “older, inexpensive, off-patent and unglamourous,” nitrous is a victim of market forces: “Nitrous oxide is like an ‘orphan’ drug—little known outside of dentistry, lacking elan and pizzazz, with no companies or influential professional groups that stand to profit by its greater use.”

Of course, no drug is perfect, so here’s the small print on nitrous oxide:

Side effects include drowsiness, dizziness or lightheadedness, nausea and vomiting. The greatest risk is a loss of consciousness, particularly if there is too much nitrous in the mix, and that’s why self-administration is critical. Doctors and midwives knowledgeable about nitrous say a key safety feature is that if the woman becomes too drowsy, her hand will fall away from her face, rendering the device non-functional, and forcing her to breathe room air again.

–The drug is self-administered by the mother after initial supervision, and generally monitored by a nurse or midwife. Using a mask over her face, or breathing through a tube, the woman inhales the compound during contractions as needed. The full effects can be felt in less than a minute and the gas clears from the woman’s body after just a few breaths of regular air; to protect bystanders from unnecessary exposure, special machinery “scavenges” or sucks the gas out of the room.

–Nitrous oxide is a greenhouse gas, produced by power plants, sewage treatment and slash-and-burn agriculture, among others. It’s a fuel booster for race cars and propels whipped cream to squirt. But while there have been international agreements to phase out nitrous oxide use, health providers says medical use – only a tiny fraction of overall usage – may be exempted.

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  • Anonymous

    Because it’s not as good as epidurals. Epidurals provide much more relief, so if your insurance pays for them why bother with nitrous.

    Imagine you lived in a country where the government paid for all your food. I’d bet that it’d be nearly impossible to find cheap food. We’d have news articles like “no hot dogs available in US; only steak”.

    • Bronwyn Carlisle

      Read the post above yours. In New Zealand the government pays for all childbirth costs, and we get nitrous. In fact, read the whole article you are commenting on – in every one of the countries where nitrous is available the government is paying for the childbirth.

  • julie

    wow they poison our food by using GMO but they wont let women in labor use “laughing gas” thats just messed up.!!!!

  • Merewyn Groom

    I live in NZ and used the gas for my labour in the last part of the 1st stage, it was brilliant! I’m amazed and saddened that it is not available to you all in the USA. I didn’t have any of the side effects and was able to delivery my baby naturally and healthy. I didn’t use any pain relief for the 2nd stage (actual delivery) and I think that was because I had plenty of energy (physical and mental) in part due to having used the gas as I was going into transition.

    Sorry if you don’t use all the same terms, I hope you can understand what I mean.

    USA is all about freedom and personal choice right? Ask for it!

  • Angela R

    I’m proud to have been able to deliver my baby without the use of narcotics or an epidural, but there has been a tremendous psychological and physical cost to pay, as the pain I experienced was traumatic. I would love to have had another option available, one that is safe for mom and baby. Thanks for bringing this issue to the public, Rachel.

  • Katy

    Also amazing : I had to pay hundreds to have my child receive nitreous rather than a general for dentistry when general is a much greater risk.! Less invasive treatment should always be the first option for doctors and patients.

    • geedavey

      Weird, my dentist administers nitrous for free. No cost, no insurance bill, nothing. Buffalo, NY.

  • Zeresh

    To answer the question. Because it is not necessary, women can have a feeling of wellbeing while birthing without the need of drugs. ie hypnobirthing

  • Lauren0426

    It’s not available because MOST OBs do not believe in laboring. It doesn’t fit their agenda that laboring is mostly unsafe and that surgical birth is best. The current drugs used are well-known as cascades to a fast c-section.

  • Karen

    I weep that it’s not available. Seriously. I suffer dental anxiety and seek out dentists who use it – yes, it’s even going by the wayside in dentistry, according to my anecdotal evidence. In favor of “sedation dentistry” which I never prefer due to having to bring a driver to appointments, as well as not being able to use it while breastfeeding.

    Anyway, that’s all just to say I am familiar with NO2 and it’s effect on me, and am 100% convinced I would labor happily with it. Do you think I could hire my hygienist to come administer it at home or the hospital???

  • Lubbaduck

    Is there any effect on baby?

    • Anonymous

      Not according to studies, doctors reports and widespread use. RZ

  • Cantabrigian

    This sounds fantastic. I am also an advocate of what works, and I wish I had access to this during my deliveries. During my first delivery, I intended to go without pain meds but encountered a protracted labor and severe pain from contractions. I finally requested an epidural. It eased pain greatly, but the effect of my epidural faded in and out and I ended up with an allergic rash from the tape across my back. Nitrous oxide sounds like a miracle drug in comparison.

  • Melgirl

    Another money issue that the author does not address…will anesthesiologists be able to make kaboodles of money off of nitrous? Probably not since nitrous can be safely overseen by non-M.D.s. So, anesthesiologists will continue to push for high-intervention and higher-risk epidurals for moms, ambivalent to the infections, accidental spinal punctures resulting in painful spinal headaches, rare deaths, and the immobility that causes vast numbers of mothers to experiend “failure to progress” and end up with a painful cesarean. This certainly won’t change unless mothers demand it.

    • Anonymous

      Good point. Thanks, RZ

    • anonymous

      I am an anesthesiologist. With current reimbursement rates, we do not generate any significant income from labor epidurals. It is a service that our hospital has asked us to provide. As a hospital employee, I do not get the option of saying ‘no’ to this request. I take call for 24 hours at a time, sleeping in the hospital if I am lucky enough to not have cases at night. I would much rather have laboring women use nitrous than call me for an epidural at 3:00 AM. I don’t know why nitrous is not offered; it’s probably a cultural phenomenon. There are lots of ways to take care of patients; people tend to stick with what has worked well; nobody wants to be the first to try something new.

      @Melgirl: It sounds like you have had a bad experience. I’m sorry if this is the case. All the doctors I work with are ethical and compassionate people. We also do not ‘push’ for epidurals. We get called to see our laboring patients only after they have made a decision to get an epidural. I have found that the labor nurse is the most influential person in this decision process.

  • Gordon

    It would also be great to assess the role of Acupuncture in anesthesia for C section .
    In many developing areas the absence of anesthesia is the limiting factor in access to C section.
    Acupuncture could be made available at very low cost and provide women with life threatening conditions access to a life saving intervention..
    The experience in China could be very helpful in providing the needed evidence.

  • Rachel Zimmerman

    According to Childbirth Connection, a nonprofit research group, nitrous oxide “does not appear to have adverse effects on the condition of the newborn.” However, they also say it “has unknown effects on the alertness of newborns and their ability to interact with their new environment: still, nitrous oxide dissipates rapidly and may not cause any problems.”

    Bill Camann, chief of obstetric anesthesia at Brigham & Women’s Hospital says in his book ‘Easy Labor’ that “No adverse clinical side effects are known to impact the newborn.”