Education of Stakeholders and Guideline Proposal for Nitrous Oxide at an Army Hospital

The aim of this project was to educate Army hospital personnel about nitrous oxide (N2O) for labor analgesia and to provide them with a sample clinical practice guideline. Nitrous oxide is an inhaled gas that provides an effective form of pain control for most laboring women. For decades, women in other developed countries have used N2O to decrease labor pain. The use of N2O for labor pain is increasingly requested by women in the U.S., and is offered in Navy and Air Force hospitals. Although it has become more popular in the U.S., most women do not have access to this option for labor pain relief, especially those in the Army. This gap was noted by the Army chief Certified Nurse Midwife, who subsequently requested movement towards introduction of N2O at an Army hospital. The first N2O self-administration machine was introduced in1934 in England and its use has expanded to many other developed nations, with up to 75% of laboring women now choosing this method for pain relief. In the U.S., epidurals are currently the preferred method of pain relief, with only 5 US birthing institutions offering N2O in 2012. However, in 2014 over 150 institutions offered N2O for labor pain. The Food and Drug Administration has approved devices that deliver a controlled mix of 50% N2O with 50% oxygen. Laboring women use the device to self-administer N2O with a mask that limits on- demand flow with inhalation. In comparison to epidural anesthesia, N2O has many advantages, including a decreased risk for maternal hypotension, prolonged 2nd stage of labor, and operative vaginal delivery. Also, labor progress is not affected and other interventions can be avoided, such as intravenous access, urinary catheterization, and bed confinement. With N2O use, women can remain mobile, and can also choose other pain control methods, such as hydrotherapy, position changes, and epidural anesthesia, if desired. The onset of action is immediate for N2O, which also clears the body within minutes. Furthermore, there appears to be no adverse effect on fetal outcomes. Side effects of N2O are minimal and include nausea, vomiting, and drowsiness. The project objectives were to, 1) compose and submit a sample guideline to an Army hospital institution for the use of N2O in labor, 2) increase knowledge of N2O use in labor among stakeholders through an educational presentation, 3) improve the guideline by revising it based on feedback from participants, and 4) disseminate the N2O guideline to the Army Certified Nurse Midwives and other stakeholders. To undertake this project, the OB providers and nurses at the hospital site were contacted to coordinate a date for the proposed presentation. An educational presentation and a guideline were given to 51 participants. Assessment of participant learning and feedback were obtained from 46 pre-and post-tests. Analysis of the tests showed an overall 46% improvement in knowledge after the presentation. Feedback from participants served to improve the sample guideline. The guideline was then disseminated to other Army stakeholders. The goal of this project was to increase stakeholders' knowledge of N2O use and present a sample guideline to be adopted for N2O use at the hospital site. Once stakeholders at this hospital became aware of the benefits of this pain control method, they were 16% more likely to want to implement it at their institution.