Here's a review put out by the American Society of Anesthesiologists on the use of nitrous oxide for labor analgesia:

http://www.asahq.org/For-Members/Clinical-Information/Nitrous-Oxide.aspx

I personally love using nitrous as part of my anesthetic and typically use it to begin masked inhalational induction in kids before dialing in a more pungent and potent anesthetic gas to induce a full general anesthetic.

It is generally quite safe but I won't use it in patients with certain conditions (most cardiac lesions, pulmonary HTN, issues where I'd like the kids to be receiving a higher percentage of oxygen).  And wow, in teens, in can sure cause an impressive disinhibition, as I experienced first-hand today when trying to put in an IV catheter while the kid was breathing N2O.  It was not pretty.

And even though it IS very safe, with a very very rapid onset/offset because of its relative fat insolubility (so it doesn't accumulate in tissue the way our other inhalational agents do) the thought of it being given outside of an OR or perhaps a dental suite where the dentist is credentialed in using it, kind of freaks me out just because it is so rarely done in the U.S. and most L/D suites aren't set up to scavenge the waste gas.  I am nearing the end of pregnancy and am very conscious of performing maneuvers to minimize the amount of escaped anesthetics that I am sucking in every day (esp N2O which has been implicated in premature births and miscarriages among healthcare practitioners exposed to its use at work) -- and that's difficult.

But from a breastfeeding perspective, I think it would be an ideal labor analgesic. :)  I personally would love to trial remifentanil as a low-dose patient-controlled-analgesic set up, as it's rapidly metabolized (in about 8 minutes) and so fetal exposure and accumulation would likely be quite low.  But I don't know that it's really used much for this purpose.

-Sarah Reece-Stremtan M.D. (pediatric anesthesiology fellow in Washington DC)

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