Transcript of a July 25 chat with Dr. Darshak Sanghavi

Angela--Shaw----Boston--com--Staff Hello chatters! Thank you for joining today's chat with Dr. Darshak Sanghavi. He should be checking in shortly, so send in your questions now.

question Dr. Sanghavi, as a physician, wouldn't you agree that ANY medical intervention runs the risk of potential side effects? It seems to me that the decision to receive anesthesia during childbirth should be one made by the woman and her physician based on the risks and benefits specific to her. Your article supposes that a woman's decision to forgo anesthesia is based on such things as wanting to be a "martyr" or being "uneducated." I find that argument completely sexist. Why can't you suppose that the woman is making a rational, educated decision by weighing the pros and cons specific to her own treatment?

Dr. Darshak Sanghavi First of all, I'd like to thank the Globe for asking me to participate in this web chat.

Dr. Darshak Sanghavi Thank you for the question. Of course, any medical intervention does have potential side effects. But many activities in life have risks. The key question is, what is the magnitude of the risks of an epidural, compared to no epidural? Further, how are the risks presented? Finally, to what exact complication (increased risk of cesarean or maternal fever, for example) does "risk" refer? And lastly, how good is the data?

Dr. Darshak Sanghavi Reviewing this data--and there is a lot of good data about this--the risks for almost all of the possible side effects are not statistically significant. Many women, however, are not told this clearly.

Dr. Darshak Sanghavi Of course women should decide what to do with their bodies. I'm not advocating forcing anything on a laboring woman. But I do believe that we have a responsibility to be very clear when the data are very clear.

mamamama Dr. Sanghavi LOVED the article. Wondering if you found any correlation between those who are mystical/religious and increased desire to go without pain meds? Or between those without faith/religion and those willing to trust the science of pain meds? Best wishes.

Dr. Darshak Sanghavi Thank for your your kind words. I specifically asked this of many midwives/obs, and also looked to my personal clinical experience. Overall, there is no strong correlation, although there's not a lot of good data about this. Anecdotally, some ob's report that (and this is extremely suspect and full of speculation) Catholics are sometimes less likely to choose pain-killers, while Asians and Jews are more likely. But take that with a (huge) grain of salt.

new--dad--tomorrow My wife is scheduled to be induced tomorrow with our second, 11 days after her due date. What should we expect and what are the chances of needing a cesarean?

Dr. Darshak Sanghavi Congratulations on your impending fatherhood. It's probably best if you speak directly with your doctor about these questions, since I'm not directly involved in your wife's care.

TJohnson Do you have an opinion re: the Bradley Natural childbirth classes? I heard that their success rate for natural births are over 90% (as reported by one of their teachers).

Dr. Darshak Sanghavi I have never taken a Bradley class or reviewed their curriculum in detail. It's certainly possible that 90% of women deliver successfully without any pain relief. I'd ask the instructor what happens to the other 10 percent. Also, it's important to be clear about whether you're being told epidurals are dangerous or that natural childbirth is somehow healthier for your wife and baby than one where pain-control is used.

Ginny As a doula, I was disheartened by your perspective on avoiding childbirth pain. I am never directive with my patients but help them to make their own decisions by giving an objective view of information on the choices they may be trying to make. I had the experience recently with a non-speaking Hispanic woman who had settled into her own rhythm of pushing. A resident rushed in, said she was not being productive and demanded an interpreter to count to 10 and push. The woman had severe tears and required an extensive epistiotomy. Is this right and acceptable?

Dr. Darshak Sanghavi Of course, women deserve to be treated in a compassionate and understanding manner by their doctors. In this case, it sounds like her needs may have been neglected. Much about childbirth, to be honest, can be improved today as you indicate.

Dr. Darshak Sanghavi But it's important to separate this issue from pain control. As a doula, you may be aware of other women who call themselves "epidoulas"--doulas who provide continuous support to women who choose pain control, but also like having more attention than they may get from hospital based providers. I wholeheartedly support those kinds of options for women. Chris Just got back from a 38 week ultrasound, the machine sas my son weighs 6.4pounds, I was told this is "on the light side" Should I be overly concerned?

