Entonox has been suspended in some hospitals

[Soubriquet]

link

It’s a hard one. I mean, on one hand I feel for hospital staff. No they shouldn’t have to be exposed to something that can cause health problems now it’s being documented. But labouring women also need pain relief and not every alternative works.

Oramorph did nothing for me
Pethadine made me sleepy
I wasn’t allowed a water birth
Epidural is known to need more interference.

I do hope a compromise is made somewhere

Air exchange is not good enough. Nitrous oxide is heavier than air and as most ventilation is high up on a wall will do nothing at all.
We do monitor and even with a mini scavenger system the levels are way above U.K. safe levels. You really need an active scavenging system and active monitoring .

The biggest danger of nitrous oxide is neurological damage , which is cumulative and irreversible and there are plenty of examples of it happening to medical/dental professionals.

Oh yikes that’s depressing 🙁

If you want to be depressed read this academic.oup.com/annweh/article/63/3/337/5373585.

This shows damage to personnel at 50ppm. The legal limit in the states is 25ppm , in the U.K. 100ppm!

This is a paper on dental personnel who are much nearer to the mouth and exhaled nitrous oxide , but other medical personnel will be equally at risk.

The "compromise" to allow nitrous oxide to be used in labour will , in all likelihood, still involve risk of permanent , life changing damage to medical personnel.

For those who don't want to read the whole paper this is a pertinent paragraph

Effects associated with nitrous oxide extend beyond personal adverse health effects and pose potential patient safety concerns as well. Acute neurologic effects from low-level anesthetic gases, such as nitrous oxide, among dentists and dental assistants have included decreases in mental performance, audiovisual ability, and manual dexterity (Fernando and Nissanka, 1991; Shaw and Morgan, 1998). Specifically, decreased psychomotor performance regarding visual perception, immediate memory recall, cognition, and motor responses have been observed in personnel exposed to nitrous oxide concentrations up to 50 parts per million by volume (p.p.m.v) over a period of 2 h according to Szymańska (2001). These neurologic effects may lead to the inability to control a dental drill or unknowingly injecting a needle in the wrong location.

Again I remind people the legal limit in the U.K. is 100ppm more than the amounts quoted and most medical uses will result in far,far higher levels.

I’m due to give birth in three weeks time, only ever used gas and air, I’m so scared. It’s added so much extra stress on to this pregnancy, and I’ve opted for homebirth now to use gas and air but fully prepared to travel further to another hospital if I need to go in. It’s horrendous the hospitals haven’t provided safe environments for their staff, there has to be a solution, there’s going to be a lot more interventions due to this.

I e found an article in the BJM from 2002 about risks on Labour wards. Over twenty years ago! I’m furious, I’d assumed these risks were a recent discovery.

Results: Environmental levels exceeded the legal occupational exposure standards for nitrous oxide (100 ppm over an 8 hour time weighted average) in 35 of 46 midwife shifts monitored. There was a high correlation between personal environmental concentrations and biological uptake of nitrous oxide for those midwives with no body burden of nitrous oxide at the start of a shift, but not for others.

oem.bmj.com/content/60/12/958

Bmj even!

The statistics about the French epidural/c section/instrumental birth rate are very interesting.

I'm in Australia and went private for my second birth. We have a mix of public and private medicine . I looked at the stats here carefully beforehand and they do show epidurals are associated with greater risks of c section, instrumental birth and perineal trauma in this country too. So it's not just the NHS.

I had no idea about effects of gas on staff at the time, but having looked it up I see the allowed safe rate here is 25 v 100 in the UK so I am reassured that they must be doing more in terms of ventilation etc.

The French must be doing something differently in labour and pregnancy care to both Aus and UK if they are managing not to have greater rates of complications using all those epidurals. I'd like to know what! I did know that France offered all women a postnatal physio course as standard, so I had in idea they were pretty good. Can anyone speak to any other differences? Do you have pre natal physio too?

@kenne No prenatal physio as such, but in both my full term pregnancies (same clinic, different doctors) the doctor recommended using an Epi-no in late pregnancy to reduce the risk of tearing/episiotomy, a session with an osteopath to help get everything into alignment, and acupuncture to promote spontaneous labour. Second time round when I was planning my VBAC I did all those things because I was hoping to avoid being induced. No idea whether any of it worked or it's all just woo, but I did go into spontaneous labour, my baby was in a much better position and I had a fast and easy VBAC with only a very minor tear.

After both vaginal births and C-sections women do perineal re-education with either a midwife or kiné, and after that it's recommended to do abdominal re-education too.

