Top image: Aditya Romansa / Unsplash. All images by Shiva Bharathi Gupta for RICE Media unless otherwise stated.
I am deathly afraid of pain. I pull plaster bandages off slowly, inch by inch. Never ripping them off. Splinters are horrifying; paper cuts a nightmare. The pain of childbirth? Something I can’t imagine.
I’m bringing this up because when my mother gave birth to me, she was unable to opt for pain relief because of a medical condition: idiopathic scoliosis.
Something that I inherited as well.
The pain relief option that my mother wanted to opt for was an epidural—a procedure that involves injecting a local anaesthetic into her lower back.
This helps to numb the lower body, effectively easing the pain of contractions. But because of her scoliosis, the curvature of the spine was too difficult for the anaesthetist to carry out the injection safely.
She gave birth with only the help of nitrous oxide (AKA laughing gas), which she deemed ineffective.
“I felt like I wasn’t breathing in anything,” she told me jokingly, “I couldn’t feel anything, and it wasn’t very useful.”
Another common pain relief option is the opioid injection, which involves injecting an opioid into the woman’s thigh muscle. However, epidurals are widely regarded as the most effective. In recent years, more new mothers have been opting for one.
But as the epidural becomes the new norm for effectively reducing pain during labour, there are many other women out there, like my mother, who fall between the cracks. I’d like to think that minimising pain is a human right—but not everyone can get one, even for something as agonising, universal, and beautiful as giving birth to a human.
At the Mercy of Medical Conditions
Like me, 36-year-old Hazel has a low pain tolerance.
So when she became pregnant with her son in 2019, an epidural was a no-brainer. But towards the end of her third trimester, she was informed by an anaesthetist that an epidural might put both her and the baby at risk.
She was presented with a spectrum of scenarios that could happen if she opted for the epidural. The best-case scenario: She and her child would be healthy. The other end of the spectrum: Both mother and child would not survive.
Hazel suffers from a medical condition called immune thrombocytopenic purpura (ITP), a blood disorder characterised by low platelet counts. She was first diagnosed at the age of 16.
Because of her ITP, Hazel suffers from unknown bruises on her legs. With eczema, she also finds that her skin takes longer to recover. Her gums are prone to bleeding
Otherwise, she tells me that she has led quite a normal life and doesn’t see herself as someone who’s chronically unwell. At one point in time, she even started running marathons.
“I told my doctors that I think I’m healthy. I didn’t feel anything abnormal.”
Since her life was largely uninterrupted by her condition, she never expected pregnancy complications.
A Mother’s Optimism
Hazel always assumed she would get an epidural if she asked for it.
It wasn’t impossible to receive an epidural—her platelet count just had to be above 100,000. However, her platelet count hovers around 50,000 to 60,000. Never higher, never lower, even with medication.
She was told that she ran the risk of a stroke if they were to administer the epidural with too low of a blood count. If not, a heart attack.
Dr Lim Ming Jian and Dr Paul Tan Hon Sen, the obstetrician-gynaecology anaesthetists behind the Instagram account @twodrsonegoal clarify this side effect.
“If an epidural is administered in a patient with a platelet count that is too low, the consequence is the formation blood clot around the spinal cord (an epidural haematoma), which may lead to paraplegia, other permanent neurological deficits, or an infection may develop (an epidural abscess).”
“The risk of heart attack and stroke is more likely due to massive bleeding during the delivery which is a significant concern in a patient with low platelet count,” they shared.
To make matters worse, five months into her pregnancy, Hazel was diagnosed with gestational diabetes, which only increased her chances of a stroke.
Hazel remained positive despite being presented with horrifying potential outcomes a mere two weeks before her due date.
“I didn’t think I would be so unlucky. I was naively optimistic in that sense.”
Blown Out of Proportion
Fortunately, Hazel and her son, now three years old, came out of labour safe and sound. He was born healthy with a normal blood count.
But the process didn’t come easy for Hazel.
In the two weeks before she was due, she doubled down on medical steroids to artificially push her platelet count up. Water retention and moon-face were the side effects.
“Believe me, I didn’t look good,” Hazel asserts.
“Towards the last few weeks, my legs were really swollen and wearing shoes was difficult and uncomfortable. The bloating was worse than before when I was just pregnant. My body size was a lot bigger than usual.”