Dr. Darshak Sanghavi This is a complicated question. Many weights may or may not be very accuarte, and the answer to your question also depends on whether you have any other known complications. It's best to speak to your doctor about this.

Ginny Isn't there a risk of infection when an epidural is administered? This spring a woman died shortly after she gave birth from an overwhelming infection.

Dr. Darshak Sanghavi Infection during childbirth was a scourge for many years--so called "peurpureal fever", urospesis, and other infections were epidemic. In fact, for years in the last century, many physicians failed to wash their hands when tending pregnant women, and spread infection. (For more info, Google a doctor called Semmelweiss, who fought for better handwashing.) I don't mean to imply that women get infections from poor handwashing today, but that there are many reasons women get infections following delivery. To my knowledge, no study has ever found a higher risk of infections caused specifically by epidurals, which are placed under extremely sterile conditions.

chandani Dr. Sanghavi, I enjoyed your article immensely and it offered an interesting perspective-- a male doctor's insights into choosing pain during childbirth. I agree absolutely in the importance of educating women and allowing them access to options when it comes to bearing children. However, I also think your summary sidestepped an important point: YES, everybody is born and nobody remembers being born, but not everybody gives birth. Only women give birth. Women in the United States and elsewhere achieve a certain mythologized status through their ability to bear children and suffer this pain. In my opinion, it is a sad statement of society in general that this remains to be the case. What concerns did you have as a male doctor, and somebody who can personally never understand having to make this choice as a female, writing this article? thanks again.

Dr. Darshak Sanghavi You're right that as a male I will never experience labor. And as you note, I take a risk when I write about things outside my personal world of experience.

Dr. Darshak Sanghavi But I (in some way) also view my role as a public health advocate. In this manner, for example, I haven't had tuberculosis--but have been interested in tuberculosis prevention. And I haven't had direct experience with being abused as a child, but I have an interest in public health proposals to prevent child abuse.

Dr. Darshak Sanghavi In the same manner, I am interested pain during childbirth, since the lack of access to care and public misinformation about pain is, in my opinion, a public health issue. So that's why I write about it.

tlightner There are is a cascade of interventions that follows many epidurals -- including not being able to move, which can keep babe from moving into a good position, not being able to push effectively due to mom being flat on her back which can lead to the necessity of forceps or vacuum assistance, and if mom still can't get babe out -- she may need a c-section. Why did you fail to address any of these issues in your article?

Dr. Darshak Sanghavi Numerous modern studies debunk the notion that epidurals increase the likelihood of cesarean section. It is possible that epidurals are associated with a slightly higher chance of "assisted" deliveries with vacuum or forceps, according to the Cochrane Collaboration. But last year's study from the New England Journal of Medicine disputes that also.

Dr. Darshak Sanghavi On that note, Ultra-low dose epidurals ("walking epidurals") allow women to push, and in many cases, move and still feel sensation. And "patient controlled" epidurals allow women to directly control their level of comfort. So today, women should have a tremendous degree of control over their labor.

Dr. Darshak Sanghavi Yet many hospitals, particularly small ones, don't offer this. That is what concerns me. thingsthatyougohmm When researching Ina May Gaskin, did you consider, research or speculate on the reasons why The Farm has acheived such amazing statistics?

Dr. Darshak Sanghavi This is an interesting and complex question. Gaskin's data was publised (I think) a few years ago in the American Journal of Public Health, and examined. I would need to review this in some detail to answer your question credible. But I can speculate that she works much harder to ensure vaginal delivery--and is much more patient than some obstetricians. She also probably is much more willing to encourgae women to tolerate pain for a longer time to acheieve a vaginal birth. And she does not use fetal monitoring, which can increase the risk of c-section. It is also conceivable that she works with a highly selected group of women who may not represent all women--after all, her typical patient seeks her out and want to deliver in a commune called the Farm. What she has accomplished (if her c-section rate is really as low as she claims) is impressive, but may not be for everybdy.

almostdone Can you talk more about a "walking epidural"? I think that many women struggle with the idea of lose of control in labor and become hesitatn/nervous about the idea of becoming bound to the bed to have pain relief

Dr. Darshak Sanghavi A "walking" epidural refers to a specific use of very low does of continuous infusion of synthetic narcotic and local anesthetics into the epidural space. (You can read a nice description of them in Bill Camann's book, which I cite in the article, and also GIlbert Grant's--the chief of ob anesthesia at NYU) book for specific details.

