In the polarized landscape of parenting, it often seems there's no such thing as a middle ground. Parenting books and blogs portray parenthood as a minefield of divisive choices: Breast vs. bottle, cloth vs. disposable, sling vs. stroller. The first of many fraught decisions a mother faces—one she makes before she's even a mom—is the choice between "natural" (unmedicated) and pain-free (anesthetized) childbirth. As expectant women quickly learn, either choice comes with a caricature: You can forgo the drugs and be a smug, crunchy masochist, or you can accept them and be a selfish, epidural-dependent wimp.
But part of the reason the childbirth debate has become so polarized is the dearth of any middle ground between full-on epidural anesthesia and nothing at all. (Unless you count breathing exercises as a pain-control measure.) Lately, though, a number of midwives have been pushing for a third way. They are advocating that more delivery rooms offer nitrous oxide, the inhaled anesthetic more commonly known as laughing gas, familiar to many of us from dental procedures (and, perhaps, ill-advised experiments with Reddi-wip cans).Why are midwives—a group that in this country is usually associated with natural childbirth—leading the charge to bring a new drug to laboring women?
Nitrous oxide has a lot going for it. Unlike the epidural, which offers complete pain relief but renders a woman immobile from the waist down, nitrous oxide merely blunts pain. But it also lets a laboring woman walk, perch on a birthing ball, whatever. It's comparatively cheap, and it's fast-acting, offering relief in less than a minute. Perhaps most key from midwives' point of view, it is easily administered by the laboring woman herself. She grabs the mask when she knows a contraction is coming. She stops as the contraction ends. In other words, she is empowered to manage her own pain.
What nitrous oxide isn't is new. The gas was first used on laboring moms in the 1880s and came into more widespread use in the 1930s, when a series of technical advances in Great Britain made it easier for laboring women to self-administer through a mask. Nitrous is still used widely in other countries' delivery rooms: According to data parsed by nurse-midwife and former Centers for Disease Control and Prevention epidemiologist Judith Rooks, well over half of laboring women sampled in the United Kingdom use nitrous oxide today. In other places, including Finland and the Canadian province of British Columbia, close to half of women use it.
Why don't we have it here? As the Associated Press has reported, only a handful of American hospital delivery rooms still offer nitrous to laboring women. It was more widely available in this country from the '30s through the '50s, says pediatrician Mark Sloan, author of Birth Day, but several factors blunted its popularity. For some reason, Sloan says, the idea of women self-administering nitrous oxide didn't catch on here the way it did in England, where midwives started towing nitrous around with them to home births. In the United States, by contrast, hospital deliveries were the norm, and doctors and nurses were told to deliver nitrous by holding a mask over a laboring woman's face with each contraction. When, in the '50s and '60s two rival inhalational anesthetics came along, both of them less time-consuming to administer, they elbowed nitrous oxide out of the way. It later turned out these rivals were dangerous, but just when nitrous might have been poised to make a comeback, the epidural arrived on the scene.
So what about epidurals? For their intended purpose—obliterating pain—they're pretty great. However, they also render a laboring woman unable to walk or even pee, leaving her hooked up to a machine in a prone position. And there are other issues. William Camann, head of obstetric anesthesia at the Brigham & Women's Hospital in Boston and co-author of Easy Labor: Every Woman's Guide to Choosing Less Pain and More Joy During Childbirth, says that while recent research offers no evidence that epidurals increase the C-section rate (as natural childbirth advocates sometimes claim), they can slow labor, which may or may not increase interventions like vacuum extraction. And if for some women being numb below the waist is a godsend, it can make others feel like spectators, separating them from the experience of an ancient, sacred act.
Inhaling nitrous oxide is an entirely different experience. Because it doesn't totally block pain, it is never going to be all things to all women, but rather one option in a bag of tricks. (Narcotics are another option, though they can slow a baby's breathing.) Some women might use nitrous oxide to get through an entire childbirth, while others might use the gas for early labor pains and get an epidural later on. Nitrous is "less of an analgesic than a mood affecter, in a way comparable to the way that opioids work," says Mark Rosen, the director of obstetric anesthesia at the University of California-San Francisco Medical Center, which has been offering nitrous oxide to laboring women for at least 40 years. "Patients would say, 'You know, the pain is just as bad but I don't care about it as much.' "
I can attest to that, sort of. My daughter was born by way of epidural, but I did have laughing gas a few years back during a dental procedure. Maybe two minutes elapsed between when I started breathing in the gas and when the dentist told me to open my mouth for a needle full of local anesthetic. During those two minutes, I forgot why I was there. The local anesthetic didn't remove all of the pain, but the discomfort seemed somehow separate from my body–the pain was beside me, not of me. I was relaxed and a little euphoric.
It's only in the last decade or so that nitrous oxide has popped back up on the U.S. radar. First, back in 2002, Rosen published a review of the available literature on its use in delivery and found no indication that the gas poses harm to mother or baby. More recently, Rooks, the epidemiologist and nurse-midwife wrote an influential editorial in the journal Birth advocating for its wider availability, and the American College of Nurse-Midwives followed suit with a pro-N2O statement. Rooks has also started a listserv for medical professionals interested in learning more about the drug. Vanderbilt University Medical Center plans to offer nitrous oxide to laboring patients in the coming weeks, and Dartmouth Hitchcock Medical Center hopes to offer it when new equipment becomes available, possibly later this year.
But if nitrous oxide is to take off in this country, it will need to first conquer some cultural barriers. The National Center for Health Statistics surveyed 27 states and found about 61 percent of women giving birth to single babies vaginally in 2008 opted for either an epidural or a shorter-lasting spinal block. In England, by comparison, only about one-third of all laboring women do the same. For Americans, writes Sloan, "the goal of hospital labor pain management is often the complete obliteration of pain; in Europe and elsewhere … the objective is 'good enough' pain relief." How will American women warm to the idea of "good enough" pain relief? Randi Hutter Epstein, author of the childbirth history Get Me Out—and mother of four children, one of whom was born after a nitrous oxide-assisted labor in England —questions how many mothers will choose to forgo the mental clarity an epidural allows. "I think that American women tend to be control freaks when they're pregnant and giving birth,'" she says. "The thought of being a little woozy and out of it doesn't seem to me right now to be a very American thing."
What is American, though, is choice, and this is the biggest argument in favor of nitrous oxide. Michelle Collins, a nurse-midwife at Vanderbilt, points out that moms in postpartum surveys tend to rank pain relief as less important than feeling like they were empowered in their own labor. In other words, our experience of hardship is predicated on more than the physical experience of pushing out a baby. It has to do with having options, with being consulted, with knowing what's happening to our bodies. This idea flies in the face of much modern labor care, which is predicated on the idea that women want the most pain-free labor possible. In fact, pain may not be the only point.