SARASOTA MEMORIAL HOSPITAL DEPARTMENT POLICY

Transcription

1 PS1006 SARASOTA MEMORIAL HOSPITAL DEPARTMENT POLICY TITLE: NITROUS OXIDE USE IN THE INTRAPARTUM/IMMEDIATE POSTPARTUM PERIOD Job Title of Responsible Owner: Director, Women s EFFECTIVE DATE: REVISED DATE: POLICY TYPE: (maternal) 11/15 11/17 DEPARTMENTAL INTERDEPARTMENTAL DEPARTMENTS PROVIDING NURSING CARE 1 of 5 PURPOSE: To provide nitrous oxide by inhalation as an analgesic alternative for women in labor, as well as for therapeutic use in the immediate postpartum period. Nitrous oxide has been found to be effective at relieving pain, decreasing anxiety, inducing euphoria and/or reducing the awareness of pain. The machinery delivers a blend of oxygen and nitrous oxide to the patient as per her demand. In the interest in allowing patients the process of choice, Sarasota Memorial Health Care System offers nitrous oxide analgesia which has been and is currently used extensively world-wide as a primary form of analgesia for labor and birth. POLICY STATEMENT: The pain of labor is best managed in joint effort amongst the patient, obstetrician, anesthesiologist, and RN. It is the primary goal of Sarasota Memorial Health Care System s obstetric and anesthesia departments to provide patients with choices in analgesia while in labor and the autonomy to select the best form of labor pain management for their particular situation. In allowing patients free choice, the use of nitrous oxide may be a viable option as a form of analgesia for labor, birth or postpartum repairs. EXCEPTIONS: Contraindications include patients who: A. Cannot hold their own face mask B. Have impairment of consciousness, or are intoxicated with drugs and/or alcohol C. Documented vitamin B12 deficiency and are receiving vitamin B supplementation D. Have impaired oxygenation, defined as oxygen saturation consistently less than 95% room air. E. Do not have a category I or category II fetal heart rate tracing that has been deemed by the medical provider as being safe. F. Patients with decreased cobalamin function (e.g. Crohn s disease, Celiac disease, gluten intolerance, pernicious anemia, strict vegan diet). G. Patients with pneumothorax, bowel obstruction, increased intra-ocular pressure or recent eye/ear surgery. Precautions include patients who: A. Have received intravenous opioids within the last 2 hours B. Have hemodynamic instability as defined as a systolic BP less than 100 C. Patients who choose to have IV opioid administration, must wait at least 5 min. after inhaling nitrous oxide. Materials:

2 2 of 5 1. Nitrous oxygen delivery system a. Administration of nitrous oxide for labor analgesia requires attaching the apparatus/equipment to the tank of nitrous and to the tank of oxygen supply utilizing a blender specifically designed for obstetric use to deliver up to 50/50 delivery ratio and instructing the woman and her support person how to use the devise for self- administration of inhalation analgesia. b. Nitrous administration equipment and tank will be stored in a locked room when not in use which can be accessed by OB anesthesia team, attending provider and L&D staff. 2. Nitrous Oxide Ordering: A. There must be an order from the OB provider B. Patient should be screened upon admission. Set-up and Administration of Nitrous Oxide A. Pretreatment and evaluation: Assessment of patient suitability (mother and fetus) and absence of contraindications. B. Obtain vital signs including BP, HR, Temp., oxygen saturation, and fetal heart rate evaluation upon initiation of nitrous; then obtain Vital Signs per unit protocol. Set-up: ensure equipment is properly connected and operating Patient Preparation A. Informed consent of patient to include possible side effects: nausea, vomiting, fatigue. Patient advised not to move about without assistance once nitrous use has been initiated. B. Instruct patient on self-administration: placement of mask to create seal; timing of breathing for maximum analgesic effect; only patient allowed to hold the mask. Usage Guidelines: A. Nitrous oxide must be administered under the supervision of the OB provider or nurse B. Patients using nitrous oxide as the sole anesthetic agent do not require pulse Oximetry or an IV. C. Patients will receive no assistance in holding the delivery mask. Patients who are unable to do so may not use nitrous oxide. D. Patients may not affix the mask to their face in any fashion. E. Patient will inhale and exhale into the mask/mouth piece. Termination of Treatment: Use of nitrous oxide is discontinued when patient desires or when the need for analgesia is no longer present.

