The psychological impact of childbirth: Unscheduled cesarean delivery increases risk for acute stress response

IntroductionCesarean delivery is one of the most common surgical procedures in the United States. Despite their frequency and medical necessity, the acute psychological impact of unscheduled cesarean delivery is unknown. This study aimed to assess the rates and nature of peritraumatic stress response during and shortly after unscheduled cesarean delivery, and whether acute stress predicts later mental health symptoms. Methods1,146 patients receiving routine perinatal care at a tertiary, urban hospital were assessed for peritraumatic stress reactions during the delivery hospitalization (mean: 31 hours postpartum). A subgroup (n = 795; 69.4%) completed an assessment at approximately 1.9 months postpartum. Delivery mode, obstetric complications, prior trauma exposure, and antepartum and postpartum psychiatric symptoms were obtained from questionnaires and medical records. Chi-square tests adjusted relative risk estimates, mixed-effects models and regression analyses were used to evaluate acute stress by delivery mode, its persistence over time, and associations with postpartum mental health outcomes. Results10.4% of participants met criteria for clinical acute stress (PDI [&ge;] 15). Among women undergoing unscheduled cesarean, 26.6% reported clinical stress, with higher rates observed for cesarean performed during labor (29.3%) and those with greater obstetric morbidity ({rho}=0.20, p< 0.005). Compared with vaginal delivery, unscheduled cesarean delivery was associated with fourfold increased risk of acute stress (26.6% vs. 6.3%, relative risk=4.20, 95% CI: 2.92-6.05). Adjusting for demographics, primiparity, obstetric complications, labor induction, prior trauma, and antepartum mental health, unscheduled cesarean remained associated with increased risk. Stress levels among patients undergoing unscheduled cesareans was persistently elevated over time (estimate=0.39, p=0.44), while vaginal delivery was associated with a significant symptom reduction (estimate=0.52, p=0.03). Acute stress strongly predicted subsequent posttraumatic ({beta}=0.48, p<0.001) and depressive ({beta}=0.30, p<0.001) symptoms and maternal-infant bonding ({beta}=0.32, p<0.001) difficulties. ConclusionsA substantial proportion of women undergoing unscheduled cesarean delivery experience significant psychological stress during childbirth with enduring morbidities. Screening for acute traumatic stress during postpartum stay is warranted to optimize mental health outcomes. Key PointsChildbirth can be a traumatic experience yet how it associates with delivery mode and obstetric complications is poorly understood. In immediate postpartum assessments, 27% of women undergoing unscheduled cesarean delivery reported clinically significant acute stress using the peritraumatic distress inventory (PDI), with elevated symptoms persisting after two months and associated with maternal mental health morbidities. Compared to vaginal delivery, unscheduled cesarean was associated with a threefold increased risk, after adjusting for parity, mental health history, trauma exposure, obstetric complications, and labor induction. Unscheduled cesarean delivery is associated with substantial acute psychological stress with enduring implications. This warrants immediate screening for birth trauma to prevent postpartum psychological morbidity.