During my internship, I’m often asked about the differences between Belgian and Slovenian midwifery practice. In this blog, I will shed some light on one of the major differences. It is no secret that giving birth is generally not something to be laughed with. Most women who enter the labour ward are somehow frightened by the expected labour pain, not in the least because of horror stories told by their mother or friends. The cry for pain relief is probably one of their loudest. The Belgian and the Slovenian answer to it, vary considerably. In Slovenia, there is space for some laughter in the labour room! But is that laughter the best medicine for labour pain?
Pain relief
In Belgium, pain relief in the labour ward generally boils down to either epidural anesthesia or nothing. 70% of the Flemish women who gave birth in 2014 received epidural anesthesia. Recently, the Flemish Professional Association of Midwives (VBOV) announced that it will start exploring the admission of laughing gas. So far, only one Flemish hospital has introduced laughing gas in the labour room (A.Z. St. Blasius Dendermonde).
Contrary to Belgium, in Slovenia four options for pain relief are available: laughing gas, two sorts of opioids (remifentanil and pethidine) and epidural (spinal) anesthesia. Where epidural is the golden standard for labour pain relief in Belgium, in Slovenia its use has only begun to rise in recent times and is still far from established practice. All options have their pros and cons, which I will not discuss here. I will however discuss the most commonly used method of pain relief in Slovenia: laughing gas.
Laughing gas
Laughing gas is a simple anaesthetic agent that has been in use in medical settings for two centuries now. It made its entrance in obstetric care in the 1930s because of its anxiolytic and analgesic effect. It is a mixture of nitrous oxide (N20) and oxygen, and in the obstetric context usually contains 50 percent of each.
Advantages
Laughing gas is seen as a analgesic that does not intrude in the course of the birth since it doesn’t intervene with the release of oxytocine, the hormone that is the key to progress in labour. Laughing gas works rapidly and its effects expire quickly once administration is stopped. Furthermore, its availability expands the number of options for pain relief during labor and it might add to women's feeling of being in control since they can administer it themselves (though solid research data seem to be lacking on the latter). When used for a limited period of time during labour, laughing gas is considered to be safe for both mother and child.
Disadvantages
Laughing gas is seen as a generally less effective painkiller than neuraxial anesthetics. Also, when compared to women who received no analgesics or a placebo, women who received laughing gas more often suffered from nausea, vomiting, dizziness and drowsiness. Furthermore, laughing gas cannot be administered when contra-indications such as hemodynamic instability or impaired oxygenation exist. Caution is necessary if a woman simultaneously receives other sedative medication.
Effect on health care workers
There are also questions about the effect of laughing gas on health care workers. In animal experiments, under a number of conditions a teratogen effect was found, but in humans, the picture is less clear. Furthermore, laughing gas might be a cause of disruption of the vitamin B12-metabolism. Based on the outcomes of the animal tests one author urges reservation when using laughing gas, and advises to only use it under strict indications (that, he claims, do exist).
Because of the lack of conclusive scientific evidence about possible congenital disorders caused by laughing gas, the Dutch Association for Anesthesia and the Dutch Association for Obstetrics and Gynecology urge to not expose pregnant staff to (high doses) of nitrous oxide (especially not in the first term).
Debate about laughing gas in the labour ward
In 2004, the Dutch Health Care Inspection (IGZ) advised hospitals to restrict the use of laughing gas in labor wards “as much as possible” and to “preferably” end its use. The debate that followed led to strict rules for the use of inhalable analgesics in Dutch labour wards: thorough ventilation of rooms, an exhaustion system in the room and a ‘scavenging system’ fitted to every mask (measures, by the way, that are not imposed on the labour ward here in Slovenia). The Royal Dutch Association of Midwives (KNOV) adds annual checkups of staff exposed to laughing gas, a risk assessment and evaluation, training and a protocol to this list. Nevertheless, the KNOV considers the IGZ’s discouragement of the use of laughing gas to be based upon methodologically doubtful research.
My impressions
As a Belgian student, working with laughing gas was a quite new experience to me. The impression might exist that nitrous oxide gets all women to laugh their way through labour, like in this YouTube video:
However, this is not really my experience so far. Rather, women in serious labour are holding on to their mask as to their lifeline, gulping gas during contractions. Some start to say funny things or laugh a bit, but most of the time the women concentrate on making it through the contraction. From their reports, the gas only seems to take away the top of the pain. Even with the gas, labour is hardly a laughing matter.
