A Nurse-Directed Model for Nitrous Oxide Use during Labor
Pinyan et al. MCN (May June 2017)
Supplemental Digital Content
Table 2
Nitrous Oxide/Oxygen Policy
1.Scope:
1.1Applicable Entities: This policy applies to our facility.
1.2Applicable Departments: Women’s Services Department.
2.Purpose: To support the physical and emotional wellbeing of patients in the Women’s Services Department. Nitrous oxide as analgesia is a complement to the family-centered care environment.
3.Policy Statement(s): We offer Nitrous Oxide as a self-administered, minimal analgesia option for the antepartum, intrapartum and postpartum period. This analgesia option is delivered via demand flow, at a fixed 50%/50% Nitrous Oxide/Oxygen mixture.
4.Policy Guidance:
4.1Candidates for nitrous oxide self-administration are women admitted to the Women’s and Infants Services department.
4.2Nitrous Oxide will be ordered by the provider and initiated and managed by the RN who has demonstrated competency.
4.3Contraindications for nitrous oxide use are:
4.3.1Patients with presence of a potential space the gas could fill: Pneumothorax, intraocular surgery, bowel obstruction or middle ear surgery.
4.3.2Current Vitamin B12 deficiency.
4.3.3Acute drug or alcohol intoxication or impaired consciousness.
4.3.4Hemodynamically unstable.
4.3.5Impaired oxygenation <94% on room air.
4.4Precautions for nitrous oxide use are:
4.4.1Patients receiving epidural/spinal analgesia, unless approved by anesthesia provider.
4.4.2Heavy meal within four hours of administration of medication.
4.4.3Evidence of maternal/fetal compromise.
4.4.4If the patient has received intravenous, subcutaneous, or intramuscular narcotics continuous pulse oximetry must be maintained for four hours from narcotic administration.
4.5Safety Concerns:
4.5.1Supportive person and visitor/family abuse: zero tolerance
4.5.2.1Will be clearly outlined verbally and in writing when
providing education to the patient.
4.5.2.2Nitrous Oxide will be removed from patient’s
use if there is any suspicion of abuse of use by
persons other than patient.
4.5.2The demand flow system has a quick connect
attachment and when not in use, will be disconnected and
stored in a secure location.
4.6Documentation
4.6.1Provider’s orders.
4.6.2Time of initiation and discontinuation.
4.6.3Hourly vital signs with spot check of oxygen saturation level.
`4.6.4PRN spot checks of O2 saturation if needed.
4.6.5Ongoing assessment of pain level with documentation in electronic record.
4.6.6Hourly patient safety and LOC documented in electronic record.
4.6.7Monitoring of fetal well-being as ordered by provider.
4.7Observe for adverse effects: disorientation, lack of cooperation/aggressiveness, or change in level of consciousness.
4.7.1Notify ordering provider immediately if adverse effects are observed.
4.7.2Discontinue use of nitrous and administer supplemental oxygen.
4.8Consider discontinuing the use of NO/O and administer supplemental oxygen if normal side effects are not tolerated by the patient or resolved by nursing interventions. Normal side effects include: nausea, dizziness, dry mouth, drowsiness, and tingling in fingers.
4.9Patients will be assessed for state of consciousness prior to ambulating:
4.9.1Patient must have stable vital signs.
4.9.2Patient must dangle feet at the bedside prior to ambulating.
4.9.3If no evidence of dizziness or excessive motor weakness, patient may proceed with assistance with initial attempt to ambulate.
4.9.4Patient may move freely at her will, once there is no
evidence of dizziness and patient steady on her feet.
4.10Patient may not receive additional opioids during nitrous oxide administration (combinations of nitrous oxide and opioids can result in respiratory depression, hypoxia, and unconsciousness).
4.11If NO/O is discontinued, ordered opioids can be given immediately without the need for provider consult.
4.12If an epidural is in use, OB anesthesia must be consulted if there is a desire for NO/O to be used in conjunction.
4.13NO/O may be used in conjunction with hydrotherapy. RN to remain at bedside with patient under this circumstance.
5.Definitions:
NO/O is a colorless, odorless and tasteless gas made for inhalation. NO/O’s rapid onset of action and quick clearance prevents accumulation in maternal or fetal tissues. When NO/O is administered, without opioids or other central nervous system depressants, it is defined as minimal analgesia. Responsible Parties: Women’s & Infants Nursing Staff who provide care to patients.
Table 3
Nitrous Oxide /Oxygen Procedure
1.0Scope:
1.1Applicable Entities: This procedure applies to our hospital.
1.2Applicable Departments: Women’s Services Department.
2.0Purpose: To support the physical and emotional wellbeing of patients in the Women’s Services Department. Nitrous oxide as analgesia is a complement to the family centered care environment.
3.0Procedure:
3.1Antepartum & Postpartum Administration
3.1.1Obtain an order from the provider for NO/O for analgesia.
3.1.2Obtain written consent from patient.
3.1.3Upon initiation, equipment should be checked for proper
functioning including appropriate readings on all line/tank pressure
gauges, mixture gauges and scavenging system.
3.1.4May be initiated and discontinued by patient as appropriate.
3.1.5Must be self-administered by the patient (the patient holds
the mask). Never held by family member, support person or staff.
3.1.6Explain the importance of the timing of the beginning of
inhalation when being used for labor pain management.
3.1.7Demonstrate the importance of maintaining seal around
the mask and instruct the patient to inhale and exhale through the mask.
3.1.8Instruct and supervise the patient’s usage until she is
confident and proficient in the use.
3.2 Intrapartum Administration
3.2.1 Instruct the woman to begin breathing deeply at a normal
rate into the mask at the onset of a contraction and cease only
when the contraction has passed its peak.
3.2.2Palpate contractions, to assist the woman in recognizing
early onset.
3.2.3Instruct the woman to remove the mask between
contractions and to breathe normally.
3.2.4Continuously assess the patient’s pain level and level of
consciousness during use.
3.2.5Document pain level, O2 spot check and state of
consciousness at least hourly in the EHR.
3.2.6The RN initiating NO/O use will remain with the patient
until the patient demonstrates competence in use.
3.3 Equipment
3.3.1A NO/O demand flow delivery system, scavenger tube, 2
oxygen cylinders and 2 nitrous oxide cylinders.
3.3.2Disposable individual patient mask and bacterial filter.
3.3.3Quick Connect Key will remain in Pyxsis when not in use
(system not operational without the Quick Connect Key).
3.3.4Will be maintained by Biomed Department.