The Effect of Traumatic Childbirth on the Incidence of Postpartum PTSD, MDD and Anxiety Disorders

Post- traumatic stress disorder (PTSD)- definitions The criteria for the diagnosis of traumatic experience involve the experience of a specific traumatic stressor and, subsequently, four axes of symptoms: (i) re-experiencing of the traumatic event, including nightmares, intrusive thoughts and emotions; (ii) avoidance of stimuli associated with the traumatic event; (iii) hyperarousal, expressed as difficulties sleeping or concentrating, irritability, enhanced startle responses, irritable, aggressive, reckless or self-destructive behavior and (iv) persistent negative alterations in cognitions and mood. Formal clinical diagnosis of PTSD can only be made after symptoms have been present for at least 1 month. The definition of a traumatic event includes the witnessing or experience of serious threat to life or bodily integrity, or injury (either physical or emotional) to oneself or others [1]. As such, the subjective and objective experience of giving birth became recognized as a possibly traumatic event for some women [2]. As a result of a traumatic childbirth, women may experience general distress, flashbacks, dissociation, amnesia, sleep disturbances, negative evaluation of self-worth, difficulty breastfeeding, relationship problems and problems with their own sexuality [3-7], problems with bonding with their infants [8-12], or significant fear of subsequent childbirth (tocophobia); many choose not to conceive again for this reason. The afflicted women that do choose to have further children may insist on a cesarean delivery in hopes that it will not be as traumatic [6].

PTSD after childbirth- prevalence, risk factors, clinical characteristics and long term implications About 2- 6% of women will experience the full DSM-V criteria for PTSD at some point after giving birth [13-14]. An additional 22- 40% may meet the criteria for subsyndromal PTSD, and another 20-50% of women may report the childbirth experience as traumatic [13-14].

It is not known at this point what are the characteristics of women who may develop postpartum PTSD, making it impossible to predict or to prevent this outcome. However, several risk factors have been recently elucidated. Several predisposing/prenatal factors associated with the childbirth experience itself have been associated with PTSD. These include previous psychiatric history [15, 16, 17,18] (especially depression in pregnancy), socio-demographic problems [19,20, 21] (lack of support, problematic relationship with the partner), parity (primiparous more at risk), personality traits and disorders [22 -24] (trait anxiety; anxiety sensitivity, neuroticism), previous trauma [25-26]

• previous childbirth-related trauma; sexual abuse), maladaptive cognitions [27] (pre-existing, maladaptive schemas; negative cognitive appraisal of past childbirth; autobiographical memory specificity, fear of upcoming childbirth), nature of delivery [28, 29] (type and number of interventions; duration, fear of harm to self or baby, emergency cesarean section (CS), instrumental delivery- especially forceps- assisted, episiotomy), perception of care from medical staff [24, 29], perception of loss of control [24, 30], perception of pain [24 ], infant complications [28-29] (especially low birth weight, low Apgar score, asphyxia, resuscitation, prematurity), and peritraumatic dissociation [31-32] - feeling of unreality; alterations in perception of time and place; feeling of disconnection from body). Women having unplanned caesarean section births were likely to report PTSD-type symptoms. However, there was no association between PTSD type symptoms and planned caesarean section births [16, 33]. PTSD is also associated with preeclampsia [34-35]. Preeclampsia is associated with both maternal complications (e.g. eclampsia, abruptio placentae, pulmonary edema, acute renal failure) [36-37], and perinatal complications (e.g. fetal growth restriction, preterm delivery, and perinatal death) [38, 39-40]. As previously described, these adverse pregnancy outcomes are known to be associated with PTSD [41, 43, 44 -46]. Other seemingly routine aspects of pregnancy may increase vulnerability to active PTSD, especially in victims childhood sexual trauma or intrafamilial abuse [47, 48, 3-4], previous pregnancy loss [5,6 ] or prior traumatic birth [7], or when pregnancy is a result of sexual assault. Inherent physical aspects of pregnancy such as increased breast sensitivity and fetal movement are potentially triggering. Routine aspects of prenatal care, including vaginal and breast examinations, can be triggers, especially for sexual trauma survivors. Labor itself, especially medicalised labor can exacerbate a sense of powerlessness and vulnerability, which can trigger PTSD symptoms [49]. Physical changes of pregnancy, especially cardiovascular, respiratory, gastrointestinal and renal system alterations, also could affect the experience of PTSD symptoms [49], since they might resemble physical sensations associated with anxiety.

It is unclear whether traumatic birth experiences can lead to other types of psychopathology, such as postpartum depression or anxiety disorders, and more research is needed to answer this question. However, since there is a known association between traumatic experiences and affective and anxiety disorders in general- one can surmise that this association exists also between these disorders and traumatic birth experiences [10, 12, 16].