All this just to ensure her eligibility for an epidural. But even on the fateful day of labour, Hazel couldn’t escape the pain entirely. She had to deal with four hours of pain from contractions without anaesthesia before she could get the green light for an injection.
“For someone like me who has a low tolerance for pain, the four hours felt like 40 hours,” she admits, laughing.
At this point, many other things could still go wrong. The blood test could reveal her platelet count was too low. Or that by the time they could administer it, she could have missed the window for anaesthesia.
According to Dr Lam Yun Khoon, a medical officer in a public hospital, “Sometimes if a patient is very close to delivery, close to 10 cm dilation, and their contractions are very close together, we advise against an epidural as they might not be able to stay still during the procedure, which increases the risks of complications.”
But Hazel wasn’t even able to worry about any of that.
“The pain was taking over my mind and soul—I couldn’t even think about whether I could be given the epidural. I was just bracing for the next contraction.”
Fortunately, the doctor returned with good news. An epidural was approved.
“It was such a relief. But I was already in pain and crying; it was very dramatic,” she recounts.
Many assume that an epidural guarantees pain-free childbirth for everyone. But it’s not foolproof. Medical conditions such as scoliosis and ITP, conditions that might otherwise not have a huge impact on their lives, prevent some mothers from being able to opt in.
Dr. Lim and Dr. Tan explain this in an Instagram post.
“Certain conditions can also make it unsafe to receive epidurals, including low platelet counts, which increases the risk of blood clots in the spine and paralysis, bad infections, and severe heart or brain conditions,” they told us separately.
But even women who can opt for a pain-free birth might not have total control over the decision.
It Takes a Village
Ashley*, 28, would absolutely have preferred to opt for an epidural. But as the oldest granddaughter in her extended family, her pregnancy was subject to the opinions of all her family members.
“There was a lot of feedback from relatives. My mum’s three other sisters and my grandparents strongly discouraged me from opting for an epidural.”
This opinion was driven by the fear of postnatal effects, such as backache, rheumatism and a longer time for recovery.
Dr. Lim and Dr. Tan explained that from their experience, women who are afraid of getting an epidural are usually concerned about side effects, some of which are based on misconceptions that have circulated around the general public.
But Ashley still suffered from backache despite not getting an epidural. However, she did acknowledge that she experienced a faster recovery compared to other new mothers.
She posits that she would still have preferred an epidural in hindsight. Against her wishes, she was rendered powerless in that situation—Ashley had to concede to her family.
“There was no space to reject the idea because there are so many of them and only one of me. I felt that I have a responsibility too as the oldest child.”
“I was stressed. There were so many people giving their input throughout my whole pregnancy, even after delivery.”
She was never given a chance to choose from the start. When she found out about her pregnancy, her mother and youngest aunt happened to be at the hospital too as they were accompanying her grandfather to an appointment. The news spread like wildfire among her relatives.
Feeling pressured by her family, she obeyed and opted out of the epidural, even though the decision purely lies with the mother in the delivery room. If she had secretly opted for it behind closed doors, and her family had found out, she supposes she would have been subjected to a lifetime of being chided.
Regarding her plans for a second child, Ashley tells me that she would probably opt for the epidural. Without her family’s knowledge.
“The only regret I have is not standing firm in my decision. They would just keep nagging. But eventually, they will stop.”
“My siblings and cousins will probably do the same after seeing what I went through,” she surmises.
After all, most women want pain-free labour. Ashley shares that among her circles of mothers, most of them opted for an epidural. When they weren’t given one, they simply missed the window for when it could have been administered.
However, she also tells me that some women, believing in the benefits of natural birth, would rather go through the pain than risk the possible consequences of an epidural. But the journey isn’t smooth for them either.
An Unattainable Scenario
Syahirah, 37, is one such mother. She advocates for natural childbirth. No anaesthesia, no stitches, no medical intervention.
Sharing a similar view to Ashley’s family, she believes that giving birth naturally can result in faster recovery and reduces the risk of postnatal complications. But like Hazel and Ashley, things didn’t pan out as planned.
When she was pregnant with her first child, she assumed that natural birth was achievable. Up until labour, she had held onto that hope. But after being in labour for nine hours, it became clear that it wouldn’t be possible.
“The baby was supposed to pass under the pubic bone to enter the birth canal and come out. But for the longest time, my baby could not pass my pubic bone.”
