Some hospitals are suspending gas and air supplies after it was discovered that it poses health risks to midwives. What can be done to ensure that pregnant women continue to receive the care they require?
Leigh Milner knew exactly how she wanted her labor to go when she was expecting her first child. Her birth plan included an epidural for pain relief, and she was hoping for “all the drugs,” she says ruefully. However, this was not the case. Milner, a BBC presenter, gave birth to Theo last month at Princess Alexandra hospital in Harlow with only paracetamol for pain relief, in what she describes as a positively “Victorian” experience.
Labor progressed quickly after she was induced at 38 weeks due to pre-eclampsia, a potentially dangerous pregnancy complication that causes high blood pressure, and she quickly realized she needed something to help her cope while she waited for her epidural. “The pain was just unbearable; my whole body was shaking; I had no idea where I was; I was slipping in and out of consciousness,” she says.
Many women would take a gulp of gas and air at this point, the bedside mix of oxygen and nitrous oxide familiar to mothers as the most common form of pain relief in labor. However, supplies were temporarily suspended at the Princess Alexandra, as well as a handful of other hospitals across south-east England, when Milner gave birth in February after the hospital discovered excessive levels of nitrous oxide (which can pose a long-term health risk to midwives) in the air on the ward.
“I kept pleading, ‘I need something for pain relief,’ and the only thing they could give me was paracetamol because they didn’t have gas or air. “I was terrified and didn’t know what else to do,” Milner says. It wasn’t until she arrived at the labor ward that she learned there wasn’t time for an epidural. She gave birth to Theo while being prepared for an emergency caesarean and was left “writhing in pain” for hours while her husband, Chris Berrow, cared for the baby. “It seemed like it would never end – it was a mess from start to finish. “I understand they need to keep the staff safe, but they also need to support women giving birth,” says Milner, who is eager to talk openly about her experience because she believes there is a broader expectation that women in childbirth should just grit their teeth and bear it. “There’s a ‘get on with it’ mentality. And, yes, I have a beautiful, healthy baby boy, and I would do it all again for him. But I don’t think we can keep telling mothers, ‘At least you have a healthy baby, move on, everything is fine.’ Birth is unpleasant, but it should not be traumatic.”
According to the Care Quality Commission (CQC), 76% of women who gave birth in England last year used gas and air at some point during labor. It doesn’t so much relieve pain as it does make it more bearable. However, it is popular because women can use it as needed, it works quickly, and it does not slow down contractions (which stronger opioid painkillers such as pethidine can). While some women use it as a stepping stone to something more substantial, others use it to build their hopes of a “natural” birth with minimal intervention. However, as Milner discovered, concerns about air quality, particularly in older maternity units, mean that it cannot currently be assumed in some parts of England.
While inhaling gas and air (known as Entonox) during labor is completely safe for mothers and babies, long-term cumulative exposure, such as midwives working day after day on poorly ventilated wards with gas accumulating in the atmosphere, may pose health risks. It can impair vitamin B12 absorption over time, causing nerve damage and possibly anaemia. Although research is inconclusive, some studies have linked occupational exposure to fertility issues and the risk of miscarriage.
After detecting high levels of nitrous oxide on the unit, the William Harvey hospital in Ashford, Kent, restricted access to gas and air last November (it has since been restored). Weeks later, Basildon University Hospital in Essex suspended gas and air, citing previous tests that revealed “an issue” with nitrous oxide levels on the maternity unit. Some unit employees are reportedly considering legal action against the Mid and South Essex NHS foundation trust, which runs the hospital, and the Health and Safety Executive is looking into it.
Ipswich Hospital suspended gas and air use in December, but reintroduced it after installing new ventilation, and North West Anglia NHS foundation trust temporarily suspended gas and air at maternity units in Peterborough and Huntingdon following air-quality tests in late February. Meanwhile, after recording high levels of Entonox in its maternity unit, Watford General Hospital avoided a break in service by installing machines to extract the gas. (The Princess Alexandra hospital, where Milner gave birth, says three temporary gas-and-air units are now available, with permanent ones on the way.)
Pain relief in labor is a touchy subject, fraught with guilt and debate over whether suffering is an essentially “natural” part of childbirth or something that no one would be expected to endure in other fields of medicine. Even before the current gas and air problems, some mothers struggled to have the birth they desired. In 2019, the CQC discovered that more than a third of women switched from their planned form of pain relief in labor, mostly for medical reasons, but in 3% of cases due to a lack of an anaesthetist (only anaesthetists can give epidurals) and in 19% of cases due to a lack of time.
Gas and air may be the only option for those whose labors come on suddenly. “It takes the edge off and makes you feel calmer,” says Kathie, a mother of two daughters from Suffolk, whose labors both lasted two and a half hours, with no time for an epidural. “It also makes you feel less anxious because it gives you something to do; even wearing the gas mask and breathing in gives you something else to focus on.” When things were moving at a frighteningly fast pace, she says it helped her feel less out of control. But, while gas and air can be a godsend for mothers, they can also pose hidden dangers to those who care for them.