3 3 of 5 Documentation: Nurses and obstetric providers will document in the patient s Electronic Medical Record (EMR) as part to the progress notes/cpn that nitrous oxide was administered, time of initiation/ discontinuation of nitrous, and any side effects or complications. Tank Replacement Steps: A. When the ProNox alarms indicate a cylinder is low, remove the tank that alarmed low from the room and: B. Use the green cylinder key to turn the yoke valve clockwise to firmly close both cylinders. C. On the low cylinder turn the regulator T-bar counter clockwise to loosen the regulator from the cylinder. Lift the regulator off the yoke and replace the cylinder. Ensure the regulator still has the washer around the inlet. D. Remove any protective wrap from around the yoke of the new cylinder. E. Place the regulator over the yoke of the new cylinder, lining up the index pins and gas inlet so they slide into their receiving holes. F. Hand- tighten the regulator T-bar so the regulator is firmly attached to the cylinder yoke. G. Use the cylinder key to slowly open the cylinder yoke valves by turning the valve counter-clockwise. Keep turning the key until it will not turn anymore; do not force. H. Opening the nitrous oxide cylinder first will prevent unnecessary audible alarms. I. Listen for leaks at the yoke and at either end of the hose. Tighten connections as required. J. Check the cylinder pressure on the regulator gauges. A full nitrous oxide tank will read approximately 750 psi. A full oxygen tank will read approximately 2200 psi. K. Check the supply pressure indicators on the front of the nitrous oxide delivery unit. Both indicators should be green. L. The audible alarm may chirp at the beginning of inspiration. This may be due to the high flow demands of the patient breathing in quickly, or may indicate the cylinder is approaching the pressure where the alarm will become continuous meaning the cylinder needs to be changed. PROCEDURE: Patient holds mask over nose and mouth creating a sufficient seal to activate the regulator to open flow and inhales the nitrous oxide/oxygen 50/50 blend. No additional opioid administration is allowed without the direct supervision of anesthesia team while the patient continues use of nitrous oxide. Patient is instructed that to obtain the greatest benefit, she should place the mask to her face and inhale deeply approximately 30 sec. prior to the start of the contraction as it takes approximately sec. for the nitrous to become most effective. Patients must be instructed to exhale the nitrous oxide into the mask. RESPONSIBILITY: It will be the responsibility of the Director of Women s and Children s Services to see that nursing is aware of, and adheres to, this policy.

4 4 of 5 REFERENCES: American College of Nurse-Midwives Position Statement. Nitrous Oxide for Labor Analgesia December Bishop, J. (2007). Administration of nitrous oxide in labor: Expanding the options. Journal of Midwifery and Women s Health 52(3) May/June 2007 pages Pro-Nox Nitrous oxide delivery system hand-out. Carestream Medical d. Accessed October 22, Rosen, Mark. (2002). Nitrous Oxide for relief of labor pain: A systemic review. American Journal of Obstetrics and Gynecology 186(5) Stewart, L., & Collins, M. (2012). Nitrous oxide as labor analgesia: clinical implications for nurses. Nursing for Women s Health, 16(5), AUTHOR(S): Renee Maietta, MSN, RNC, C-EFM, CBC Clinical Coordinator Labor & Delivery/MBU Debbie Dietz, MSN, RNC, C-EFM, CBC Advanced Practice Nurse Labor & Delivery/MBU Judy Cavallaro, MSN, RN, CBC, Clinical Manager Labor & Delivery/OB ECC/MBU Dr. Kyle Garner, MD, OB Chief of Staff

5 5 of 5 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy Date Committee/Sections (if applicable): Clinical Practice Council 11/2/17 11/8/17 Pam Beitlich, Director, Women s and Children s Vice President/Administrative Director (if applicable): 11/7/17 Connie Andersen, VP/Chief Nursing Officer