In the end, the only way for her to give birth was for her to deliver via Caesarean (or C-Section). The procedure mandated an epidural.
“During the birth of my first child, I was disappointed because everyone around me was also positive and optimistic that I would be able to give birth naturally. I didn’t know how my body would work.”
She continued to try for a natural birth for her second and third labour. Every time, they would bump into the same hurdle. For her youngest, she had spent 18 hours in the delivery suite before giving birth via Caesarean.
Her postnatal period wasn’t easy either. After her first birth, she suffered from postdural puncture headache (PDPH), a possible complication of an epidural.
“It creates this feeling of not being able to sit up straight. If you did, you’d feel nauseous to the point of vomiting, and it doesn’t resolve until they inject blood back into your epidural space. I experienced it for five days.”
She also had back pain for about half a year after her first and second children. But after her third child, the pain was especially prolonged.
“I had back pain for one and a half years. It was really, really long. It could be due to other factors, like age, but it’s quite a long time to be having pain and specifically hurting where the entry point is, where there’s scar tissue.”
Take It Case by Case
But of course, everybody experiences birth and the epidural differently.
While Dr. Lim and Dr. Tan acknowledge that epidurals provide very effective pain relief, they warn that epidurals should not be treated as superior to other forms of labour pain relief that should be used in all patients.
Possible risks they identified include temporary shivering, itching, nausea, and slight drop in blood pressure, which can be treated, and will stop after the epidural is removed.
Uncommon side effects, with a less than 5% risk include inadequate numbness, headache, changes in foetal heart rate, and abnormal sensations in the legs after epidural has been removed. Extremely rarely (<0.0001%), epidurals can cause nerve damage, infection, and blood clots in the spine.
“This is not to say that we are against epidurals. As you can see, most of the risks are either mild and temporary, or very rare.”
However, Dr. Tony Tan, an obstetrician and gynaecologist at the Tony Tan Women and Fetal Clinic & PLL Anaesthesia Clinic at Mount Alvernia Hospital, disagrees.
“The epidural is superior to other forms of pain relief and whilst some may be able to fulfil a vaginal delivery without the use of epidural, many others may not. Other than those who are medically contraindicated to having an epidural, the rest should have an option to have an epidural if they choose to have effective pain relief.”
Dr. Pay Lu Lu, an obstetric anaesthetist from the same clinic, reports that most women are happy with their epidurals and that epidurals are effective in reducing pain most of the time.
“Although one can expect some labour pain halfway through or at the end of the labour, a top-up dose can be given effectively.”
Overall, from a medical point of view, an epidural has many benefits. Dr. Lam says that an epidural is recommended for first-time mothers especially, to make the labour process more comfortable.
“It allows patients to rest well and conserve energy for the pushing process at full dilation, which can last up to an hour.”
“Another benefit is that the epidural can be used during the repair of episiotomies after delivery, and make it painless and comfortable.”
But ultimately, the decision belongs to the mother.
“We are firm believers that mothers should understand the benefits and risks of the types of pain relief available, and choose what fits their needs the best,” say Dr. Lim and Dr. Tan.
Worth the Pain
Despite not being able to achieve her ideal of natural birth, it’s clear that Syahirah will always prioritise her children’s well-being.
After two Caesarean births, she knew it would be difficult for her youngest to be born naturally. Her doctor suggested that her youngest child be induced if she wanted to carry on with a natural birth. Since the baby would be smaller, there would be a higher chance of it being able to pass under the pubic bone, increasing her chances of giving birth naturally.
After much thought, Syahirah declined.
“I’d rather have a Caesarean and have a fully developed, vigorous and healthy baby than have a natural birth where my baby is premature.”
Syahirah went through long hours in the delivery suite and suffered from postnatal pain—and found it all worth it.
“The complications and side effects I face now are just something I have to take responsibility for in the healing process. I don’t regret my decisions. I can’t imagine my life without my children.”
Ashley and Hazel share this motherly sentiment.
“Just looking at him sleep, eat well, laugh and giggle, it’s all worth it,” says Ashley.
Even Hazel, who had to endure the pain and discomfort of childbirth with her low pain tolerance, had no regrets.
“Every time I see my child, when I play with him, chat with him, watch TV with him, get him to bed, feed him milk, I get reminded that everything is worth it.”