Leah Hazard is a Scottish NHS midwife, activist, and author of Womb: The Inside Story. “There’s a genuine feeling of frustration, anger, and fear because some of the midwives have had real issues with their health and fertility – and, in some cases, B12 deficiency,” she says of being approached by several midwives in recent weeks about the impact high Entonox levels at work may have had on them. They are looking back and are very angry about it. I’ve also spoken with midwives who haven’t tried to start a family yet but have worked in labor wards and are concerned that some harm has been done.”
While hospitals have been chastised for abruptly suspending services, Hazard argues that expecting midwives to risk their own health is unreasonable. “You would never say, ‘Why don’t builders just keep working on that asbestos-laden building for a few more weeks?'” It’s primarily a service provided by women for women, and [midwifery] has always been regarded as a warm and fuzzy, docile role. There is an assumption that we should simply put up our hands and shut up.”
Since the potential risks of Entonox, which is also used in dental surgeries and, in rare cases, operating rooms, have been known for decades, she believes hospitals should have prioritized ventilation long ago. The investigation into what happened in Basildon by the Health and Safety Executive may shed some light on why problems are only now emerging in a number of hospitals.
The Royal College of Midwives has also argued that the current crisis is the result of a lack of “proper investment” in maternity services, which have long suffered from chronic understaffing and creaking old buildings, as Dr Suzanne Tyler, executive director for services to members, put it. “This problem has arisen as a result of poor ventilation in delivery suites and labor wards, but this is only the tip of the iceberg. We’ve heard of crumbling walls, propped-up ceilings, and even sewage flowing into wards. Birth partners were unable to attend scans during Covid-19 due to a lack of adequate ventilation and appointments taking place in cramped quarters.”
According to Hazard, the fact that the risk from Entonox appears to be highest in older hospitals with poor ventilation brings back painful memories of the pandemic. “We were well aware that we were frequently working in poorly ventilated rooms, rather than in gleaming new buildings. Many of us caught Covid and have been very ill,” she says. For many midwives, these new worries about safety are “the last straw”. But staff are also, she says, concerned about the impact of painkilling methods being withdrawn on the women they look after.
In theory, there are plenty of alternatives, from “natural” options such as hypnosis and water births to stronger opioids such as pethidine. But Hazard says there is no exact equivalent to gas and air. “They all have their own specific profiles in terms of risks and benefits – it’s not like you can say, ‘Really sorry, we don’t have any gas and air, but why don’t you have some morphine?’ That’s a completely different rung on the ladder. Alternatively, ‘Sorry, why don’t you have a birthing pool?’ “Of course, not everyone wants to give birth in water.”
The National Childbirth Trust (NCT), which has been receiving calls from concerned pregnant women, is advising those in affected areas to speak with their midwives about alternative methods or see if they can transfer to another hospital. Val Willcox, the NCT’s practice manager, says wards should always have enough anaesthetic cover to meet epidural demand, but women “might want to think about other strategies for coping with contractions” if there is a wait during busy times. After gas and air, non-medical interventions such as deep breathing, massage, and hypnosis are the most common forms of pain relief, followed by Tens machines, which use electrical pulses to relieve pain.
According to Francesca Treadaway of the campaigning charity Birthrights, it is critical to resolve the uncertainty on some maternity wards because having some sense of choice and control during labor is critical to wellbeing both in childbirth and early motherhood. “Giving birth is a life-changing event – it’s seismic – and birth is your introduction to parenthood. “How the birth goes affects how you feel postnatally as well,” she says. “You do have rights over your treatment, whether that’s giving birth or having another kind of operation. It’s traumatic when you don’t have a choice.”
Birthrights has received several calls about gas and air in recent weeks, she says, and some women only found out about it after reading about it on social media. Treadaway is especially concerned about the impact on pregnant women who had their first babies during the pandemic, on labor wards that were operating under severe covid restrictions at the time, and who may be carrying difficult memories from that time into a second pregnancy. “At best, you’re going in with some trepidation.”
Milner is recovering well six weeks after Theo’s birth and clearly smitten with her son. But her distressing experience on the labour ward did, she says, colour their first days together. She is keen to take up the hospital’s offer of a “birth reflections” session to go over and process her experience with a midwife. “I do feel like it kind of robbed me of those nice feelings that you’re supposed to feel, because I’d look at him and feel so happy and so grateful that he’s here, but then I’d start crying because the moment he came into the world was not a happy time. I didn’t have that euphoria, when people say: ‘I looked at him and fell in love.’ I looked at him, relieved that we had both survived.”
Erin Balsa is a highly skilled and knowledgeable health journalist with a passion for educating the public on important health and wellness topics. With extensive experience in both traditional and digital media, Erin has established herself as a trusted voice in the field.