Jenny MacKay was six hours into labor when the pain became unbearable. She had been in labor since around 6 p.m. that day, but midnight rolled around, and the pain was getting worse.
“You just are in a lot of pain to the point that you just can’t function,” the 31-year-old said. “ …It’s a special kind of pain. You only go through it if you have children.”
Had the Keene resident been at a hospital, she would have likely received an epidural anesthetic injection, a popular pain-relief method used in most childbirths in the U.S. But MacKay, who gave birth in June 2015, wanted her second child to be born at the midwife-run Monadnock Birth Center in Swanzey, where an epidural is not an option.
She didn’t take that decision lightly. Having given birth to her first child in 2011, MacKay understood the pain — she didn’t use an epidural then either. But at the center, she had another option available to her: laughing gas.
Most people know laughing gas — nitrous oxide — from the dentist’s office. They might associate the gas with the woozy, out-of-body feeling they may have felt during wisdom teeth removal surgery.
In the delivery room, nitrous oxide is used for shorter periods of time and in lower concentrations, according to nursing professor Michelle R. Collins of Vanderbilt University in Nashville, Tenn., who wrote a 2012 paper on the topic in Reviews in Obstetrics and Gynecology.
The pain-relieving effects of nitrous oxide begin within 30 to 50 seconds of inhalation and dissipate just as fast, according to Collins’ paper. It carries no serious side effects or risks when used in labor, though its use can cause temporary dizziness, she wrote. Nitrous oxide can be an attractive alternative to epidural anesthetic injections because it’s noninvasive.
According to a 2007 paper in the journal Anesthetic Progress, the exact way by which nitrous oxide alleviates pain is unknown, but findings to date have indicated that nitrous oxide causes the release of natural opiates in the spinal cord.
MacKay said she used nitrous oxide right before a contraction began, inhaling as the contraction proceeded and removing the mask once it subsided. Though she’s not sure if it alleviated her pain, MacKay remembers that the gas didn’t make her sleepy, dizzy or woozy.
“It was nice to have it,” she said. “It was just nice to feel like there was something in my back pocket if, like, labor was too much.”
An Old Practice
The use of laughing gas in childbirth is rare these days in the United States. Approximately 400 hospitals and 100 birth centers nationwide offer that option, Collins wrote. That’s a small fraction of the number of hospitals and birth centers in the United States. According to the American Hospital Association, in 2015, there were more than 5,500 hospitals nationwide. There are more than 340 birth centers, according to The American Association of Birth Centers’ website.
But nitrous oxide is a staple in delivery rooms in other developed countries, including the United Kingdom, Australia, Canada and Finland, Collins wrote in her paper.
The practice, according to Collins, dates back to 1881, when Polish physician Stanislav Klikovich published a paper that demonstrated its use on 25 laboring women.
Though nitrous oxide remains, by far, the rarest choice for pain relief during childbirth in the U.S., more women are using it. According to a nationally representative survey by the nonprofit organization National Partnership for Women & Families, 3 percent of women who gave birth in 2005 used nitrous oxide. That number doubled to 6 percent in 2011. During that time, epidural use fell from 76 percent to 67 percent, but it still remained the most common pain-relieving method during childbirth.
Other medication options to ease the pain of labor include narcotic medications and general anesthesia.
Nitrous oxide has also garnered some interest locally. At Brattleboro Memorial Hospital and its obstetrics and gynecology clinic, women often asked about nitrous oxide use in childbirth, said Erinna Cooper, director of the hospital’s birthing center. (At the time this article first published, Brattleboro Memorial planned to begin offering nitrous oxide as an option in delivery rooms in January 2018.)
Cooper described many benefits to using nitrous oxide in the delivery room.
“It doesn’t require an IV, it is self-administered, has a very, very short-lasting effect, and people can administer it only as needed,” she said. “And really, one of my biggest thoughts is, ‘Would this buy us some time … to get (women in labor) through a little crunch time?’ Maybe we’re waiting for the epidural to come in. Or maybe they’re at the end of delivery, and they don’t want some IV medication, and they don’t want an epidural, but they need a little bit of help getting to the end.”
Cooper said the hospital explored insurance billing as part of its preparation for the new option. For now, she said, insurance companies will cover the cost of the disposable masks used to administer the nitrous oxide during labor, but not the cost of the nitrous oxide-oxygen mixture the women inhale. Cooper said the hospital will absorb these costs for now, but that she suspects insurance companies will begin covering the cost of the gas as its use becomes more common in childbirth.
In the meantime, though, it’s still relatively uncommon.
Neither Dartmouth-Hitchcock Medical Center in Lebanon nor Cheshire Medical Center, an affiliate of Dartmouth-Hitchcock Health, offer nitrous oxide in their delivery rooms.
Michael R. Barwell, media relations manager at Dartmouth-Hitchcock Medical Center, said the hospital previously offered nitrous oxide as an option to women in labor, but discontinued its use. He declined to provide further information on the topic or answer a detailed list of questions, including how long the service was offered at the hospital.
A representative from Monadnock Community Hospital in Peterborough did not respond to interview requests, but a 2013 report in the Monadnock Ledger-Transcript stated the hospital had begun offering nitrous oxide to women in labor that year.
At the Monadnock Birth Center, the Swanzey center where MacKay had her second child, nitrous oxide became available two or three years ago, according to Executive Director Mary Lawlor. But women rarely use it, she said.
“We didn’t really expect a lot of people to use it; we wanted it on hand as a reassurance for people.”
‘It Takes the Edge Off’
Annique Sampson, a midwife practicing in Vermont and New Hampshire, used to work at the Monadnock Birth Center until about two years ago. In her time there, she said, two or three women requested nitrous oxide. She attributed its uncommon use to the personal preferences of women who come to the center.
Most of them, she explained, are interested in an all-natural birth. But the option to use nitrous oxide sometimes allays the concerns of first-time mothers.
“It takes the edge off a contraction, so when someone’s feeling like they need an extra tool, and we tried the birthing tub and positional changes and other kinds of hands-on support … it (is) like another level of pain management,” she said.
The women who did use it did so at the tail end of birth, when the contractions are frequent and can be overwhelming, Sampson said. The self-administration gives women control over their pain management.
“So when she feels a contraction coming on, she takes a deep breath,” Sampson said. “And she has to be the one to hold the mask for herself. No one could do it for her. So she actually is empowered to control the amount of gas that she is consuming.”