I wonder whether some sort of placebo effect can be ascribed to the use of the mask. Since the women are administering the gas to themselves, they seem focused on their own breathing, which is in general very important during labour. This focus on a steady, deep breathing might add to the relief by drawing the women’s attention away from the actual pain. Thorough research into this matter and the actual effect of laughing gas seems to be lacking.
My experience is also that the use of laughing gas doesn’t enhance the mobility of the women (which I consider to be very important for the progress of labour), since the effect often seems to lead to their staying in bed. I also have some questions about how consciously they experience their labour when using the gas, and the psychological effect this has.
Personally, I don't feel too comfortable working without ventilation measures, like we do in Slovenia. Out of precautiousness, I would endorse the ventilation measures described above, in the interest of the newborn, the partner attending the labour and the medical staff present. I don't have a clear cut answer to the question whether we should advocate the introduction of laughing gas to Belgian labour rooms. Somehow, I have the impression that intensive one-on-one coaching by a midwife, back massage, guidance in using the correct breathing techniques (maybe the administration of some extra oxygen), the use of different positions, et cetera might be as effective. This makes me wonder what the added value of laughing gas really is. I am looking forward to more evidence-based insights on this.
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Literature used:
Brief Hoofdinspecteur Inspectie voor de Gezondheidszorg (IGZ) (2004). Kenmerk IGZ/FMT/GB-04-31749. Den Haag: IGZ.
Collins, M., Starr, S., Bishop, J. & Baysinger, C. (2012) Nitrous Oxide for Labor Analgesia: Expanding Analgesic Options for Women in the United States. Rev Obstet Gynecol 5(3/4): e126-e131 doi: 10.3909/riog0190
Devlieger, R., Martens, E., Martens, G., Van Mol, C. & Cammu, H. (2015) Perinatale Activiteiten in Vlaanderen 2014. Brussel, SPE. Found on the internet:
http://www.zorg-en-gezondheid.be/sites/default/files/atoms/files/SPE_jaarrapport%202014.pdf
Klomp, T., Van Poppel, M., Jones, L., Di Nisio, M., Lagro-Janssen, A. (2012) Inhaled analgesia for relieving pain during labour. Cochrane Database of Systematic Reviews. Found on the internet:
http://www.cochrane.org/CD009351/PREG_inhaled-analgesia-for-relieving-pain-during-labour
Knape, J. (2006) Lachgas niet onveilig, maar wel steeds minder nodig. Ned Tijdschr Geneeskd 150(19): 1053-1054
KNOV (2009) Adviesrapport – Het gebruik van Relivopan in de eerstelijns verloskunde. Utrecht: KNOV werkgroep ‘Etonox’. Found on the internet:
http://www.knov.nl/fms/file/knov.nl/knov_downloads/911/file/KNOV.adviesrapport_Relivopan_eerstelijns_verloskunde_november_2009.pdf?download_category=overig
Nederlandse Vereniging voor Anesthesiologie [NVA] en Nederlandse Vereniging voor Obstetrie en Gynaecologie [NVOG] (2008) Richtlijn medicamenteuze pijnbehandeling tijdens de bevalling. Found on the internet:
http://www.nvog.nl/upload/files/definitief-richtlijn-pijnbehandeling-bij-de-partus_def-091208.pdf
Rooks, J. (2011) Safety and Risks of Nitrous Oxide Labour Analgesics: A Review J Midwifery Womens Health 56(6): 557-565. Found on the internet:
http://www.porterinstrument.com/~porterin/dentalcontent/app/webroot/files/datasheets/Safety-and-Risks-of-Nitrous-Oxide-Labor-Analgesia-JMWH-[2011].pdf
Schyns-van den Berg, A., Engel, N., Marcus, M. & Beenakkers, I. (2010) Partus en pijn hoeven nergens hand in hand. Medisch Contact 65(50): 2716-2721
VBOV (2015). Lachgas tijdens de bevalling, een optie in België? Press release by the Flemish Professional Association of Midwifes. Found on the internet:
http://www.vroedvrouwen.be/nl/vroedvrouwen_in_de_media