As for the epidural point, I wonder whether the statistics in the UK and Australia reflect the fact that epidurals are less common and women who have one are more likely to be having a long and complicated (or induced) labour, and also more likely to end up needing other interventions, whereas women having a fast and straightforward labour are unlikely to have an epidural. Correlation, not causation, if you will. Whereas in France where nearly every woman has an epidural regardless of what kind of labour she is having, the same effect isn't seen.

I have no idea really, I'm just speculating. But if it were true that epidurals alone increase the likelihood of these interventions independently of other risk factors, I would expect to see more instrumental deliveries and C-sections in France.

France did previously have a reputation for very high rates of episiotomies, which was acknowledged to be a problem and the majority of obstetricians now avoid doing them wherever possible (incentivised by the fact that the episiotomy rate for each hospital is one of the published statistics). In the clinic where I gave birth the epidural rate is 97.5%, with 2.5% episiotomies and 23% C-sections (including electives).

This is horrific, I had no idea. Absolutely staff have to have safe working conditions. Instead of protesting the ban people should be complaining they should produce safe working options. I suspect if r&d were interested they could fairly quickly develop portable equipment that both supplies entonox and scavenges w effectively so it isn’t an entire new building needed.
its like the engineered stone benchtops scandal in Australia (obviously before anyone jumps on me it’s completely unlike in that people get a benchtop not women in labour get pain relief) Apparently they’ve known for many many years working engineered stone kills people and only now are they warning people and actively campaigning to do something about it. Shocking that it even needs a campaign when who with a conscience could buy an engineered stone benchtop knowing that’s someone’s life at risk - mostly young men who should have their lives ahead of them.

What about nitrous oxide via ventilator?
There's talk of the nicu i work on starting nitrous oxide for persistent pulmonary hypertension. Usually we transfer these babies out and treatment starts when the transfer team arrive. They are talking about us starting treatment before the transfer team arrive.
Will it be the same risk?

Isn’t it nitric oxide rather than nitrous oxide? So less nitrogen in the formula and more oxygen? So I’d have thought due to the lower nitrogen content and smaller amounts hopefully it would be ok but I’d be asking.

Sorry you're right it's nitric oxide. I can't remember the % of nitrogen and I'm on mat leave at the moment so out of the loop.

You've hit the nail on the head with all your posts! Yes to correlation vs causation. There may be a few other things at play here.

I think it was you (forgive me if I'm wrong) who described in an earlier post a "walking epidural" where local anaesthetic type and dosage is adjusted to allow a woman to be mobile. It's not offered where I live (I'm not in Europe), but it may be more commonly used in France where epidural uptake rate is higher so protocols for walking epidurals are easier to establish. It can help with coordinating pushing etc if you can feel the contraction. Also mobility during labour tends to speed things up.

I also suspect that pelvic re-education must make one more aware of where on earth pelvic muscles are and what to do with them (for the next baby).

I live in a system, which like the NHS seems to discourage epidurals. It's cheaper. But the number of times, back when I covered labour ward, that you get called to an exhausted woman to put an epidural in is phenomenal. That mum is highly unlikely to push effectively when the time comes. You could usually predict who you'll be meeting later for the inevitable Caesarian. Yes, most of the time it is a funding issue and we are busy b/c we also cover theatres and we can't leave an anaesthetised patient, but I'm also aware that some midwives lie to their patients that "anaesthetist is busy" when they haven't actually checked.

It is sad that women continue to be short changed by dogma which is ultimately driven by trying to save money and staff continue to get harmed in the process by poorly designed working spaces and practices, again because it is cheaper.

The nitrous exposure is just the tip of the iceberg - lead gowns (and their inadequacy/ non existent checks on integrity) and radiation exposure, PPE practices and ventilation - the chickens are coming to roost unfortunately. Frankly I'm surprised my two DC were born at term and healthy, which is awful to think about. And no, I couldn't ask my employer to pull me off radiology lists and the like during pregnancy.

Good post, @iamanicicle. Are you an anaesthetist?

In France they tend to just do classic epidurals and prefer women to stay on the bed once they've had one. The first time I said bugger that and stood up anyway. The second time I was planning to do the same but by the time I'd had a nap I was fully dilated so I didn't have time.

As someone who prepared for my first labour hoping to avoid an epidural and ended up with a C-section, I now think of the two anaesthetists who did my epidurals as playing an integral role in giving me better birth experiences (both in terms of pain relief and emotional support). They were brilliant.

I was very wary about having an epidural because of all the stories I got told.

If no gas and air is the way forward, they need to be more upfront about what pain relief is available, the proper risks and benefits and then actually make it available