Improvement Story

Introducing Nitrous Oxide
for Labor Pain Relief

Michelle Collins PhD, CNM
Associate Professor of Nursing and Director, Nurse-Midwifery Program, Vanderbilt University School of Nursing

What did you set out to change or improve?

Adding the option of nitrous oxide as labor analgesia.

How did you change it? What new policy, process, or practice did you put in place?
It was an involved process, but began by partnering with OB anesthesia and then meeting with all of the services involved (peds, MFM, OB docs, nurses, nursing management, risk management, etc.) to discuss their concerns. We addressed each services concerns (and they were many and varied) and wrote a policy for use of nitrous oxide, based on the policy in place at UCSF.

Who was involved in making the change and what was each person’s role?
I, as the CNM leading the initiative, sought out OB anesthesia personnel to partner with in the endeavor. The OB anesthesiologist and CNM teamed together to write the policy, write the inservice education for both providers and nursing staff, and present the program together at every required point. We worked together on finding and purchasing the equipment as well.

How did you determine if the change worked? What data did you collect? How did you define “success”? How did you ensure your change didn’t have any unintended negative consequences?
We calculated usage rates monthly and were able to determine our usage rates were actually higher than existing nitrous programs in the US (there are only a couple of others). We learned along the way how to approach problems; for example, we learned quickly that a patient could not get on hands and knees with pillows in front of her and bury her face in the nitrous mask. It is meant to be patient controlled and when the patient control is removed, she loses that ability to hold the mask, thus allowing more gas delivery than if she were holding it.

What was the biggest barrier to making the change and how did you overcome that barrier?
Trying to find someone amenable to it in the anesthesia department. I could not get it done on my own as a CNM; it really required that OB and anesthesia work hand-in-hand together. It was helpful to find a young anesthesiologist who I could also get fired up about the option, who was willing to “politic” her anesthesia peers to accept the option.

If you had one piece of advice for someone who wanted to make a similar change in their setting, what would you advise?
Partner with anesthesia; if you do not, you will be knocking on doors, speaking to deaf ears. “Outsiders” (i.e. ob, particularly CNMs) can face many barriers to being the impetus for an initiative that is seen to be in the realm of the anesthesia department. However, if “one of their own” is the one to try to smooth things over and bring in this new initiative, it will probably be received much better.


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