Case report

Background: Pain relief during labor has significant impact on the experience and perception of the birth. The 50/50 blend of oxygen and nitrous oxide (O2/N2O) has long been used to control labor pain, reaching rates of use as great as 70% in some countries.1-3 

Case Report: This case describes a 29-year-old full term pregnant woman, diagnosed with dyskinetic cerebral palsy, with neurosensory deafness and cognitive impairment. Brief communication was possible. She arrived in the maternity in active labor, showing intense agitation and involuntary arm and back movements. Before any analgesia technique, informed consent was signed and she was monitored. The 50/50 blend of O2/N2O was instituted with a face mask, while a lumbar epidural catheter was placed. She was instructed how to operate with the facial mask and keep the position. The epidural catheter was placed without intercurrences and pain relief was achieved with Ropivacaine and Sufentanil. O2/N2O mask was withheld after the procedure. 

Discussion: Although less efficient than epidural analgesia in pain control 3, N2O has intense analgesic and anxiolytic properties, showing a good safety profile, which makes it a very good agent to control labor pain or as a bridge drug to help positioning for an epidural catheter placement.3 
The pain and anxiety control introduced by N2O facilitates correct and stable positioning, valuable factors that improve the success of any epidural technique, especially in situations where unintended movement can compromise safety and produce associated complications. 

Learning Points: N2O has important analgesic and anxiolytic properties, which makes it an interesting drug to use as a bridge to more efficient forms of labor pain control. Future studies should be done to test if the association of an inhaled analgesic technique during the epidural catheter placement leads to significant reduction in the complication rate (p. ex. accidental dural puncture) in agitated patients and potentiates maternal satisfaction with the procedure. 

References:

(1)	M Collins, “A case report on the anxiolytic properties of nitrous oxide during labor”, Journal of Obstetric, Gynecologic, & Neonatal Nursing, October 2014
(2)	J Nolan et al, “Anaesthesia and pain management in cerebral palsy”, Anaesthesia 2000.
(3)	M Collins, S Starr, J Bishop, “Nitrous oxide for labor analgesia: expanding analgesic options for women in the united states”, Reviews in Obstetrics & Gynecology 2012. (418)


05 / Nitrous oxide as a bridge to epidural labor analgesia in a patient with cerebral palsy.