Dr. Darshak Sanghavi But they (and many other obstetricians) believe this option should be offered to all women, since it allows sensation in many women. To be clear, the "walking" epidural doesn't always allow women to walk, but it does allow a less "dense" type of anesthesia that many women find strongly preferable.

Dr. Darshak Sanghavi I would encourage people--and health providers and insurers--to begin tracking statistics about availability of these kinds of up-to-date techniques, so that propective mothers can make more informed decisions about where to deliver.

Sheilby Your article gave the impression that women who choose to forgo pain medication are opting for painful childbirth for no reason. I choose to go without an epidural and I would not describe my labor as painful -- I would term it as intense. Although I am not normally a mind over matter type of person I found that the sensations of labor did respond to relaxation in an amazing way. The few contractions that i was "caught" out of my relaxed mode hurt. You do not seem to give any credence to the idea of natural methods of pain relieve. Do you believe in them?

Dr. Darshak Sanghavi Yes, I do give credence to the notion that natural methods can give relief. Guided imagery, some kinds of hyponosis, and other stratgies can help a great deal. While these likley aren't good for things involving extemee pain (for example, appendectomies or major surgery), they are very helpful in conjunction with traditional medical care in, say, putting stitching in older children. I solidly agree that mental strategies are very important.

Dr. Darshak Sanghavi But I do not believe that most women with labor pain should think that these strategies will be the only thing they need. I object to many natural childbirth educators implying that all that's needed is mental imagery, for example.

Constance I am contemplating not getting an epidural and the main reason is that I think it will be better for me and the baby if I can use my legs to stand up and move around and eventually deliver in a position that is not restricted by being halfway numb. I'm not ruling out pain meds but it just seems to be a slippery slope that itself leads to complications. The rates of Cesareans are way too high in this country, and I believe it's because we use pitocin and epidurals too much.

Dr. Darshak Sanghavi You should ultimately make a decision that you feel comfotable with, and not feel bullied by anyone on either side of this debate. But you should have good information as you make your selection. On that note, I strongly feel that your fear abut having a cesarean as a result is unfounded. You may end up with a cesarean either way--but it's hard to make an argument that tyhe epidural was the influencing factor.

martha "Dr. Sanghavi, Have you read any research on the Hypno-birthing method of labor? Or about the fear-tension cycle? I practiced the hypnobirthing techniques throughout my first pregnancy, and found them quite useful -- I labored for 3 hours without pain medication, and delivered a healthy baby girl. My decision to forgo pain medication was an extremely educated one, not the result of misinformation as your article suggests.

Dr. Darshak Sanghavi I don't mean to say that all women choosing no pain medication are misinformed. But many of them--as evidenced by the large number of women who think it (for example) increases the risk of a cesarean--are getting bad information.

kavin I have heard epidural causes chronic backpain after delivery for some women. Is it true?

Dr. Darshak Sanghavi According to several studies, this claim has not been substantiated (for example, the British Medical Journal study cited in the article).

Dr. Darshak Sanghavi It's always worth asking what the quality of a study is. Many previous studies blaming epidurals for all kinds of mischief are not well designed and well-controlled. It's hard to sift through bad and good data when Googling. That's why it's very important for respected obstetricians and members of the medical establishment to take some of the control back for prenatal education.

worcester You also discussed in your article that continuous fetal monitoring has not been shown to reduce risks as compared to occasional fetal monitoring. Why do you think that many local hospitals require continuous fetal monitoring once anesthesia is given?

