Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Discuss the use and administration of nitrous oxide during labor 2. Describe the concerns regarding administration of nitrous oxide during labor and co-administration with other analgesic agents
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 9/8/2021 through 12/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.25 contact hours.
Nitrous oxide (N2O), an anesthetic gas, is used during labor and for postpartum perineal repair. While the obstetric analgesia and anesthesia practice bulletin (2019) states that “nitrous oxide can be used safely with other forms of analgesia”, ACOG has released a follow-up practice advisory (2021) which notes that there may be risk for respiratory depression when nitrous oxide is combined with other agents, such as opioids, in concordance with the American Society of Anesthesiologists. Therefore, ACOG states
Based on this concern for potential maternal adverse consequences, co-administration of systemic opioids or sedatives/hypnotics and inhaled nitrous oxide for labor analgesia is not recommended
Administration of Nitrous Oxide
50% mix of nitrous oxide in 50% oxygen
Blended from two separate gas cylinders or
Hospital piped gas supply or
Single premixed cylinder
Self-administered via face mask or mouthpiece
‘On demand’ valve
Limiting exposure to others
Scavenging capabilities required to avoid environmental exposure
Effectiveness of Nitrous Oxide
Not as effective in reducing pain scores vs epidural
Does not impair patient mobility
Additional monitoring not required
Self-administration provides patient with control
Medication effects stopped as soon as mask or mouthpiece is removed
Nitrous oxide rapidly crosses the placenta
Rapid elimination by neonate upon commencement of breathing
Adverse effects include
Nausea and vomiting
Use with Other Analgesic Agents
The American Society of Anesthesiologists Committee on Obstetric Anesthesia Working Group addresses the use of inhaled nitrous oxide during labor
Nitrous oxide is a valuable alternative to neuraxial analgesia
Nitrous oxide is safe when used at a 50% N2O/50% O2 concentration
However, safety record is based on not combining nitrous oxide with other sedating agents
The American Society of Anesthesiologists states that
It is important to note that the addition of systemic opioids to N2O analgesia appears to increase the likelihood of maternal hypoxemic episodes
As a result, the co-administration of systemic opioids and inhaled N2O labor analgesia is not recommended
OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.
Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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