Dr. Darshak Sanghavi That's in interesing question, and one that I've written about previously for the Boston Globe. You can see the piece at my website, www.darshaksanghavi.com, under the writing archive, from August 2004.

mustbeacrazyone Why do you seem to believe that all women who choose not to have pain-meds are in agony, I have given birth to 4 kids all at home with a qualified midwife, I am expecting #5 in a month, I have never experienced excruciating pain, in fact I have enjoyed all my birthing experiences

Dr. Darshak Sanghavi Thanks for sharing your story. As I mention in the article, a small minority of women (somewhere less than 5 to 10 percent or so, according to some studies) feel little pain during childbirth. For this highly selected group of women, pain control is not very important. But it's worth asking, how does a woman know if she falls into this category before delivering? And does a past experience really predict the next one (that is, just because it didn't hurt before doesn't mean it won't hurt during the next pregnancy).

Dr. Darshak Sanghavi My point is just that women should have access to pain control when they need it--no matter where or when they deliver--and not be made to feel guilty for accepting it.

Sheilby You claim that numerous modern studies debunk the the notion that epidurals increase the risk of c-section. However, that is not true. The recent studies including the one you referred to compared early epidurals to late epidurals -- not no epidurals to any epidurals. The fact of the matter is, even when only comparing low risk moms, women attended by midwives consistantly have lower rates of c-sections. How do you explain this?

Dr. Darshak Sanghavi To clarify, most modern studies do not compare epidurals to no anesthesia whatsoever. Doing good studies on any clinical problem requires a "randomized" design, where women enrolling in the study randomly get treatment A or treatment B. At major academic medical centers, human subject review boards (which review all research) have concluded that randomizing women to no medical pain relief is unethical.

Dr. Darshak Sanghavi Thus, most studies about the safety of epidurals compare them to 'systemic' pain control, such as intravenous narcotics. ON the basis of these studies--which are the only ones we are every likely to have now in the US--most credible authories have concluded epidurals don't increase the risk of c-section.

Dr. Darshak Sanghavi To compare this to midwive experiences is dicey, since they have very different patients who may not be directly compared to hospital-based patients.

sandy When I had my 1st child, I was "stuck" at 9cm for 2 hours, the baby was also posterior. The pain was so bad that I was completely stiff and the residents were trying to convince me to a C-section. I got an epidural, relaxed for 45 minutes, and the next exam showed that I made it to 10cm and the baby has turned to anterior. I pushed for 45 minutes (short for 1st child), no instrument delievery, and done. I suspect the epidural actually helped me relax and saved me from a C-section. What do you think. Now here is the real question I want to ask. Dr. DS, if you were to give birth, at which stage would you ask for the epidural?

Dr. Darshak Sanghavi As you note, epidurals can occassionally shorten labor (and occassionally also prolong it briefly).

Dr. Darshak Sanghavi In answer to your question, I believe a woman should ask for pain control whenever she needs it. With uncommon exceptions, there is not really any such thing (for some anesthesiologists) as being "too late" or "too early" for pain control, if a woman wants it.

helen I read your article eagerly, but ended disappointed. I was thoroughly educated about my choices going into my 2 births 5 and 3 years ago, and each time chose the pain of a natural delivery. The first was a pitocin-led birth with random heart-less pain; the second was a midwife-assisted birth with searing but productive and efficient pain. Both my husband and I are tearfully proud of the hard work I did to birth our sons. Did I choose unnecessary pain? Maybe. But it was a birth of me into my new life as a mother. I do belive the depth of my birth expereinces set the stage for all the hard work we do today parenting 2 intensely active and healthy preschoolers.

Dr. Darshak Sanghavi It is wonderful that you were satisified with your birth experience and now enjoy a happy family.

annieb I too enjoyed your article. However, I just recently gave birth to our third child and have not had good luck with epidurals. I have been at two large Boston hospitals with 3 different anestisia teams and cannot say that the epidural worked as it should have. What do you think about the sometimes "false" promise of a pain-free delivery?

Dr. Darshak Sanghavi This is a valuable point. You're right that there is no guarantee of a pain-free delivery, either from natural childbirth or pain-controlled childbirth. But my experience and the medical liteature suggest that epidurals in the vast majority of cases offer substantial pain relief over no pain control.

Dr. Darshak Sanghavi Thank you for your questions. It's 1:00 pm now, and this concludes the web chat. For further information on some of my work, you can see my web site at www.darshaksanghavi.com. Best wishes, Darshak Sanghavi